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Implementation of Critical Limb Ischemia Clinic in an Office-Based Vascular Surgery Center

Authors

Stephanie Sheridan, Vascular Nurse Practitioner, Christopher LeSar, MD, Nicole Tinney; Vascular Institute of Chattanooga, Chattanooga, Tennessee

Abstract Number
6

Introduction: There are approximately 18 million American citizens suffering with peripheral artery disease (PAD), of which an estimated 2 million have critical limb ischemia (CLI), which is the deadliest form of PAD. Predominantly in the elderly population, individuals with CLI have a high prevalence of multiple chronic comorbidities such as diabetes, hypertension, renal insufficiency, cardiovascular and cerebrovascular disease, and a history of smoking. Costing an estimated $43,000 per patient each year for clinical care alone, CLI is an economic burden. Hospitalization for an infected wound can escalate health-care cost from $19,000 to $42,000, an increase of 121%. If the limb affected is unsalvageable, the cost for amputation (nationwide population) is an estimated $10.6 billion. However, an endovascular revascularization procedure requires the patient to recuperate at home, and 2-year status post procedure, approximately 80% of these patients are walking and 90% live alone. This is in contrast to data for amputation, which shows a 2-year mortality rate of 30%-50%, with 36%-50% requiring another amputation. 

Objectives: Our goal was to implement an office-based CLI clinic aimed at the preservation of limbs and preventing amputation in high-risk populations. After researching established CLI clinics and investigating the plan of care, we created an algorithm for early intervention with the CLI population in our office and surrounding community. Utilizing that algorithm and corresponding program plan, we hope to improve quality of life for the patients we serve with early assessment, diagnosis, and intervention by revascularization, while also creating PAD awareness within the community. 

Methods: Our case study followed a 65-year-old male who presented with ischemic ulceration on the right foot with previous medical history of hypertension, coronary artery disease, dyslipidemia, and a left above-the-knee amputation with a significant history of smoking. He had a palpable femoral pulse but an absent popliteal or tibial pulse. Following angioplasty, the limb was revascularized to promote wound healing and salvage the right lower extremity. 

Results: Our CLI clinic will prevent lengthy hospitalization, improve CLI patient outcomes, and reduce avoidable despair of underdiagnosed and undertreated vascular disease. The office-based vascular practice is a necessity for the advancement of evidence-based practice in the vascular realm. 

Conclusions: The CLI clinic will improve awareness and the approach of PAD. Multiple studies show that aggressive revascularization is an essential component of prevention of amputations; nevertheless, evidence-based research is key to improving the care provided for patients with PAD who develop CLI.

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