The concluding segment of a five-part virtual series to help practitioners reduce rates of PAD-related amputation and improve quality of life through professional development and education. During this web-based course Lori Henderson discusses multidisciplinary approach to Limb Salvage and the care network for CLI patients that make up an amputation prevention team. Dr. Jason Mendivil reviews pathophysiology of diabetic foot ulcer development, wound management, levels of amputation and assessment of tissue loss and infection. Lastly Dr. Joseph Griffin discusses the evolution of CLI treatment, advancements in minimally invasive endovascular techniques, and growth of multidisciplinary centers. A final case review demonstrates how IVUS helps to identify diffusely diseased SFA lesion and the decision making behind the utilization of Phoenix atherectomy and drug-coated balloon (DCB).
or esteemed faculty here today to talk to us about some of the very important in my opinion, nuances of tackling and taking care of a patient. I tell my patients that the work starts after we've done the procedure, that's where the work starts so that I'm going to kick it off to Laurie Henderson. She's a nurse and clinical coordinator with Dr lake Roger in el paso texas. Without further ado Laurie, I'm gonna turn over to you, I'm really excited to be here and my name is Laurie Henderson's doctors have said and I uh and the administrative director and clinical coordinator um they call me the quarterback affectionately in our team with Dr Mandeville, dr raja and all the wonderful doctors that we work with here in El paso. Um and uh yeah I'm excited to be here. Thank you for for this honor of being able to share our knowledge and our experience with you. We've developed a great program out here and um you know I want to start with just a quote of one of our our leaders in in the cli fight dr craig walker. He always starts with this, you know for some reason it's considered conservative treatment to chop someone's leg off and aggressive to do an angiogram. And this is so very true and this is why we do what we do because we have to raise awareness around the treatment of cli. Um And of course dr Saban dr mustafa have been great mentors of ours and great leaders in this fight as well. So I'm very honored to be on this panel with with all of you today. Um So our objectives today of course we're going to be to review the clinical background of self treatment. Look at the A. C. C guidelines uh huh. For Cli. Which are have been a wonderful uh you know, support for what we're doing here. Um and then look at the identification referral process and the whole multidisciplinary process of of a cli team in a multidisciplinary program. Um So you know, when we look at the P. A. D uh overview, it's really devastating. Uh There's over 20 million people um that are affected by ph D. And that's rising every year with 1 to 2 million people suffering from the most severe form of ph d critical limb ischemia um with a 25 percent mortality in % 1 year and 60% over five years. So you know that this is a devastating prognosis when you look at at this disease. Uh And 150,000 amputations are still performed every year. So we have a lot of work to do. Um most of those amputations are done without performing even an angiogram. When we look at the the revascularization component, um the U. S. Is behind our other counterparts in the world with only 50 to 75% doing angiograms before amputation and sadly not even a revascularization in 62 7% 60 to 70% of cases. So we see this in our hospitals here locally, we've fortunately been able to change that paradigm here, you know, and when you look at the mortality rate in terms of comparison to cancer rates, for example, you see uh just a lack of awareness. I think we have a lot of work to do in educating our communities, our partners in in uh in the medical community that we work with and just to to raise awareness around what we can do around what is possible and that amputation does not have to be the end result for these patients. And if you see here major amputation and CTL I mortality is second only to lung cancer. And there's so much more awareness in other disease states. So we have to really start um, you know, doing a better job with this, this awareness and getting getting the word out to our partners in the medical community as well as direct to the consumer. So just for our part, you know, to look at the the uh based kind of the basics of P. A. D. And C. L. I. Um you know, we're looking at patients who may show up with Claude, occassion pain or discomfort. And a lot of a lot of times this is uh it's it's MS diagnosed as uh you know, something else. They may have arthritis or osteoarthritis. So a lot of times the early phases of the disease are missed. And it's not until we have them come in with wounds that we see more severe, that they we see them identifying that is it is an arterial uh disease or issue. Um So, you know, some of the signs and symptoms that will see is discoloration to the affected extremity um initially, but, you know, absent pulses sometimes, but as you get into the signs and symptoms of cli you're gonna see more severe wounds and uh color changes, lower temperature and one of the legs. You want to look at male growth and hair growth. Um And of course, you'll have regroups and pulses and these are the patients that that show up to our. Er but I guess the message here is that it doesn't matter how severe it is. Even the most severe limb salvage cases are salvageable. And I'll show you the end result of some of these pictures, because I know you're looking at the far right in thinking there's no way that that can be saved. But in fact with good vascular revitalization, with good surgical podiatry and a great team work, um we absolutely can uh save these patients. So when looking at at the avoiding avoidance of amputations that he's our earlier diagnosis, appropriate medical therapy, early referral for revascularization. I think that becomes a key is straight in line blood flow to the foot in infection control wound care. And then of course, many things come after his doctor sub said a lot of the work happens after the revascularization. But um I often tell our nurses and our team members that there's a triad of specialties that we have to have in our team for a good limb salvage team. And that is podiatry, vascular and infectious disease. At a minimum. Those three components must be consulted on every admission and on and must stay on the case for the duration of the care because you're going to have multiple issues throughout. And you will have to have that support from from this entire team. And I wanna thank DR Saab for for this data because this has led our fight against cli just showing that over so many years that they increased PVT encounters and endovascular procedures. They prove that we can reduce major amputations. Um And this is data from metro heart and vascular where dr uh Jihad Mustafa and Dr Fadi sobbed have have led the fight in treating Cli. So we thank you for this data because this has been great information to give us the ammunition to to bring these programs to our communities and really start working in the same manner and you see a minor and an increase in the minor amputations. I'll just. No but that's okay because if you have a toe amputation or a T. M. A. As dr Mandeville will will share with us later you still have a functional foot, they're still able to emulate and that's the key. And as you can see just on an overview, endovascular or bypasses so much better than any amputation, 60-80% of patients can never walk after a major amputation. Um And as I said before the A. C. C. Guidelines HsBC guidelines have been wonderful in giving us the support we needed. We were working without a whole lot of data before and now we have these guidelines that are telling us very specifically that a patient with cli must have revascularization quickly to minimize tissue loss um that we should have an interdisciplinary team. So they're talking to us about a Cli team from the very beginning and uh that you must have direct in line blood flow to the foot to those wounds. And so this is an important factor