The 32nd International Symposium on Endovascular Therapy (ISET; 22–25 January, Hollywood, USA) had a particular focus on treating critical limb-threatening ischaemia (CLTI). In the session “Improving outcomes and prognosis for CLI”, conference attendees learnt about the global scale of the disease, the importance of adequate wound care post-treatment, and the possibility of revascularisation in the outpatient environment. The session was co-developed and sponsored by the CLI Global Society, a patient advocacy organisation that aims to improve patients’ quality of life by preventing amputations and death due to the condition.
Michael Jaff (Harvard Medical School, Newton, USA), vice president and founding board member of the CLI Global Society, spoke first to define CLTI and to outline the risks it poses to patients. “This is obviously a very important session for all of us who deal with these patients for a whole host of reasons,” he said. “We need to recognise that these patients are begging for our help.” He pointed out that patients with the most advanced class of the disease, categorised as Rutherford class 6, “had the highest prevalence of bilateral limb amputations before coming for this intervention”. He called this the “striking, sobering reality” of CLTI in the USA.
“The prognosis for one year after the diagnosis of CLTI is terrible: 25% of patients will have died, and 30% are still alive but have had a major amputation,” he disclosed. “Patients with chronic CLTI have a three-year limb-loss rate of approximately 40%, and quality of life indices of CLTI patients are very similar to end-stage cancer. Readmission rates are very high. We must identify these patients early, and we must have a sense of urgency for revascularisation. Amputation has to be considered the last possible option, not the first.”
Iterating this message, ISET founder and president of the CLI Global Society Barry Katzen (Miami Heart and Vascular Institute, Miami, USA) said: “Part of what we are trying to do is get this call to arms, and hearing Michael [Jaff]’s sentinel announcement about how vigilant all of us have to be to implement change is an important part of the message we would like to deliver.”
As the only society in the world dedicated to serving this patient population, the CLI Global Society is using its resources to get more data on the disease. Katzen explained to the ISET audience: “One thing you might know from your own hospitals is there are insignificant DRG [diagnosis-related group] codes, it is hard to actually quantify the cost impact, and the federal government and payers do not really understand or recognise CLTI as an entity or a disease, which leads to a lack of financial resources, payment for physicians, and payment for hospitals. So one of the things that the CLI Global Society did is invest its resources in creating science.”
Citing a recent CLI Global Society study published in the Journal of the American Heart Association (JAHA) that used Medicare data to investigate the impact of CLTI on the US population, Katzen said that patients with this disease have a poor long-term prognosis following their initial diagnosis, specifically pointing out that through four years, only 42% were alive and free from major amputation. “We need to raise disease awareness,” he said, echoing Jaff, “and we need to implement coding to better define CLTI, so that when you are looking after these patients, CMS can actually identify them. This is a major initiative of the CLI Global Society.”
The CLI Global Society, as “a non-professional society without political turf”, in Katzen’s words, has forged a coalition between the Society for Vascular Surgery (SVS), the Society for Cardiovascular Angiography and Interventions (SCAI), the Society of Interventional Radiology (SIR), and the Society for Vascular Medicine aimed at initiating a coding change regarding CLTI. Katzen anticipates this being implemented in October 2020.
Richard Neville (Inova Heart and Vascular Institute, Falls Church, USA) took to the podium next to discuss the importance of an integrated approach to the CLTI patient. “It is frustrating,” he said, “because I feel as though I have been giving this presentation for about 20 years. I was talking with Vickie [Driver, Brown University School of Medicine, Providence, USA, fellow panellist] earlier, and we were saying how this idea of a multidisciplinary team started with the diabetic foot. It seems that they have had a lot more progression and moved things along faster than we have with these CLTI teams. But we have to keep pushing forward—I think as more people get interested and recognise this is an important disease entity.”
Promoting the idea of an integrated limb preservation team, Neville said the ultimate goal is to decrease the rate of amputation. The team would also work together to decrease the rate of patient mortality and medical comorbidity, address the current disparity of care, and raise awareness of endovascular methods of limb preservation. A multidisciplinary approach to CLTI treatment would streamline care, he argued, and would provide a referral source for the community, as well as a forum for research and both patient and physician education.
“There has been good data across the world showing that these teams can reduce amputation rates,” Neville disclosed, highlighting data from the USA (82% reduction), Sweden (78% reduction), and the UK (62% reduction).
Generalising rules for establishing a multidisciplinary team is challenging, he continued, as the development of an integrated CLTI group depends on the people and facilities available locally. However, Neville emphasised that one commonality was the need for a physician champion: “You need somebody in the system that just takes this to heart. I would argue that you need someone that wants to take care of the vascular needs of the patient, someone that wants to work on their soft tissue, and we are now going to add vascular medicine in the mix. But you need someone who is passionate who wants to put a team together, go to conferences, and talk to people.”
Describing giving a similar talk in Beijing, China, Neville shared some advice from his Asian colleagues: “We used to call this the limb salvage centre [where the interdisciplinary CLTI team were based], but the gentleman who was hosting me in Beijing told me we cannot call it that—in Mandarin, the same Chinese character for ‘salvage’ is the same as for ‘trash’. So it is now the limb preservation programme!”
Commenting on the limb salvage versus limb preservation debate, Driver began her talk with an anecdote from her military days: “A general came to see me one day, he had been in Afghanistan and Iraq overseeing 35,000 of our [US] troops. He was diagnosed with diabetes. How was he diagnosed with a foot sore that would not heal and an infection? He went on to lose part of his foot. He said to me, ‘Thank god you do not call it limb salvage anymore’.”
She continued: “Wound care is never basic in a CLTI patient. In fact, it requires advanced care before and after vascular interventions.”