Identifying the ‘No Option for Treatment’ Patient in Critical Limb Ischemia

Over the last decade, advanced techniques for extreme limb salvage have become available, but are not necessarily preferable for every patient. The focus of the Wednesday afternoon session, “More About CLI: The ‘No Option for Treatment’ Limb and Extreme Limb Salvage Techniques and Results,” is identifying patients for whom limb salvage is a feasible option and those for whom it is not.

“This is an important session, addressing those patients in whom it may be futile to continue pressing for the high-end, complex reconstructions we can perform,” said co-moderator Dr. Richard F. Neville, of the Heart and Vascular Institute in Fairfax, Va.

“There are patients in whom we should just say, ‘Let’s not do four angioplasties, a bypass, and multiple plastic surgeries. The best thing is to give them amputation and rehab them,” said Dr. Neville. The global crisis of type 2 diabetes, the costs and morbidities associated with leg amputation, and mortality rates post amputation have gained the attention of policy makers who have begun pressuring health systems to find less costly alternatives.

“The government has realized what many physicians have known for a while: In the long run, it costs the health care system a lot more to amputate than to save a leg,” said Dr. Neville.

The co-moderator of the session, Dr. Sean P. Lyden of the Cleveland Clinic College of Medicine at Case Western University, argued that new therapies are in high demand. “We still have a lot of patients where our current options of open surgery or endovascular therapy fail [but] too many patients get amputations yearly in the United States. Finding new options for these patients is critical.”

The typical VEITHsymposium attendee is well aware that limbs can be salvaged, but there is a lack of awareness of the range of possibilities for critical limb ischemia across most other specialties. “We vascular surgeons know it’s possible, but we have to get the word out to the primary care doctors, the endocrinologists, and others to let them know that this can be done,” said Dr. Neville.

The criteria for which patients make the best candidates for extreme limb salvage are still evolving. “It’s harder than you think,” said Dr. Neville. “There are many different opinions about what should even go into the decision-making process. Even thought leaders from vascular surgery, podiatry, and plastic surgery are struggling to decide on what factors are most implicated. It’s not that the specialties are in disagreement, but we can’t quite come to a consensus yet.”

Data surrounding critical limb ischemia outcomes will be discussed at the session, and the panel will debate what are the best criteria for determining extreme limb salvation algorithms.

“If we could come up with guidelines or a scoring system, that would allow us to have a helpful tool when discussing treatment options with the patient’s family who typically want us to do everything, even when we know it’s not the best thing to do,” said Dr. Neville.

Session 27:
More About CLI: The ‘No Option for Treatment’ Limb and Extreme Limb Salvage Techniques nd Results
Wednesday, 1:00 p.m. – 2:06 p.m.
Grand Ballroom East, 3rd Floor

Over the last decade, advanced techniques for extreme limb salvage have become available, but are not necessarily preferable for every patient. The focus of the Wednesday afternoon session, “More About CLI: The ‘No Option for Treatment’ Limb and Extreme Limb Salvage Techniques and Results,” is identifying patients for whom limb salvage is a feasible option and those for whom it is not.

“This is an important session, addressing those patients in whom it may be futile to continue pressing for the high-end, complex reconstructions we can perform,” said co-moderator Dr. Richard F. Neville, of the Heart and Vascular Institute in Fairfax, Va.

“There are patients in whom we should just say, ‘Let’s not do four angioplasties, a bypass, and multiple plastic surgeries. The best thing is to give them amputation and rehab them,” said Dr. Neville. The global crisis of type 2 diabetes, the costs and morbidities associated with leg amputation, and mortality rates post amputation have gained the attention of policy makers who have begun pressuring health systems to find less costly alternatives.

“The government has realized what many physicians have known for a while: In the long run, it costs the health care system a lot more to amputate than to save a leg,” said Dr. Neville.

The co-moderator of the session, Dr. Sean P. Lyden of the Cleveland Clinic College of Medicine at Case Western University, argued that new therapies are in high demand. “We still have a lot of patients where our current options of open surgery or endovascular therapy fail [but] too many patients get amputations yearly in the United States. Finding new options for these patients is critical.”