in looking at at the whole process of treating Cli. So what is a CLI program and what is a limb salvage team? It's a multidisciplinary approach to amputation prevention, where the patient is at the center of the care team with the specialist working around the patient and in unison to give the patient the best outcome and the focus is to optimize profusion to the targeted wound. Um The cli specialist or interventional cardiologist, vascular surgeon are are the are the key to revascularization and amputation prevention coordinator is definitely a must to lead the coordination and keep everyone in communication and focused on on the optimal uh you know, limb salvage. And so as I said, who are the members of our team is essentially everybody touching the patient, the nurse practitioner, cardiologist, infectious disease podiatry, wound healing experts. We definitely want to include our nephrologist because we're looking at preventing renal issues as a result of procedures but we we have to have them involved in the care so that we can get ahead of these issues. Um And then of course rehab and physical therapy towards the end of treatment. But we we need to bring all these people into what we call our circle of care, an amputation prevention. And so if you see kind of the flow of how this works, the patient would come into the er or into the system and the navigator is automatically uh one of the first people that is uh called on this referral so that we can get all the coordination started. Um We get vascular procedures started, get the podiatrist wound care, everybody on board. Um But it does start with getting someone um kind of in the center of your of your program as a navigator, as a coordinator so that you keep all the pieces together. There's a lot going on for these patients. And if you don't have someone to help guide them as well as communicate between the physicians, it's very easy for these patients to get lost in the system. And they often do and end up with an amputation despite all of our efforts. So the last thing we want is for a patient to come in and get a beautiful revascularization and then get lost in the system and end up at another hospital with a major amputation. And of course if at any point during uh you know their treatment even before, during after. If there's a setback, you know, we go back to the navigator into vascular. So I'll go through a little bit more about how that flows in just a bit. But the clinical goal goals are gonna be no amputation without a diagnostic angiogram. And we're very excited to share that through our program. And over the last five years we've been able to develop policies and protocols in our hospital that have have been very successful. We have a committee, we have a group of physicians that meet every month discuss the policies and protocols. And if a patient is referred for amputation there's a hard stop in the O. R. A patient cannot be scheduled for major amputation without a committee meeting. Will have a urgent committee meeting dr Mendivil has been on many of these calls with us um where we discuss the case. Uh We look at all the images from the revascularization, um or or angiograms. We look we talk with the podiatrist infectious disease. Everybody weighs in on whether more can be done before major amputation is is ordered and there's no consult to orthopedics without a cli team on on the case. And so this is the goal of of a good cli program is to get to the point where we cannot have these patients have a major amputation without having everybody weigh in on whether everything has been exhausted before we go that route of course revascularization to restore direct in line blood flow, continuous surveillance of the wound and any sign of decreased perfusion to the wound um warrants reevaluation by your cli specialist um And of course very close coordination amongst all the physicians. Um So just to share with you a little bit about our best practice example and how the flow of our referral process within the inpatient setting goes uh You know the patient will be identified either on the floor and the er the cli team is activated. Um The team gets uh start gets all the physicians that need to be consulted. Um We talked about the team earlier and uh you know we order our basic noninvasive studies and then we start to prepare for angiogram. That's the gold standard. Even if a noninvasive study is not uh you know significantly abnormal. If you have gangrene, if you have a severe non healing wound that's infected, it's still warrants an angiogram to be able to identify and make sure that we have looked at every aspect because there are limitations to the non invasive studies um You know depending on who was reading them and who the technician is. So we have to know that under graham is the gold standard. and our guidelines support this. Um From there we will go on to to plan any surgical intervention by the podiatrist. Um You know some caveats to that or or um issues where the order might be reversed is of course in a gas gangrene situation. But we have to be very well versed at at assessing these wounds, making sure that we know um you know, the order of of treatment generally vascular goes first, podiatry goes after. And from the data that that we have based our treatment algorithm on uh we generally like to wait for major amputations. I mean any major tm A shall I say a minor amputation, but that's going to be for example a. T. M. A. Or a toe amputation. Anything other than a debridement. Um We like to wait a good uh 2- four weeks to allow demarcations to allow for profusion. Um And of course we use the aneurysm concept to make sure that we're doing direct in line treatment for this patient. Um And we follow guidelines based on uh human dynamics of cli not just the general human dynamics uh that are found in our hospital administration in our in our regular guidelines because when there is a wound present you're gonna need much more oxygen to that tissue. So you do have to be much more aggressive and you need a TCP 02 of greater than 30 to 40 to really heal a wound. So that's our goal is pre imposed assessment of the TCP 02 S as well. Um So when we're looking at the flow of the patient from a navigator's perspective, I find that the patient education is crucial. We have to get the patient on board, we have to make sure that they are understanding um the commitment, we need them to be accountable for coming to appointments, coming to wound care visits, um an adoption of the care plan along with us. Um And it's very essential that the family and the patient are aware of the fact that there will be multiple surgeries, possibly multiple, multiple revascularization is necessary throughout their care, but this is necessary to save their limb and most of them will agree that this is definitely worth it. Um And we were there with them, we provide an emergency hotline for them, We answer their calls, I give patients a cell phone number where they can reach me directly Um and and our call center if they do need something and we commit to see them urgently. Try to avoid er visits by means of of triaging their calls after they discharge and and trying to see them in the office the same day. The next day we have a 24 hour policy to bring patients in for urgent visits if necessary. And of course the patients and family are taught from the very beginning that they must come to a specific facility if they have to come to the er they come to our facility you know designated as the peripheral vascular Center of Excellence. Um that there to try to come in and see us urgently before going to er if it's possible and that there never to consent to an amputation without talking to our team because of course they will show up to another hospital and the wounds are significant. Um And a lot of times they either first uh consult at another hospital is to orthopedics after we've done all this work. So we have to do a lot of education with the patients and that happens in the inpatient setting. So as they go through the process, we're talking to them every step of the way. We're educating every step of the way. Um And we're guiding the discharge plan. So we're working with case management, we're