This month, Dr. Jihad Mustapha interviews Bailey Estes, BSN, RN-BC, RNFA, CNOR, RCIS. She is a cardiac cath lab nurse and research coordinator at Hendrick Medical Center in Abilene, Texas. The team she works with is focused on treating peripheral arterial disease (PAD) and critical limb ischemia (CLI).
J.A. Mustapha, MD: Bailey, why did you choose to become a registered nurse and what path brought you to CLI work?
Bailey Estes, RN: It has always been important for me to do something where I am helping people every day and making a difference in their lives. Helping take care of my grandfather who had severe cardiovascular and peripheral artery disease inspired me to become a nurse in this field.
When I started working in the cath lab, peripheral vascular interventions were largely unpopular amongst the staff and physicians. The cases were long and the patients often came back for multiple procedures. The complexity of these patients intrigued me, so I began studying PAD and CLI to gain some insight. I was astonished that the morbidity and mortality rivaled that of some of the world’s most recognized and researched diseases such as breast and lung cancer. If a patient receives an amputation, their two-year mortality is 30-50%.1 I was disturbed to learn that Texas has one of the highest rates of amputation in the country.2 Having such a high association with death and disability, I could not fathom why more people, especially health care professionals, were not doing more to raise awareness and fight this disease.
The poor prognosis associated with PAD and its under-recognition was unacceptable to me. I decided that if I wanted to do something to change these statistics, I would have to start with myself. I learned everything that I could about interventional treatments and patient care for PAD. I went to training courses and conferences, such as the AMPutation Prevention Symposium, during my personal time. I found ways that I could make a difference in cases by the way I prepped each patient. Simple things such as reviewing diagnostic workups, preparing all possible access sites, feeling and marking pulses, assessing location and characteristics of wounds, and assessing patients’ symptoms aided the physicians and started to make a difference in patient care and outcomes.
I recently went back to school to become a nurse practitioner. I feel as though I have a unique opportunity to impact my community by providing optimal PAD/CLI care and have an impact on the future of CLI treatment. As a nurse practitioner, I will have less restrictions to treat patients and provide referrals to the proper lines of care to make sure these patients don’t fall through the cracks. These patients require adamant follow-up and management, which is something I will be able to provide for them.
Dr. Mustapha: You and your team have built a large CLI practice with a significant number of complex cases. What goes through your mind when you review a complex CLI case during your preparations for the cycle of care?
Bailey Estes, RN: I primarily scrub in on PAD and CLI cases. It is my favorite part of this job. Planning is the most important part of the CLI intervention. Collaborating with your interventionists and team not only makes the case go smoother, but can help improve patient outcomes. With proper planning, we have improved the efficiency and safety of the procedure, including reduction of radiation and contrast exposure.
When a peripheral case comes in, I will review the chart, first looking at labs for kidney function, weight, comorbidities, Rutherford class, wound assessment, diagnostic studies, and prior interventions. The physicians and I review the prior ankle brachial index, Doppler studies, computed tomography angiogram and prior invasive angiograms. This information gives me an idea of the state of our patients’ overall health and helps answer questions quickly, such as:
- What is the target limb/vessel?
- How extensive are the symptoms/tissue loss?
- What are our probable access sites?
- Do we need to conserve contrast for kidney function?
- Is the patient body habitus going to affect the access sites?
Diagnostic studies give important information as to where the disease is located and how extensive it is. Disease location can help to predict appropriate access sites and how to position the patient on the table, as well as what equipment is likely needed in the room. If there is suspected iliac or common femoral disease, it can affect groin access sites. I check to see how the diagnostics tests correlate with symptoms. I specifically like to look at ankle-brachial index and Doppler ultrasound correlation. Specifically, looking at wave forms (biphasic or monophasic) can help narrow down the location of the disease.
If the patient has had previous interventions, I like to see how the vessel was treated and what size balloons or stents were used as a reference. Once the patient is on the table, I always assess and mark the pedal pulses myself to help with access and assessment post procedure.
Disease location and access considerations are very important:
- Bilateral severe iliac disease: we consider brachial access and common femoral accesses.
- Unilateral iliac disease: we consider bilateral common femoral access.
- Proximal superficial femoral artery (SFA) and ostial SFA: consider contralateral common femoral artery (CFA) access and pedal access.
