Vascular Disease Management spoke with Richard Neville, MD, Associate Director, INOVA Heart and Vascular Institute at INOVA Health System in Falls Church, Virginia. Dr. Neville discussed the importance of a multidisciplinary approach to treating CLI and PAD, and he explained how to put systems into place that facilitate better communication between specialties. He will be presenting on these topics at the 2020 International Symposium on Endovascular Therapy (ISET) in Hollywood, Florida.
Tell us about CLI and complex PAD and what you will be covering in your presentation at ISET.
We will be covering the importance of a multidisciplinary approach to complex CLI, and we will also focus on the development of endovascular procedures such as deep venous arterialization and pedal loop angioplasty. We will also address the controversy surrounding drug-elution technology. Another point of discussion is the continuing role of surgical options for complex CLI and how we are developing innovations and improvements in some of our surgical techniques for complex CLI patients.
What role does communication play in treatment of complex CLI?
Patients with CLI are often treated primarily with endovascular therapy, while patients currently undergoing surgical bypass tend to have more complex disease and failed attempts at revascularization. For example, a snapshot of our surgical procedures indicated that 38% of the bypass patients have already failed endovascular therapy. We know from the literature that patients who have failed endovascular therapy have less chance of a successful bypass and limb preservation. To improve success, it is important to improve communication between surgeons and interventionalists so that we collaboratively discuss cases before endovascular procedures are performed. The surgeon and interventionist should both have input and will benefit from jointly discussing options. As a result, we will be better able to identify patients who can benefit from a bypass first, and we will improve patient care.
How can clinicians help to put systems in place that facilitate better communication?
That's the million-dollar question, and there is no single right answer. When I am asked that question by colleagues, my response usually is “all politics is local.” Everything depends on the specific environment and institution. The ability to enact change is dependent on physician champions in the system that want to take on the challenge. Ideally, one of those physician champions should be a surgeon and dedicated interventionalist. A soft tissue specialist such as a podiatrist or plastic surgeon is also a vital champion. These physician champions will be able to push forward new strategies and work with the local healthcare administration to implement an effective program. Administrators often do not have CLI on their radar and may not realize the large volume of patients that we treat and need to treat, as well as the impact on the population’s health as well as and the downstream contribution to the hospital.
If a clinician is not in a position to change systems, what can be done on a day-to-day basis to improve communication?
A good way to start is to create a multidisciplinary conference or a dedicated floor for CLI patients. We educated the nurses on the floor where CLI patients are sent so that everyone had the necessary knowledge and experience to treat these patients. We also instituted what is called a “sprint process,” which is essentially a clinical pathway with some financial input laid on top. Those are some simple steps , but the important steps are enlisting physician champions and gaining the buy-in of the administration.
In an ideal system, how would a patient with CLI be treated?
The ideal treatment paradigm for these patients revolves around streamlining care and expediting care. Time is tissue. With most CLI patients, you cannot waste time. When we actually tracked patients through the system without an organized program, patients need 7-9 visits before receiving definitive therapy. These visits include seeing various physicians, having a vascular lab study, having a computed tomography scan, an arteriogram, a wound evaluation, etc. Patients with CLI are not mobile and upwards of 8 visits places a burden on them and their support structure. We need to streamline the process so that patients can promptly receive their therapy in a system with the patient at the center of the process. Another important point is the availability of a soft tissue specialist. As a vascular physician, it is frustrating to do a beautiful revascularization procedure but not have a plastic surgeon or podiatrist who can heal the foot.
In 2020, when is the best time to offer a patient a distal bypass?
We are awaiting the results of the BEST-CLI trial, but at this point in time, I think about offering a bypass first to patients based on the patient, arterial anatomy, conduit, and extent of the wound. If patients have a reasonable life expectancy, then I might offer them a bypass first for durability, because we know that there are a certain number or re-interventions often necessary with endovascular therapy, and these re-interventions increase cost and can marginalize outcomes for the patient. Additionally, bypass may be more effective in patients with a large volume tissue loss. Also, in those patients with TASC D occlusive disease, I might offer them a bypass, although we are becoming more aggressive with endovascular therapy, including the use of pedal interventions for TASC D disease. Another group of patients offered bypass are those who have failed endovascular therapies. Before attempting additional endovascular procedures , we may want to consider offering a bypass to a patient who has failed an endovascular therapy. I see patients all too often who have had multiple atherectomies and stent placements, and my options for treating them at that point are very limited.
What role do you see for endovascular therapy in the treatment of CLI and PAD?
The endovascular revolution started years ago, and continues to advance with a focus on data and quality as is demonstrated by the ISET meeting. There have been some bumps in the road, such as the recent paclitaxel and drug-elution controversy, and there are concerns around the inordinate growth of outpatient atherectomy. However, endovascular therapy is certainly the main treatment that we offer patients. But we must not forget that there are other options and that we may want to try a surgical option rather than endovascular re-intervention in certain scenarios. Overall though, the endovascular revolution has proved a major success as an innovative advance in healthcare.
In the surgical space, are there any advances in imaging or techniques that are exciting?
Surgical advances involve bypass with alternative conduit with the lack of saphenous vein and deep venous arterialization for patients with poor distal target arteries. The distal vein patch has been a good option for those patients without autogenous conduit,t and the deep venous arterialization concept involves revascularizing the venous system. We have initial experience with this concept, and I think it is very exciting and promising.
Are there any new technologies that you are excited to see?
There is interesting technology in terms of assessing tissue perfusion, which is critically important. In the past, we have used the ankle-brachial index, which is not the greatest metric. People also use toe-brachial index and toe pressures, and people have tried skin perfusion pressures, etc, with shortcomings involved with these modalities. I'm hopeful that in the future there will be technologies, such as hyperspectral imaging, that can assess the need for revascularization as well as determine results regarding tissue perfusion after intervention. We are going to start a trial with hyperspectral imaging in the near future. I think we need some way to better assess tissue perfusion. With better assessment, we will be able to determine whether we need to do more endovascular therapy, or perform a bypass, or utilize wound care. I think we desperately need some way to better guide our choices in terms of tissue perfusion.
What more can be done to raise awareness of CLI and PAD?
We need to promote greater awareness of both CLI and PAD. Awareness of the scope of the problem, and advocacy for our patients, is one of the prime missions of the CLI Global Society. The problem of CLI is often underappreciated by healthcare policy professionals and physicians. The impact and scope of CLI is exploding around the world, so we hope that the CLI Global Society will have an international impact on the health of this patient population. Another important problem to address is disparity of care, including racial disparity, socioeconomic disparity, and access disparity. The CLI Global Society is an important organization that can hopefully have an impact and help practitioners engage appropriately in a CLI practice. .While this Society is not the SVS, SVIR, nor the AHA, advocacy and improving care are main focuses of the CLI Global Society.