working with the discharge team to get home health on to get antibiotics set up to start maybe some physical therapy as well. It's very important that you select your home healthcare companies very carefully and make sure that they have good wound care nurses and that they know your protocol for triaging patients as well. And of course the wound healing surveillance starts as the patient discharges. You know, we want to see a 40% healing within four weeks, you know 50% within six weeks. Um If we're not seeing this good progress, then we do have to go back and evaluate the vascular perfusion. And our podiatrist dr mineral is very good at calling us and saying hey this wound is stalled and I think we need to take another look. And our threshold for taking them back to the cath lab for another angiogram is very low because we cannot just assume that everything's fine based on one intervention. And we've seen time and time again that they re occlude they thrombosis. So we have to be watching these wounds very carefully and be aware of not only profusion but the other thing is infection and making sure that our infectious disease partner is on board and treating with I. V. Antibiotics if necessary but following them closely alongside us. So the communication amongst all our team is constant from the in patient to the outpatient. Um I know our team is very good at calling each other and we we kind of watch out for each other. We take off our specialty. Hat and we look at the patient from a holistic, multidisciplinary view. So I'm watching for infection. I'm watching for wound healing. Doctor mandibles watching for profusion. Um Are infectious disease doctors are watching for profusion and healing. Um And we're also watching for infection. So we're calling each other as we need to make adjustments in the treatment plan. Um And we're moving the patient through that circle of care very quickly so that no time is lost on the vascular side. We see our patients very frequently one or two times in the first month and every three months. But anytime in between there we will see him on the same day if necessary. And we make that very clear to them. And of course the medical management is so important. We want to encourage smoking cessation um type blood pressure control, type glycemic control and of course your your anti platelet therapy and making sure they stay on those antique regulation regimens. And so and then of course at the end we do want to have home health involved rehabilitation in terms of set therapy and um some type of physical therapy to get them moving once they're able to um And your documentary we'll talk about the offloading. But we do try to keep our TM a patient's non weight bearing initially. But there's a lot more they can do from a therapy perspective so that they don't have atrophy. And the long term follow up is continuous. We're going to continue with weekly wound care visits. Um We're going to continue to follow our patients in the vascular setting. We do have a Amputation prevention center now so we can do many of the visit simultaneously. Doctor Mandible will do his wound care and then I'll do the vascular assessment simultaneously. And then if we need to we many times we'll do a telemedicine visit with infectious disease while they're in our center so that we can assist with any changes in antibiotics as well. So we're trying to maximize the time when they are seeing us in the Amputation Prevention Center and we continue to follow them in the L tax and the sniffs. This is a huge point because many of our patients get lost when they go to a secondary post acute care center. We have to follow those patients in some form or fashion whether you make a relationship with the attending and have them make sure they bring him to the clinic many many times. These these facilities will not bring him to clinic when they're impatient with them. So you have to just make sure that you're selecting a facility that is going to comply with your follow up protocol because that's essential. We can't afford to lose these patients for a month while they get through all tax. And again always be available. Have have a some type of call phone or call center um or your office should be well trained to receive these calls and triage the patients quickly. No one should ever be subject to amputation without a cli team on board. And so I mentioned the patient on the right there and I wanted to show you this is an incredible success story. Thanks to Dr Mandeville and dr Rogers great work. Um This patient went through a significant amount of room care. A lot of work. I have to say this patient was non funded initially. We even were able to get him um all kinds of free treatment and resources initially and then we got him A disability and Medicaid along the way, but it was just incredible teamwork between all of the team members to get them to the point where he is walking again and he's functional again. So we're really excited, he was a young man, I think 40 in his forties, so we were really excited to be able to to give him a great outcome and help him along the way. Um limb loss we know is devastating. We are committed to preventing amputations. We hope that you all will join us, we'll reach out well well uh you know, pick up the fight in your own communities and and help us as we start to, you know, bring new treatments. Um There's so many resources to learn from, especially now with all these zoom seminars and so I'm very thankful to phillips for present for offering this. Um But I just I thank you for your time and This is our cli hotline to for three ft and uh you know we can't give up blood flow, is everything. Thank you so much for your attention. All right, Laurie, thank you so much. That was really uh beautiful uh review of the horns and and the value of remaining passionate and committed about uh about doing this. I want to remind our attendees that you can actually post your questions on the Q. And a uh icon at the bottom of your screen or under check, but preferably the Q. And A. One of the questions that I'm going to quickly touch on was actually for me and Doctor Griffin uh who are who are who is our Laurie I guess. So that's that's the question. Who is the person that advocate and navigates for the patient? So um uh you know it really it really depends and I think the point that we're trying to make here is you can as long as uh cli center has to have a champion and as long as the champion can define particular rules for people that have buy in in and uh and want to participate in the patient care. So that champion and that coordinator can be the nurse can be a nurse. Navigator can be a mid level provider, can be uh can be a wound care specialist, can be the podiatrist. I mean it's all of the above. It really depends on the set up and the kind of environment that you have. And I'm going to ask that to Griffin to comment on that towards the end. But let's let's stay on task then and stay on time. Uh I'm going to turn it over to document a bill uh podiatrist. Uh It seems like you guys have an amazing program and we look forward to hearing a little bit more about how good you guys, how are you able to do this? Because let me tell you as a as an intravascular specialist or revascularization specialist. I learned as much as I can from what the magic that uh you know these these silent soldiers always in the back of our podiatry colleagues and won't care specialists so that ever do. I'll turn it over to you, Jason. Yeah first and foremost. Just you know, wanted to thank everybody for for taking the time this evening to listen to our talk. I mean um my name is Jason Mandeville. I am a podiatric surgeon at el paso texas. Um also a medical director for pulse amputation prevention centers. Um Joint venture with the lorry in addition to dr raja. Um I know dr raj, a lot of our success out here in El paso is you know, just because of his techniques and you know being able to increase that direct in line blood flow is obviously the the most critical, the most important part in the beginning of wound healing in order to decrease tissue loss. And that's the objective. You know, usually a lot of the patients that come to me, they do have