- Mid to distal SFA and infrapopliteal disease: we consider ipsilateral antegrade access and pedal access.
We have adopted dual access sites for chronic total occlusion (CTO) treatment almost invariably. We try to avoid doing ad hoc percutaneous transluminal angioplasty (PTA) alone when a CTO or multilevel stenosis is present. We also stage appropriately based on patient’s presentation and co-morbid factors. Staging the procedure allows us to prepare the patient and access sites. We also utilize the Chronic Total Occlusion Crossing Approach based on Cap Morphology (CTOP classification).3 Using ultrasound for access significantly increases safety of the access site and decreases access site complications.
Dr. Mustapha: Can you describe a complex CLI case?
Bailey Estes, RN: A 73-year-old female with Rutherford class IV symptoms and lifestyle-limiting claudication came to our cath lab for an endovascular intervention. She stated that her pain was worse in the right lower leg. Looking through her chart, I reviewed her Doppler ultrasound (DUS) and ankle brachial index (ABI) studies. Her ABI on the right was 0.52. She had monophasic waveforms in the common femoral artery, which indicate possible iliac stenosis. The DUS also showed a chronic total occlusion (CTO) of the superficial femoral artery (SFA) with distal reconstitution and monophasic waveforms in the tibial vessels. Based on this information, the patient likely had severe disease at multiple vascular levels that would affect possible access sites.
A diagnostic angiogram via the radial artery had been done a few days prior. There was a 250 mm ostial SFA CTO reconstituting in the distal SFA stent with in-stent restenosis and patent tibial vessels (Figure 1). Upon review with the interventionalists, it was decided the patient would receive an intervention of the right SFA with access and crossover from the left groin, so that we could address the iliac stenosis. Using the CTOP analysis, we decided a dual access approach from the right posterior tibial (PT) artery would be optimal as there was a flat proximal cap and favorable distal concave cap. Once the CTO was crossed, we planned to floss the wire, and perform directional atherectomy, angioplasty, and stenting, if necessary.
While setting up the case, I prepped bilateral groins and the complete right lower leg. I assessed and marked pedal and posterior tibial pulses using a Doppler. In all PAD cases, I use ultrasound to assess the tibial vessels, and find and mark adequate access points. I also make sure all the necessary equipment is in the room, including a range of anticipated balloon sizes, before starting the case.
When the interventionists scrubbed in, we immediately obtained access in the left groin and right PT. We obtain groin access first, and place a long sheath up and over the bifurcation. We do this first so that if we have difficulty obtaining ultrasound-guided access in the tibial/pedal vessels, we have the quick option to use fluoroscopy and contrast guidance. Given the favorable distal cap, a wire and support catheter were advanced from below and passed through the CTO in less than 30 seconds.
We then flossed the wire from the PT sheath through the contralateral groin sheath. Whenever it is feasible, we like to floss the wire. This makes exchanges fast and efficient, since you do not have to worry about the wire getting pulled back. Furthermore, having dual access allows us the option to treat from above or below. Due to the larger size of the balloons and atherectomy device, we opted to treat from above to decrease the risk of damaging the PT.
After atherectomy and balloon angioplasty, flow had been restored through the occluded segment. The proximal vessel still had suboptimal luminal gain and dissection, so we decided to place a Supera stent (Abbott Vascular). However, we did not want to land the stent past the ostium of the SFA, so we opted to deploy it in a retrograde fashion through the pedal sheath to ensure the proximal edge of the stent was landed directly in the ostium. Final angiography revealed excellent flow down to the foot (Figure 2).
Pulling back the groin sheath, we measured a >20 mm gradient in the external iliac artery. We treated it with atherectomy and placed a balloon-expandable stent before ending the case (Figure 3). The total case time was less than 2 hours to treat multiple vascular disease levels.
Our team prefers to pull pedal sheaths in the lab to obtain hemostasis. I will hold manual pressure until hemostasis is achieved and check distal Dopplers for patency.
Dr. Mustapha: Can you explain the results that you ended with and why it was sufficient for this patient?
Bailey Estes, RN: This patient was experiencing pain at rest and lifestyle-limiting claudication. We were able to successfully open up the CTO, which will provide better flow distally. Having reviewed prior diagnostic tests and angiograms, we were able to effectively plan out the case and treat multiple vascular levels of disease in a single case, so that the patient will not have to come back for another intervention.
