Building a Critical Limb Ischemia Program with Carlos Mena-Hurtado, MD

ESSENTIALS OF BUILDING A CRITICAL LIMB ISCHEMIA PROGRAM CARLOS MENA-HURTADO, MD DIRECTOR, CARDIAC CATH LAB, DIRECTOR OF VASCULAR MEDICINE AND ENDOVASCULAR FELLOWSHIP SECTION OF CARDIOVASCULAR DISEASE, YALE UNIVERSITY Mahesh Anantha Narayanan, MD Endovascular Interventional fellow Yale New Haven Hospital

PRESENTER DISCLOSURE CONSULTANT FOR COOK MEDICAL, MEDTRONIC, CARDINAL HEALTH AND BOSTON SCIENTIFIC NO EQUITIES OR BONDS IN ANY PHARMACEUTICAL OR DEVICE COMPANY

OBJECTIVES PROBLEM DEFINITION DEFINING THE BURDEN OF CRITICAL LIMB ISCHEMIA SCREENINGANDCOMMUNITYAWARENESS EARLY IDENTIFICATION OF DISEASE COMPONENTSOFCLIPROGRAM HOW TO ESTABLISH A SUCCESSFUL CLI PROGRAM

PROBLEM DEFINITION 11% PAD (~230 MILLIONPATIENTS)PATIENTSPROGRESSTO CLI PREVALENCEOFCLIINTHEUNITEDSTATESINPATIENTS > 40 YEARSOFAGEIS APPROXIMATELY 2 MILLION CLI ASSOCIATEDWITHMORTALITYASHIGHAS 20% IN 6 MONTHSANDUPTO 40% IN 1 YEAR PROVINGCAREFOR CLI PATIENTSCOSTAPPROXIMATELY $4.2 BILLIONWITH ADDITIONAL$625 MILLIONON 30-DAYREADMISSIONS FOWKES FG, LANCET 2013;382(9901):1329-1340 CRIQUI MH, NEJM 1992;326(6):381-386 ABU DABRH M, J VASC SURG. 2015;62(6):1642-1651.E1643

CLI TEAM Podiatry Wound care Nurses Non invasive lab Primary care physician CLI PROGRAM Vascular interventioni st/Surgeon Research (VAMOS) VAMOS- Vascular Medicine Outcomes Program Nephrol ogist Scheduling Infectious disease physician

CLI TEAM LEAD DEDICATED EXPERT VASCULAR PHYSICIAN AS THE TEAM LEAD/CHAMPION (IC OR VASCULAR SURGERY OR IR) THE LEADER SHOULD IMPROVISE TECHNICAL SKILLS AND BE ABLE TO PERFORM COMPLEX PROCEDURES ESTABLISHING GOOD RELATION WITH COLLEAGUES WHO PERFORM PROCEDURES TO BE A PART OF THE TEAM CLI IDENTIFY COMMUNITY WITH HIGH PREVALENCE OF RISK FACTORS AND ESTABLISH CLINICS IN THESE HIGH RISK AREAS FOR EARLY DIAGNOSIS TRAINING OTHER PHYSICIANS TO PERFORM MORE PROCEDURES SCHEDULED MEETINGS INCLUDING PODIATRISTS, REFERRING PRIMARY CARE AND OTHER PHYSICIANS/ NURSES IN THE TEAM TO DISCUSS TREATMENT PROTOCOLS AND GIVE REGULAR UPDATES ON CLI MANAGEMENT LONGITUDINAL FOLLOW UP TO BE ABLE TO IDENTIFY/COORDINATE/PERFORM MORE PROCEDURES IF NEEDED

BUILDING BLOCKS OF CLI PROGRAM COORDINATED BY PHYSICIAN LEADER Administration Coordinating other physicians performing procedures community Physician leader In patient and outpatient Management Quality and safety Peripheral vascular intervention coordinator

CHALLENGES TO IMPLEMENTATION COMORBIDITIES IN PATIENTS WITH CLI CARDIAC, RENAL ISSUES MULTIPLE SUB SPECIALTIES DOING PROCEDURES MULTIVESSEL AND MULTI-SEGMENT DISEASE REQUIRING MULTIPLE REVASCULARIZATION PROCEDURES INVOLVING BOTH EXTREMITIES LACK OF AWARENESS AMONG PATIENTS AND TENDENCY TO WAIT (UNLIKE CARDIAC PROCEDURES) LACK OF MOTIVATION AMONG STAFF INCLUDING NURSING, CATH LAB TECHNICIANS, VASCULAR IMAGING TECHNICIANS