some extent of tissue loss. They do have some extent of gangrene um as we're going to see here in this discussion, but my disclaimer and I think one of the one of the questions was so who do you surround yourself in the cli team? I think the most important thing, providers who are motivated, okay, who want to be able to be involved in the team Very challenging. Obviously these these patients are our patient population, um individuals are very sick. You know, obviously here, you know, foot ulcer is the initial problem in more than 85% of the amputations, One leg is amputated every 30 seconds, I'm sure um you all have heard that at one point or another and you know, Approximately 10% of people with diabetes do develop a photo, sir um during at some point in in uh in their life. So it's important when you surround yourself with um a cli team or an amputation prevention center that the providers are motivated and are dedicated to the process. And I think that's a big reason why myself, dr roger and Laurie have had, you know, a lot of success with here in El paso is that, you know, we're committed to the process and you know, committed to our our patients. Um obviously developing an ulcer is, is a it's a big problem, you know, here in in our community, especially out here in El paso where we have one of the highest per capita um in terms of population with those with diabetes, um, as we all know, approximately 10 to 15% of diabetic ulcers do not heal. And of those that do not heal up to 25% will require an amputation, which is pretty remarkable. And that the idea is to be able to you know, decrease these major amputations and in order to provide a planet grade um, you know, stable foot for ambulance nation. I think that's important. So typically, um, no patients come to me who have some degree of tissue loss, who need surgery, who need wound management. And I think, you know, the the most important thing I'm trying to convey today is is after the revascularization is to get an idea about the foot. The foot is a very dynamic structure and there's multiple um ideologies for the development of an ulceration, whether it's peripheral neuropathy, whether it's a muscle tendon imbalance that needs to be corrected, um that needs to be corrected surgically. So all these path of mechanics can can be um involved in terms of developing of of an ulceration. Obviously I've been neuropathy, nerve damage, patients can feel the bottom of their feet. Um Diabetics also have autonomic nervous dysfunction where they don't sweat so that they develop calluses, they get cracked skin. Um also modern neuropathy and development of these foot deformity. Um foot deformities where they develop any prominence is collapse of the arts that at some point need aggressive therapy debridement and in some cases a surgery you see, you've had patients come into the clinic. I think we've all had them. Hey doc, I can't feel my toes. I woke up this morning and I had blood on my socks. Um you may see that from time to time. Obviously in it pertains to this to patients with severe arterial disease. That headaches do have severe um small blood vessel dysfunction which also causes neural dysfunction. Looking at advanced like it'd end products. I think it's important to understand why these wounds don't particular to heal. Well, okay, there's structural changes in proteins. There's um you know, these elevated prolonged glucose levels prohibits the, you know, the cross linking and for patients being able to heal. Um you know in this in a in a good period of time. Um So these are just some of the reasons why patients develop a wound. Obviously diabetes in our patient population is is predominant. You know we see patients who have neuropathy nerve damage and ultimately they developed these breakdown in skin um also secondary to motor neuropathy where they develop bony prominence is as well. So you can see here are just some schematics. Looking at some pictures for you know real life patients who developed these chronic non healing ulcers that are on our limb threatening. Supporting understand diabetic peripheral neuropathy the loss of pro perception, loss of sensation to the feet is a an important mechanism in the developing of these these alterations. Obviously the blood flow to the area is very important. Um Like Lori commented that these patients come to me after they have an increase in the blood flow I mentioned dr Roger is fantastic and increasing the direct inland blood flow for these patients. Um modern neuropathy and this is an important um topic to to really kind of highlight here and I you know from this talk I want you know the audience. You understand that these patients in particular diabetic patients do develop foot deformities when you develop a foot deformity it increases the peak pressure to that area and in combination with a um foot deformity, nerve damage patients and to develop these alterations And obviously it can be complicated by diabetes, arterial disease and in most cases infection. Also patients here you've probably seen these patients in your office very common to develop a foot ulcer on the bottom of your foot. Obviously these patients do have a contracture of their cash truck solely as complex where increases the peak pressures to therefore foot. So I think understanding the motor neuropathy that's involved in the development of ulcers is is important, you know, understanding that it's not just a foot, there's instability of joints, there's an increase in peak forefoot pressures, there's the bony architecture of the diabetic foot um is lost and patients develop these bony prominence is which result in chronic ulceration. Um like I mentioned, development in achilles, um contractors, um also um stiffness of the foot, which causes immobility and increased four ft and hind foot pressures need to break down in skin. You hear obviously different patients in our clinic. Um The patient middle is one with the contracted Alex secondary to modern neuropathy, muscle tendon imbalance in the foot. I think it's important to look at the foot as a as a dynamic structure that has this interplay of multiple ligaments and tendons. You can see here the development of Alex vargas or as we know, more commonly as a bunion patients can develop wounds, Shuger doesn't fit properly, so they get rubbing on their first metatarsal head and that rubbing obviously turns into a wound. The wound turns into an infection. And unfortunately and in some cases um you know patients you know lead get an amputation, you can see here um you know further um illustrations of contracted digits, an increase in four ft pressure that lead to um you know, the development of these ulcers. Again, this picture here is a patient who has charco neural arthropod. The and I'm I'm sure you all are familiar with this disease process. Typically for a shark off of the patient develops a severe collapse in the mid foot wash out. Therefore the architecture of the foot is completely disrupted and it makes it difficult for the patient to emulate and it increases the bony prominence on the planet aspect. Therefore an ulcer is can develop. You can see here these are actually, you know, true patients. Obviously the patient has a severe shark, oh deformity and a complete blowout of the mid foot. Unfortunately I think this was a patient who underwent a below the knee amputation, but you can see the severity of the disruption of the architect to the foot. Another patient here um with severe charco deformity, a severe dislocation of the tailor's um which ultimately makes the the limb threatened. And that's where we come in as surgeons or or limb salvage specialists to be able to prevent further disruption of the foot. Again another um photo here of a patient with a shark. Oh foot deformity. And you can see here, you know, you can really appreciate on that X ray the severe subluxation of really the take home point here is that you know the the foot in particular the diabetic foot is is composed of this dynamic interplay of ligaments and tendons and you know that can severely be altered in our patient. Sure. Obviously this is complicated by patients who are diabetic patients who have severe peripheral arterial disease. And