Dr. Mustapha: Beyond the CLI revascularization, one point of interest is the post-op follow-up and its value for these sick patients. Do you currently have a CLI post-op protocol?
Bailey Estes, RN: Our facility does not have a set protocol for follow-up. This is something we are currently trying to implement. We have a good working relationship with podiatrists and wound care, all helping to build the foundation of a multidisciplinary team. We strongly believe that having a set protocol for follow-up and collaboration is vital for caring for CLI patients and are hopeful to have our program going within the next year.
CLI is a progressive disease that is not wiped out solely by surgical or endovascular intervention. These patients require medical management, wound care, physical therapy, and other important interventions to effectively achieve limb salvage. There is a grave misconception that these patients are cured after one intervention and it is wrongly considered a failure if they have to come back to the lab for staged interventions or restenosis. Patients with coronary artery disease are not met with these same prejudices if they undergo multiple interventions throughout their lifespan. Part of having a comprehensive follow-up can help to change this misconception and increase awareness and education among healthcare professionals and how they care for CLI patients.
Dr. Mustapha: What type of events and behind-the-scenes work did it take to arrive to your current decisions in your CLI protocol? Was your hospital administration involved in the program development and are they still involved now?
Bailey Estes, RN: The interventional cardiologist I work with and I are actively collaborating to build a CLI program with a set protocol for our hospital. At this point, we are in the preliminary stages and have not fully engaged with our administration regarding the details. We want the protocol to be built with engagement and expertise from all of the disciplines that will be working with these patients. A lot of logistics go into starting a program and it needs to be done thoughtfully and thoroughly for the program to be successful and have longevity.
We are fostering relationships to build a multidisciplinary team. We have been working on raising awareness through PAD dinners, which engage healthcare providers, nurses, wound care, pharmacy, and others who come in contact with PAD patients daily. Many people are unaware that PAD is a problem, so it is our job to make them aware. Otherwise, how can you fight for a cause that you do not know anything about? Building a program takes planning, patience, and a group of people working for and passionate about a common cause.
Dr. Mustapha: Medical therapy is one of the most important aspects of CLI treatment. What type of safe/stop program do you have to ensure that all CLI patients are discharged on the proper medications?
Bailey Estes, RN: We currently do not have a discharge/medication program for our PAD patients. Along with the implementation of a CLI program and protocol, this is something we would like to add. Currently the medical management is up to each physician — much like the patient follow-up, there is no set protocol.
Nationwide, PAD patients continue to be severely under-optimized on medical therapy. Medication programs have been very effective with ST-elevation myocardial infarction (STEMI) patients in order to make sure that they are discharged on and have access to necessary medications. It also has been effective in decreasing readmissions to the hospital. Similar programs would be very good for PAD patients, as they have multiple comorbidities (diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease, etc.), which need to be addressed and optimized on medications.
Realistically, CLI programs take time to build and mature, especially when done in the right way. It is essential to have administration and a multidisciplinary team on board to make the program successful. I am fortunate to work with some proactive interventional cardiologists who are treating many PAD patients in our area; however, we recognize that this is only one piece of the pie. Adding a dedicated CLI program and protocols will drastically change the care of PAD patients, which we believe will improve outcomes and decrease the amputation rate.
- Thorud JC, Plemmons B, Buckley CJ, Shibuya N, Jupiter DC. Mortality after nontraumatic major amputation among patients with diabetes and peripheral vascular disease: a systematic review. J Foot Ankle Surg. 2016 May-Jun; 55(3): 591-599. doi: 10.1053/j.jfas.2016.01.012.
- Margolis DJ, Hoffstad O, Nafash J, et al. Location, location, location: geographic clustering of lower-extremity amputation among Medicare beneficiaries with diabetes. Diabetes Care. 2011 Nov;34(11): 2363-2367. doi: 10.2337/dc11-0807.
- Saab F, Jaff MR, Diaz-Sandoval LJ, et al. Chronic total occlusion crossing approach based on plaque cap morphology: the CTOP classification. J Endovasc Ther. 2018 Jun; 25(3): 284-291. doi: 10.1177/1526602818759333.