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Quality Outcomes From a Dedicated CLI Center

Debra L. Beck, MSc

There were a number of technical realities that compelled Dr. Mustapha to move his critical limb ischemia (CLI) practice out of a hospital setting and start his own center dedicated to limb salvage, but the real driver was his dedication to the treatment of patients with CLI.

“CLI is my passion and CLI patients are my responsibility,” said Jihad A. Mustapha, MD, from Advanced Cardiac & Vascular Centers for Amputation Prevention in Grand Rapids, MI, during a Saturday session of AMP 2020 Virtual. “There is no greater need with so many opportunities for therapy ahead of us.”

In February 2018, he opened an outpatient CLI center with two interventional cardiologists and one advanced practice provider (APP). They had one lab and a total staff of 13 people, including some providing clinical research support.

To accommodate the overwhelming volume of patients needing therapy, they opened a second center in November 2018, and despite COVID-19, a third center in July 2020.

“As of August 2020, we’ve added a second cath lab to our flagship center, and will add a second lab to our second location…and we expanded into other states, with a third center opened in Las Vegas in July. We’re currently employing 6 physicians, 9 APPs, and 93 total employees."

There is a myth that outpatient centers limit product choices. Not true, said Mustapha. “I don't have to fight with a committee to bring in the product my patient needs. I choose the proper balloon for the patients versus a limited list of mandated options.”

What About Outcomes?

Based on his first Grand Rapids, Michigan CLI center, Mustapha expects to complete about 940 cases a year in 2020. This has been slowed somewhat because of COVID-19, but this number is up significantly from the 506 procedures completed in their first year of business in 2018.

Of the 770 interventions performed in 2019, 90% were for CLI symptoms (Rutherford 4-6). From January to May 2020, 93% of presentations were CLI.

“Despite this complexity of patients, complication rates are low,” said Mustapha. He reported dissection rates of 5.3% for invasive management (as compared to 3.6% for conservative management) and zero cases of compartment syndrome. “This is important because the way we approach crossing CTOs is extremely important and using extravascular ultrasound has tremendous value,” he added.

During 2019, they transferred only 8 patients (1.0%) urgently to hospital (1 patient electively) and 30-day death related to PAD was 0.3% (0.4% death rate unrelated to PAD).

While some centers do aorto-iliac CTOs, he personally does not do that procedure, but otherwise there is very little he won’t do. “Most CLI patients that aren’t currently hospitalized for other comorbid conditions can be treated in an outpatient lab,” said Mustapha.

That said, there are still hard realities — the patients are complex, the cases are long, as are the workdays, and running a business is difficult for doctors.

“But it’s the best move I ever made for my patients. I feel in control to provide proper care, in a timely fashion, to these very sick people,” said Mustapha. All care — testing, visits, treatments — happen under one roof and, importantly, patient satisfaction is “very high.”


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