this dynamic interplay is is it's it's affected and these patients are at high risk for an amputation. Some of them need an amputation, some of them need surgical reconstruction. And my point being is that it's really not just a foot. I think it's they they dynamic interplay of all these structural changes that are constantly constantly um um you know being evaluated next case and I think this is obviously we are all familiar with this diabetes related ph d. These are patients obviously with um tissue loss, patients with gangrene. And you can see here these are all our patients who develop some kind of tissue loss. And my objective as the podiatric surgeon or limb salvage specialists, is to be able to restore function to that foot to be able to minimize tissue loss. And that's our objective as as limb salvage specialists to provide a planet. Great foot, minimize tissue loss, decreased amputation. So they're able to emulate again, you know, further schematics, further pictures here with patients who have severe arterial disease. And obviously I think most of these patients underwent day transmitted partial amputee patients with diabetes obviously have atherosclerosis related inflammation. Um you have narrowing of the blood vessels and really this thrombosis of vascular beds, therefore the tissue is starved and the tissue is unable to get that vascular supply that it needs for survival. Obviously diabetic patients are are greater, are at greater risk for ischemic events. And obviously in our patient population diabetes is a major risk factor for P. A. D. I'm not going to touch on that too much. But like Lori mentioned, you know patients with diabetes do have limb ischemia are higher risk. Also they present to clinic with communication symptoms. And I think it's important even as a podiatrist, all my diabetic patients get at least once a year on arterial Doppler and if there's any symptoms there's any um abnormal results, they do follow up with the interventional lists. Thank you. Obviously the strongest risk factors for P. A. D. R. R. Diabetes and smoking. Um More than 50% of patients with Cli also have diabetes which is which is pretty remarkable I think um that gives you an idea of the you know the disease process for these patients and how complicated and how um unfortunately very, very ill these patients are. Okay I'm not going to touch on that too much. But obviously diabetes you know plays a major role in the development of critical ischemia and also um peripheral arterial disease. Also more patients here who underwent surgery. Um I believe these patients underwent a trans metatarsal amputation and you can really appreciate the tissue lost. These patients are illustrated here. Okay. Obviously infection okay. You may have patients who may not necessarily be severe limb um patients with severe limb ischemia but it's also complicated by um infection especially in our diabetic population. You can see on the photo, the second one from the right um patient with a gas gangrene infection and obviously that is obviously limb threatening and it needs to be addressed surgically. An infection in the diabetic foot becomes complicated because his blood vessels are narrowed and there is a decrease in blood flow. Um obviously diabetic patients are unable to really fight that infection. You can see here a patient with a bone infection or osteomyelitis, and we're able to do a rare resection here for that patient and ultimately save the majority, you know, save their foot and prevent further infection from happening. Okay, so here's here's where where kind of my role comes in. And I think the importance of the surgeon, whether it's a vascular surgeon or orthopedic is be able to determine what level is, is salvageable as we all know. And the literature is very, very clear that the higher the amputation, um, you know, the more difficult it is for the patient to ambulance. No, they're oxygen. Um, you know, their oxygen consumption increases with the higher level of amputation. And obviously patients with some degree of cardiac disease and it makes it difficult for them to emulate. So so is there infection? Is there at what level should we amputate in order to provide a planet grade foot for amputation for amputation? Sorry? So toe amputation ray amputations. I'm just basically just going to comment on the different uh amputation levels and you know, once you're getting into the show part signs even a below the knee or above the knee amputation against challenging, you know, for the patient to emulate and to have a functional outcome and really a functional life you can see here a nice schematic of the different levels of amputation. You know me personally I try to avoid any kind of show parts amputation. Um for me we've been able to have a lot of success with Liz franks and transmit amputations um in conjunction with muscle tendon, um surgical balancing procedures and obviously something just to comment on the gold standard for offloading these diabetic ulceration is a total contact cast. Obviously there are some contraindications for that um including infection, including severe limb ischemia. But as a gold standard in our clinic, we're implementing a total contact cast on a regular basis. Again, um, just kind of kind of comment on some advanced techniques for limb savage. This patient underwent a trans metatarsal amputation. As you can see here on the picture to the right of the screen, they ended up nice granular wound base and uh, ready for your graph. Ready like we like to call it, you hear the patient underwent a Natasha. This split thickness skin graft where I harvested from the calf. It's a lateral calf patient in great and ultimately, and appealing again, some more advanced treatment modalities for wound healing. This patient is undergoing a amniotic tissue membrane Allah graph in order to kind of stimulate graduation tissue. Again, just you know, further advanced treatment modalities using the, you know, Allah graphs in order to facilitate wound healing that are readily available in our industry, patients did well. Again another. Um let's take the skin graph and the use of negative pressure wound therapy as a as an adjunct to facilitate wound healing. Get more complicated here. I don't do too many of these um given our patient population, but there are advanced tissue flaps you can employ for wound closure. Um, rotational flaps on the bottom of the foot is also something to consider. You can see here this is a schematic um muscle transfers as well to provide them the vascular supply of the muscles in the foot to certain areas of skinny ischemia in the foot as well. You can see here some other advanced treatment modalities for wound closure. Uh, the middle one here is something I do fairly often is I do harvest bone marrow aspiration from the cal kenya's, the operating room. Um you know the cal kenya's can be a rich source for bone marrow aspiration can yield anywhere from 30- 60 CCS, which is good. Spin it down and get the mesenchymal stromal cells from that. Um, you know, again, these patients are at high risk for below the knee amputation and sometimes you got a little get a little creative, you know, we want these patients to hell, we don't want them to come back to the operating room and um, you know, these adjunctive therapies can, you know, have proven to be um you know, pretty beneficial, at least at least in my hands that it was the same patient who underwent. They transmit a partial amputation and you can really appreciate in the bottom of the bottom picture, to the right there, nice heal them. No plan to flap. Okay, again, further advanced treatments. Sometimes I employed the use of external fixation to stabilize the foot in particular to a shark. Oh, deformity. And in some cases offloading these difficult to heal heal wounds as well. Also, going back to what I had previously commented on is balancing the foot. Like I mentioned, the foot is a very dynamic structure. Sometimes you need achilles, tendon lengthening procedures, gastric procedures in order to decompress the foot and decrease that forefoot pressure. Again, these are also um you know, advanced uh you know, tibial tendon lengthening procedures to balance the foot to