CLI Beyond AMP: Call to Educate, Advocate, and Collaborate

by Mia DeFino

On the third day of the 9th annual AMP symposium, the morning general session focused on how attendees can continue to use the knowledge and enthusiasm gained in Chicago to educate the public and other physicians, advocate for policy change, and collaborate in providing optimal treatment for patients.

Paul Michael, MD, expressed how different the AMP meeting is compared with others he has attended and that in his third year at AMP he appreciates the sense of comradery and being part of a team. His presentation focused on the history of CLI and how the field developed, with creation of the first society to recognize podiatry as a medical specialty in New York in 1895 and discussion of the factors that contribute to the development of PAD.

Laiq Raja, MD, and Vlad Alexandrescu, MD, PhD, both discussed the need to correctly identify the type of ulcer being treated and the appropriate diagnostic tools to use for differentiating different ulcers and wounds.

The importance of appropriate wound care and how to manage CLI patients post-revascularization was emphasized by Vickie Driver, DPM, MS, and Dot Weir, RN, CWON, CWS. Dr. Driver encouraged the audience in their management of CLI patients. “No case is without hope. There are many pieces that are required for the care of these patients—don’t jump to skin replacement after revascularization. Only after fully identifying the wound and the situation can one decide what is the best thing to do for the patient.” Dot Weir followed by urging the audience to consider “striking while the iron is hot. When there is good blood flow restored to the foot, it is essential to give optimal wound care to lead to best patient outcomes.”

Amjad AlMahameed, MD, brought up the issue of double jeopardy for patients with chronic kidney disease (CKD) and PAD. CKD is a strong and independent risk factor for PAD, CLI, and poor outcomes. Patients with CKD tend to have more amputations even after undergoing successful revascularization, as well as more bleeding complications, wound re-infections, and much worse outcomes. Dr. AlMahameed warned that “CKD is becoming a PAD equivalent. Early and proper screening and management strategies are recommended.”

Guy Pupp, DPM, FACFAS, discussed a new treatment option for patients with CLI who have been told they have no other options, also known as end-stage CLI. While the treatment percutaneous deep vein arterialization (PVDA) offers percutaneous bypass of an unreconstructable artery using the LIMFLOW device, which is not yet approved by the FDA and is only in use by seven investigators in the United States, the preliminary data showed 70% complete wound healing at 12 months and a reintervention rate of 30% at 6 months. Dr. Pupp shared, “Although there is a learning curve with this procedure, especially for post-operative care, there is still another chance for limb preservation.”

Lee Ruotsi, MD, ABWMS, CWS-P, UHM, focused on how to improve education for primary care and community providers, as well as select specialty practices, in order to accelerate recognition of PAD, CLI, and wounds so that timely and appropriate referrals can be made to provide standard of care for patients.

Desmond Bell, DPM, told the audience that the title of his presentation changed from a question of “how do we improve things?” to “how we will defeat CLI, and that solely improving things is not adequate.” He called for increased education, advocacy, and strategy in advancing care for CLI patients. Even though there was a decrease in lower extremity amputation rates in the United States in the last two decades, there may now be a reversal in progress, particularly in young and middle-aged adults. There are many different ways to get involved to help the #CLIFighters and to advocate for CLI. Next month, is the White Sock Campaign for The Save a Leg, Save a Life Foundation, where everyone is encouraged to wear a white sock and take a photo to share on social media. This creates teaching moments and greater awareness, thereby creating solidarity with amputees.  

Dr. Driver ended the session by promoting the CLI Global Society Checklist for attendees to share with other health care providers to quickly recognize the signs of CLI and arrange appropriate care. She encouraged all to help raise awareness and join the fight against CLI by joining the CLI Global Society at www.cliglobalsociety.org.