Treatment of CLI Benefits From Team Approaches That Leave Specialty Behind

On Wednesday morning, Richard Neville, MD, will give the Alan T. Hirsch Memorial Keynote Address, “A Historical Perspective on CLI Definition and Treatment: #LeaveYourSpecialtyAtTheDoor.” In this Q&A, Dr Neville discusses his presentation, the history and future of CLI, and why talent and interest are more important than specialty.

Can you tell me about Dr Hirsch’s influence on the treatment of CLI?

It is an honor for me to give the Hirsch Memorial lecture. Dr Hirsch was a pioneer in the treatment of vascular disease and CLI. His efforts were critical to raising awareness about the disease, and he helped to establish CLI as a separate disease entity requiring its own diagnosis and treatment. I had the utmost respect for him.

Although I did not know him very well personally, I read and admired his work, and I referenced many of his studies in my talks and presentations. Dr Hirsch and I worked in different worlds, and that speaks to the history of CLI. Today, those worlds are more merged and integrated.

For example, when I started in Vascular Surgery, CLI was only one of the clinical entities that vascular surgeons handled. I’ll never forget an encounter early in my career with a vascular surgeon who said to me, “I’ll do all the carotids and aneurysms, and you can do everything else.” At the time, many surgeons wanted to focus on carotid disease and aneurysms, and did not want to concern themselves with lower extremity work and CLI.  However, we have come very far in a short period of time in addressing this important issue. I attribute that progress to people like Dr Hirsch who raised awareness, encouraged the specialties to work together, and realized that the treatment of CLI crosses specialties.

Can you tell me about the first definition of CLI and how it has evolved over the years?

CLI (chronic limb ischemia) or CLTI (chronic limb threatening ischemia) was described in the early 1980s. At that time, an international vascular symposium defined CLI as a condition in patients without diabetes having chronic ischemia leading to a major threat to the limb.  Other systems have attempted to classify CLI, such as the Rutherford system and the TASC II document, and a definition was subsequently adopted by the American Heart Association and American College of Cardiology. Since that time, the definition of CLI has evolved as various societies have added their input. At this point in time, we are trying to develop joint definitions that span societies.  In fact, new global vascular guidelines regarding CLI have recently been released after collaboration between the Society for Vascular Surgery, the European Society for Vascular Surgery, and the World Federation of Vascular Societies.  It is important to present a unified and consolidated definition to those directing health policy, as well as to physicians and patients.  The CLI Global Society is attempting to lead this international effort and is focused on defining CLI and advancing the treatment of CLI as a disease entity.

What was it like to treat CLI before it was properly defined?

It was challenging and frustrating to treat CLI alone, which is why I became involved in the multidisciplinary, team approach to CLI. I based much of my career on that concept because I realized that by treating CLI in a vacuum, we are unable to tap into the expertise that patients need to achieve the best outcomes. Patients with CLI often have complex medical needs and comorbid conditions such as wound issues, diabetes, and kidney disease, and they require a team of experts in order to have the best results.

Treatment has improved for patients in the years since the team approach was first proposed, but there is still much to be done. We are currently trying to bring the team approach to fruition in my current health care system. There is a great quote from Lou Holtz, a former Notre Dame football coach, that also applies to current progress in treating CLI. When someone asked him why his team had not won the national championship yet, he said, “Well, we’re not where we want to be, but thank goodness we’re not where we used to be.”

In the context of a multidisciplinary approach, we have all experienced patients who had good outcomes, and the patients and families were so thankful, whereas in the past, we more frequently had to perform amputations and present limited options to patients. That is what everything we do is about---good outcomes for patients---but it was harder to achieve such outcomes in the past as an individual practitioner. Now, we can improve patients’ health outcomes and prevent more amputations, and the treatment experience from the physician perspective is much more rewarding.

How does the team approach help in making decisions about whether to recommend an amputation?

Sometimes amputation is the right decision. I recently had a patient who had multiple procedures done at another facility. We might have been able to save the foot, but we had a long talk with the patient. The patient wanted an amputation and then wanted to be done with additional procedures. After consulting with him and with the multidisciplinary team, we performed an amputation, and the patient and his family were very happy. From the physician perspective, we did not make this decision in a vacuum. With a multidisciplinary approach, you are not making the decision alone.

What are some key advances in the past few decades in the treatment of CLI?

There have been a huge number of advances, but in general I would say endovascular therapy or catheter-based approaches to the treatment of CLI have certainly been significant. Additionally, there have been improvements in imaging. We do a much better job with ultrasound imaging, magnetic resonance imaging, and intravascular ultrasound. There have been advances in the bypass world, as well with surgical advances in terms of better conduits and improved techniques.

There have also been advances in terms of awareness. Health care policy experts and the health care industry have realized that CLI is a major problem for our health care system. The population is aging, and an increasing number of people will continue to develop CLI. In fact, about 20% of people over the age of 70 will develop PAD, and a number of PAD patients will go on to suffer from CLI. A large segment of our population will need effective care and those involved in health policy and industry are becoming aware of this need.

What are you hoping that everyone listening takes away from your talk?

I hope they take away how far we have come, and I hope they realize that we have come so far because of pioneers like Dr Hirsch. I also hope that they understand that in this day and age, it is best to approach the management of CLI in a multidisciplinary fashion. Treatment of CLI is no longer in the purview of vascular surgeons or radiologists or cardiologists working alone. The most important factor is having the desire, support, and talent to treat the complexities of patients with CLI. Today, there is more collaboration occurring than I have ever seen before.

This collaboration was happening before the CLI Global Society formed, but I think the power of the CLI Global Society is to build upon that collaboration, as well as to raise awareness with government agencies and examine government policy issues raised by CLI.

What are some future advances you anticipate in the definition of CLI?

We need better data and outcome analysis. In my own health care system, I am being challenged with systematizing quality and value regarding outcomes for vascular disease. The next great challenge is to take these complex patients and standardize data collection to guide outcomes. Once we have the data, we can use it to provide care that has value to our patients and the health care system.