decrease the pressure to the lateral column. Like I mentioned. Uh Gastronomy is tended recession another foot. Obviously you do have patients who are adequately perf used in particular, shark Oh, patients who have severe hind foot and mid foot deformities. Um illustrated here is what we call a tibia, taylor cal, Keino arthur diseases in order to fuse the ankle and provide a nice planet grade rectus foot for ambulance nation. Again, just um, you know, some photos here from our patients patient undergoing a transmit amputation and they tend to do pretty well. So, um, again, did the take home point here is that, you know, the diabetic foot in these ischemic patients? It's very challenging, very challenging to treat on the foot is a is a very complicated, it can be a very complicated structure and some cases they need surgery. Some cases they need balancing of the muscle and tendons in the foot. And the idea is to amputate and to salvage as much of the tissue as possible in order to provide a planet great foot. So, um that's basically what I want to I wanted to discuss today. It's a team approach and I think one of the questions earlier is that how do you choose your cli team? I think the most important thing is getting involved with providers who are motivated providers who are passionate about saving lives. And you know, that's I think that's why Lori and dr Roger and I have, you know, I've had success because we're just passionate about saving lives and um you know, we're just thankful for the opportunity to to serve our community. So thank you, Jason this, this was really a very very nice presentation I learnt when I listen to my uh podiatrist colleagues and uh uh and it's something that all of us have to learn the amount of work. Um it's humbling how much work you guys go through to to save some some of these places, your doctor a couple of questions actually that came up to you and I would like you to address. Um And uh one of the questions was um what are your thoughts about the offloading boots and the ischemic issues related to placing those boots on? How do you how do you address them? Especially for cli patients especially it's difficult to assess the wound or get access to the to the limb once you put those total contact cast on, that's one question. Um And the other question and Lori addressed a little bit. Uh do you feel that the main reason for graft failing is poor profusion? Uh So those are the two things that I would like you to address. Yes. Absolutely. Obviously a relative contra indication to total contact has is an ischemic limb. So before we get into these advanced treatments, doctor Saab the the limb needs to be adequately perf used. Okay. It can cause pain if it's not adequately perf used. So before I even consider a total contact cast or um boot immobilization or I do address the vascular status first. Okay, that's the most important thing. Um So until that is addressed, until that is corrected, then at that point we start to, you know, implement a total contact cast and in regard to the the graft failing. I I I think that's one of the big reasons is poor profusion. I do agree with that. Um But there's also several reasons why the graph failed. One obviously is infection, you know, the patients may have an underlying infection that needs to be addressed. Also, sometimes these graphs they're not bolstered to the wound correctly. They may develop a Ciroma, they may develop a hematoma that prevents that graft to fully incorporate to the underlying tissue. So, yes, the profusion is a big deal, but also the placement of the graft and adequately offloading the graft is important as well. Absolutely. All great points. Thank you. Thank you for bringing that up. Uh With that, I'm gonna turn it over to my colleague, dr Griffin, who will be talking to us about navigating uh cli practice. Um and I look forward to hearing his stock. Uh uh Mhm. All right, well, thank you. Thank you very much, doctor. So, you know, I I greatly appreciate phillips and everyone for inviting me to this. I really enjoy being able to do these on a, on a yearly basis. Um Laurie and and Jason, you guys are phenomenal. Would you guys do are great. Uh You obviously are very passionate about what you do and you can hear it in your voice, you could see it in your results and I just want to commend you for that. You know, we, we got into this approximately 12 years ago when we started uh one of the things we were seeing in our community was a very high amputation rate. We're seeing very high morbidity and mortality and all the things associated with that. And at that time, and even Dr Saab could probably even explained to you was that there was really no um organized fashion of critical in ischemia. Uh it's been very enjoyable to see the evolution of what's been going, what's been occurring over the past 10 to 12 years. And what I mean by that is not just with the technology from industry, which has been a huge help, but also, you know, within ourselves, you know, you have to be very humble when you do these kind of things, you know, and the at the time of when these things started, there was maybe one or two official limb salvage centers in the entire country. And now that you can see there's multiple and multiple and many of these these uh multidisciplinary centers around the country, uh you've seen it within the vascular surgeons who basically, 10, 12 years ago, we were basically only doing bypass or are amputations because that's all that was really offered. Uh you were seeing interventional cardiologist, not really wanting to tag the blood vessels below the knee joint in the in the tibial vessels because of the complexity as well as the vascular surgeons. Uh you saw podiatrist, you saw foot and ankle doctors not really doing a lot of complex diabetic surgical procedures and things like that. And it's been pretty amazing how all these things have just kind of um kind of just swell together to where we are today, within a short 10 year period where you have all of these things that you have just seen. You are not seeing this 10 to 12 years ago, this was just not available. Uh And it's just been really exciting to watch what I call the evolution of a critical limb ischemia. So, and having said that uh you know, 12 years ago, we attacked it, we said, well look, we need to try and do some kind of some type of conservative effort here um officially to have some type of system to to see these patients. Because as you can see in my slides, if you go to the next slide, you know, these patients come to your clinic uh their survival rate is really not high and of course they're not really they're not really dying from the limb that's ischemic. They're dying from the other comorbidities, right? So which mainly heart attack and stroke? Um So it was always you were already behind the eight ball when they were coming to you. So, you know, the question was, what do we do? Well, you know, the first thing is you just kinda in vascular started, just kind of stopped the bleeding, right? You try and quickly do what you can as fast as you can. So, you know, initially would start as just, okay, well let's get some blood flow to these patients. So if we get some blood flow then that could help, right? So as you would try to get blood flow, that was just one, you know, part of the entire thing dr Fadi alluded to that and that the real thing doesn't even start until once the blood flows began. And you're looking at these wounds on his feet, and I always call it a small window into the complex problem. You see a wound on the foot, but there's so much more going on beyond that, that wound that needs to be addressed, not just from a surgical standpoint, not just from a medical standpoint. You're talking about navigators, you're talking about social workers, you're talking about complex wound management, complex foot and ankle. You're talking about very small things like setting up transportation for patients to get in and out of these scenarios. So there was a lot of these things that evolved over the years as we've done this. So, as these patients have been coming through, you started, we started to kind of figure out how to what things you need, what things you don't need