SCREENING AND COMMUNITY AWARENESS CROSS SECTIONAL SURVEY INCLUDING 500 ADULTS >50 YEARS OF AGE SHOWED ONLY 36% OF THE PARTICIPANTS WERE AWARE OF PAD IMPORTANT TO PERFORM COMPREHENSIVE ASSESSMENT OF ALL PATIENTS AT PRESENTATION USING PROGRAMS SUCH AS THE SHOE AND SOCKS OFF PROGRAMS SIMILAR TO NATIONAL PAD AWARENESS AND DIABETES AWARENESS MONTH TO REINFORCE LEARNED CONCEPTS AND DRAW RESOURCES FROM CLINICAL SOCIETIES AND INDUSTRY SPONSORS POSTERS, PAPER MAILERS, AND SOCIAL MEDIA MAXIMIZE TURNOUT AND ENHANCE EVENT EFFICACY LOVELL M, CAN J CARDIOL. 2009;25(1):39 45 KOBAYASHI N, J AM COLL CARDIOL, 63(12_S2):S28.

PROPOSED CHART FOR CLI PATIENT ASSESSMENT MILLS J L SR J VASC SURG. 220 234.

PROPOSED CRITERIA/REQUIREMENTS FOR CLI PROGRAM 400 PERIPHERAL VASCULAR PROCEDURES PER YEAR WITH >100 CLI INTERVENTIONS PHYSICIAN AVERAGE OPERATOR VOLUME AT LEAST 50 CLI CASES PER YEAR ESTABLISHING CLI RESPONSE TEAM 24 HOUR AVAILABILITY, INCLUDE TWO PHYSICIANS AND OTHER SKILLED WORKERS INCLUDING NURSES, CATH LAB TECHNICIANS AND ULTRASOUND TECHNICIANS. TRAINED PHYSICIAN ASSISTANTS, NURSE PRACTITIONERS AND SCHEDULERS TO IDENTIFY PATIENTS WITH CLI EARLY AND REFER THEM FOR REVASCULARIZATION PERIPHERAL VASCULAR COORDINATOR- ESTABLISH/UPDATE PROTOCOLS, CONNECT TO OTHER SPECIALTY, SCREENING AND EDUCATIONAL PROGRAMS FOR THE COMMUNITY AND PHYSICIANS. A SCIENTIFIC REVIEW COMMITTEE TO REVIEW CLI CASES IN CONFERENCES TO HAVE A TEAM APPROACH AND DECIDE ENDOVASCULAR/OPEN OR HYBRID PROCEDURES QUALITY COMMITTEE TO MONITOR LONG TERM OUTCOMES INCLUDING AMPUTATIONS AND MORTALITY. SHORT TERM OUTCOMES INCLUDING RENAL DAMAGE, RADIATION TIMING AND BLEEDING COMPLICATIONS. PROCTORSHIP PROGRAM Fadi Saab M, 2015, acc.org

WHAT DO PATIENTS REALLY LIKE TO HEAR/SEE FROM OUR EXPERIENCE THOROUGH EVALUATION IN CLINIC EXPLANATION OF THE DISEASE PROCESS AND HELP MAKE CHOICES WITH DECISION AIDS CLEAR PRE PROCEDURAL INSTRUCTIONS IN CLINIC AND ALSO A FOLLOW UP PHONE CALL PRIOR TO PROCEDURES A CLI CONTACT NUMBER THAT PATIENTS ARE ABLE TO REACH ANYTIME OF THE DAY WITHOUT HAVING TO GO THROUGH THE HOSPITAL OPERATOR SAME DAY DISCHARGE AND VASCULAR CLOSURE DEVICES WHEN FEASIBLE TO LIMIT BEDREST CLOSE FOLLOW UP WITH PODIATRY IN CLI CLINIC

TAKE HOME POINTS CLI IS A COMPLEX DISEASE WITH INCREASING INCIDENCE ASSOCIATED WITH POOR LONG TERM OUTCOMES BUILDING A CLI PROGRAM REQUIRES A HUGE INFRASTRUCTURE INVOLVING ADMINISTRATIVE SUPPORT, SKILLED TRAINING STAFF, COORDINATION BETWEEN SPECIALTIES, VASCULAR COORDINATOR AND SCHEDULERS ALMOST 50% OF AMPUTATIONS WORLDWIDE ARE PERFORMED WITHOUT NON INVASIVE STUDIES/ANGIOGRAM/INTERVENTION AND IT IS HIGH TIME TO BUILD CLI PROGRAMS TO HELP AVOID AMPUTATIONS

THANK YOU