The typical VEITHsymposium attendee is well aware that limbs can be salvaged, but there is a lack of awareness of the range of possibilities for critical limb ischemia across most other specialties. “We vascular surgeons know it’s possible, but we have to get the word out to the primary care doctors, the endocrinologists, and others to let them know that this can be done,” said Dr. Neville.

The criteria for which patients make the best candidates for extreme limb salvage are still evolving. “It’s harder than you think,” said Dr. Neville. “There are many different opinions about what should even go into the decision-making process. Even thought leaders from vascular surgery, podiatry, and plastic surgery are struggling to decide on what factors are most implicated. It’s not that the specialties are in disagreement, but we can’t quite come to a consensus yet.”

Data surrounding critical limb ischemia outcomes will be discussed at the session, and the panel will debate what are the best criteria for determining extreme limb salvation algorithms.

“If we could come up with guidelines or a scoring system, that would allow us to have a helpful tool when discussing treatment options with the patient’s family who typically want us to do everything, even when we know it’s not the best thing to do,” said Dr. Neville.

Session 27:
More About CLI: The ‘No Option for Treatment’ Limb and Extreme Limb Salvage Techniques nd Results
Wednesday, 1:00 p.m. – 2:06 p.m.
Grand Ballroom East, 3rd Floor

Over the last decade, advanced techniques for extreme limb salvage have become available, but are not necessarily preferable for every patient. The focus of the Wednesday afternoon session, “More About CLI: The ‘No Option for Treatment’ Limb and Extreme Limb Salvage Techniques and Results,” is identifying patients for whom limb salvage is a feasible option and those for whom it is not.

“This is an important session, addressing those patients in whom it may be futile to continue pressing for the high-end, complex reconstructions we can perform,” said co-moderator Dr. Richard F. Neville, of the Heart and Vascular Institute in Fairfax, Va.

“There are patients in whom we should just say, ‘Let’s not do four angioplasties, a bypass, and multiple plastic surgeries. The best thing is to give them amputation and rehab them,” said Dr. Neville. The global crisis of type 2 diabetes, the costs and morbidities associated with leg amputation, and mortality rates post amputation have gained the attention of policy makers who have begun pressuring health systems to find less costly alternatives.

“The government has realized what many physicians have known for a while: In the long run, it costs the health care system a lot more to amputate than to save a leg,” said Dr. Neville.

The co-moderator of the session, Dr. Sean P. Lyden of the Cleveland Clinic College of Medicine at Case Western University, argued that new therapies are in high demand. “We still have a lot of patients where our current options of open surgery or endovascular therapy fail [but] too many patients get amputations yearly in the United States. Finding new options for these patients is critical.”

The typical VEITHsymposium attendee is well aware that limbs can be salvaged, but there is a lack of awareness of the range of possibilities for critical limb ischemia across most other specialties. “We vascular surgeons know it’s possible, but we have to get the word out to the primary care doctors, the endocrinologists, and others to let them know that this can be done,” said Dr. Neville.

The criteria for which patients make the best candidates for extreme limb salvage are still evolving. “It’s harder than you think,” said Dr. Neville. “There are many different opinions about what should even go into the decision-making process. Even thought leaders from vascular surgery, podiatry, and plastic surgery are struggling to decide on what factors are most implicated. It’s not that the specialties are in disagreement, but we can’t quite come to a consensus yet.”

Data surrounding critical limb ischemia outcomes will be discussed at the session, and the panel will debate what are the best criteria for determining extreme limb salvation algorithms.

“If we could come up with guidelines or a scoring system, that would allow us to have a helpful tool when discussing treatment options with the patient’s family who typically want us to do everything, even when we know it’s not the best thing to do,” said Dr. Neville.

Session 27:
More About CLI: The ‘No Option for Treatment’ Limb and Extreme Limb Salvage Techniques nd Results
Wednesday, 1:00 p.m. – 2:06 p.m.
Grand Ballroom East, 3rd Floor