to do. So you know, for instance as you can see in this slide if you want to talk to just about the vascular side of it uh you know you have to have competent vascular work up. You know in the old days it was like oh I feel a pulse. Well yeah. What was that your pulse or is that the patient's pulse? You know what have you? There is a demon that leg et cetera. So you need to have true noninvasive vascular services right? You need a vascular exam. You need A. And an A. B. I. Now we could go into A. B. I. Is all day long. I think that the traditional A. B. I. Is when it comes to the critical limb ischemia is it's a good basic thing to do. But it is so much beyond the T. B. I. What the to break the index and the ankle brachial index. It goes more to the injury zone concept, which I think already alluded to, you know earlier on as well as tissue perfusion, it's all about getting the oxygen to the tissues tissue level. Not in other words, FBI's are not the only answer. Now. You need to have arterial ultrasound, need to have cat scan angiography. Sometimes you need things like transport, contain this oxygen pressures and things as such. And of course you have to be able to have diagnostic and then therapeutic angiography and interventions. Uh I'm not gonna get too much into the neurological workups and things like that. Jason did a phenomenal job but those kind of things. But you have to have all those things to have a successful program. Right. For us again, I'm not going to go into this because Jason, you guys did a great job. But you know, at the very beginning there were different, there were there were different classification systems, right? I mean, which one do you use? So we've had different ones. Then basically we divided into three points as you can see the depth of the wound, right, the blood flow. And then is there a schema and infection? And basically that's what we just need to know right overall. So as you start to assess these patients and understand what they need, then that's when you would also be able to have access to specialists like you said, infectious disease, plastic surgery, you know, foot and ankle, you know, other very complex kind of scenarios. Uh and then as we would look at these wound, that's when we started to figure out, okay, where are you? What's your great, where are you going to show you why this is important towards the end? But we definitely have to have a good assessment of that. Let's go to the next slide please. So with the scheme, you know, we we basically go from grade 0 to 3 roughly somewhere around there. As you can see A B. I. Values are very important and tissue oxygenation pressures are important. Uh then that's the clinical scenario which you know, we like to keep things as simple as possible in a complex scenario. As critical limb ischemia. You know, simplicity is the key to success. So basically do you have mild moderate or severe disease? Right. I mean that's kind of what we're really looking at here. So when you have all that and you want you reestablish your blood flow. You you you have done their job and everything is hunky dory. And and you know, everyone's back to normal that patients functional. You presented prevented um You know any kind of major and minor reputation or even if there was a minor reputation. The next question is you know, how often do you see these patients, you know what's their risk? Um and things like that. So you start to develop a follow up protocol basically once they come into your program, they can never leave, right, you never want to leave a program. The second they leave a program, you know, you're starting from you start from ground zero again. Um Initially, you know, the options like I was telling you about historically was either bypass, maybe some angioplasty, right? Just using a balloon in a tibial vessels. Uh that didn't work so well bypass. You know, they work okay at times, but it's a bypass and there's a lot of postoperative complications that occur with that. Uh And then You are getting into these things about a threat to me devices which now anyone that's in this business would laugh at something like that because it's like 12 on the market at this point. But you know, back 12 years ago, there was like one or two, you know, that's all there really were. But now we have a lot of these options. So what we have started to see is that you can start to do the transition from uh complex Bypass surgery that takes you know, 3-5 hours in the operating room with wounded license with postoperative myocardial infarction, postoperative stroke. Unfortunately even death because these patients already such high risk to now being able to do that same revascularization procedure in an outpatient setting in an hour and a half or two hours. Uh and the patient goes home the same day and there's no wounds, there's no surgical wounds to worry about, everything is done in an outpatient setting and everybody is really really happy about this scenario. So uh it's been pretty impressive to see that transition uh occur like that. So I'll show you one case example what we do uh The great part about being a vascular surgeons, we could just show you the sexy slides. We don't have to show you all those gross wounds, slides like dr Jason has to do and lori. Uh But anyway, this was actually one of the very first patients we had in our program. And I always got, I like to use some of the early on patients because it was it's always a learning process. We always learn from every case that we do. That's why we do this, you know? But I remember this patient coming to see me um this was about nine years ago or so. Uh he was a third opinion. Yeah, he was a diabetic. He was in stage renal disease on dialysis. Recently used tobacco hypertension. He had a he had a previous procedure where he just had and angioplasty of the middle, superficial thermal ordering the thigh. And then that then work so well. So he had a repeat angioplasty. And then he also had to have a bypass from the public to artery which is right above the knee, down to the ankle to the to the posterior tibial artery. And then that failed. And that's when he came to me. And at that point he had a he had a right great toe gangrenous change. And at that point, you know, this is this is when we started getting at the critical limb ischemia. These were kind of like the tie was starting to change. So, um, we do an angiogram. And as you can see the angiogram here, that the slide to the left, that is the, the plain old balloon, they called it koba plano balloon, angioplasty of the superficial film order that's right above his right knee. And then the second one, the right, that's actually a tibial vessel called the posterior tibial artery. That was also included. You don't even see the bypass. You only could see surgical clips if you really looked well where the bypass was. So I was we were looking at this thinking, well, the bypass went down because his angioplasty site was basically cyanotic again. So he had an inflow and he also had what we call an outflow problem, you know? So what, what do you do in these scenarios? You know, honestly, you know, if it was three years prior to that, he would end up with a below knee amputation most likely. So, um, but with the new technology and the advancements we were, we've we've got aggressive, right? So if you can continue to go through the slide, you know, the things you start to think about in the scenario is if you're gonna use what we call it, a threat to me device, which is a device that just choose up blockage and removes it out of the body. Uh what you're going to use, how big is the vessel? What type of uh plaque you have is a lot of calcium is not a lot of calcium. Uh If I use the devices of the correct devices, all these things that we're starting to learn at this time as we were going forward. So at this point, his only option was an endovascular option. There was no more bypass options. All of that failed. So at this time there was something called Ibis. Now if you do this for a living now everyone knows what this is. But you know, this was 10, 10 years ago. I was kind of like you and the scene in the in the lower extremities, not in the heart, but in the lower extremities. And that stands for intravascular ultrasound assessment. So what we did at that point is we put it down the artery that the top left picture is a is the artery, the normal artery. But the bottom right picture is the that stenosis that you see. There's something very interesting in that picture and that if you could see it approximately 10:00 position, there's a little flat there all right around where that red color is. And that's what we call an internal dissection, meaning when that balloon was inflated, it caused the dissection within the media port or the inner portion of the artery. And that flap keeps on making that that plaque basically block up again. All right. So you we didn't know that before. We didn't have this technology to kind of understand that. So when that occurred, we wanted to be very careful. There's different devices and after the devices that you can and can't use in these scenarios. And the last thing you want to do is use a device that will actually make that flat become worse. So this is when the device I used here is called the phoenix device that we used. It was very um less traumatic to these flaps if you will. And that's that's why we chose it. So if you go to the next slide, you'll probably see what we did. So There's different, there's different lengths of devices. There's different diameters of devices you have to use certain devices and certain portion of the body. This is a medium sized devices, 2.2 mm, um, uh, in diameter. Uh, the good thing about it is that it's, it's kind of not traumatic to the normal vessel wall if you will, it doesn't cut it kind of just shaved. So I wanted to use something like that and kind of shave through that plaque and not, I'm sorry to that flat. And I cut the fact that I would actually make it worse and that's what we, and that's what we did here. So if you can continue to the next slide and you see the, the angiogram here. This was only after the, the a threat to me device. Um, there is also at the time we were using something called drug coated balloons. Um we show very good patent see rates after a threat to me. Instead of just using plain old balloons, which you'll see in the next line, we did use a drug coated balloon next life, please. Yeah. And at that point, what's also nice with that intravascular ultrasound assessment, uh, which I showed prior, as you can see that the exact diameter of the vessel wall, it is the gold standard for knowing the exact diameter of a vessel wall. And what that helps us with as we know exactly the size of balloon to use the size of stint to use. You don't want to have a stint that's too big in diameter, too small. It can actually make things worse. So we knew their size to be approximately six. So that's roughly the size of balloon and or stint that you want to use. So you can see the before and after. So obviously the slide to the left, is that flap I was telling you about in the pre procedure Ibis and then after you see me completely removed that flat, we remove the plaque and we we we use the balloon and you had a very nice, smooth looking luminous. And then there's your completion agent Graham. So you really it was very, it was one of those eye opening experiences. That's why I like to use this. This cases. Uh, you're basically looking at an order and it looks normal at this point. You know, prior obviously did not, but at this point it was very impressive. If you go to the next slide, you'll see how we we went down to what we call the bologna arteries, the tibial vessels. And you're supposed to have three vessels there by the way. Okay. And you don't even see one major vessel except a little further down. So, um not only are there new devices, there's also new wires and catheters and all these other things that before, we never really had the options to get to those very small arteries. In other words, get through what we call these chronic tool inclusions and these long chronic total occlusion and very small arteries is very difficult. But we were able to do that with certain techniques and wires. If you show the next slide, I was able to advance the ultrasound again uh down there. Now when you get down there, the avis catheter sometimes a little difficult to see blood flowing things because it's already you're already in a small vessel. But the whole point of that is to see the diameter of the vessel, see if there's any, what we call thrombosis or clot in there, that definitely changes what you're gonna do, especially what you're not going to do, etcetera. So we were able to do that, see what we're dealing with. And at that point we changed to a different size of, of Catherine. You don't want to use that original 2.2 millimeter catholic, it's too big in that vessel. That vessel, It would literally eat up that vessel. You can see we use an affecting device. We were able to get across the chronic total occlusion. Were able to what we call de bulk, which is removing the plaque, that's what an appendectomy is. Uh, and we always obviously do I buy this after, just to make sure we d bolt correctly. Winning calls those flaps or anything like that. Again, there's no promise because I can't happen at times. Um, we go to the next slide, we ended up using a balloon. Just a regular balloon. This is not a drug coated balloon at that time. You cannot use drug coated balloons and bologna vessels. Now, they're starting to be able to do that. And as you can see, we went from no flow within a vessel to now too. And I, I did the other blood vessel, but I just didn't show it for time sitting. So basically there's no blood flow in the foot to, you know, to vessel run off now into the foot. Uh, you know, this is just comparison of what we did. So the key points with all this. Um, you know, it's one of those things that if you, you don't chronic limb ischemia is, it's all all hands on deck approach. Uh, it is people that love doing this kind of gravitate to it. And those are the kind of people you want in your program and what I mean, people, I mean people, so it doesn't have to just be medical professionals. Uh, we have volunteers within the community that come, we've had prior amputee patients that will come and and explain to patients how they don't want to have an amputation. And this is, you know, these are some of the things you don't want to do. Um, we have support groups, we have, you know, charitable events and things as such and to get the, the word out if you will. And we've definitely seen a significant decrease in amputation rates. The programs usually start out with just trying to stop major amputations. You end up doing more miners and then all of a sudden all your amputation rates go down. Then, you know, your next step is wound healing with that. But then what you're ultimately trying to do at the end is to make a patient functional, right? Because if a patient could be functional, then they have a better quality of life when you get a better quality of life. That's really what this is all about. This is why you're doing this. If you if you're not trying to help someone with their quality of life, you should probably shouldn't be doing this kind of stuff, you know? So, um, from a from a technical standpoint, from a surgical standpoint, um, it's a reality that peripheral arterial disease is on the rise, diabetes is on the rise, heart diseases, on the rise, etcetera. It's only gonna get worse, meaning you're going to start, we already see more of this. So, we have to attack it. We have to get a plan Uh, to kind of save patients lives and get them functional. And you started to see this across the country. So I would say 10 years, 10 years ago, I was very scared about the reality of all this. But now that you're starting to really see a lot of people attack this has been really phenomenon. It's not just national or regional, this is international, doctor Faq. It you elaborate on that as well. We we do talks all over the world and you're seeing this across the world at this is this is a very real thing and a lot of people are attacking this. So with that said, I appreciate the opportunity to do this. Um if there's any questions or anything like that I love to answer. So, thank you very much. Thank you dr Griffin. This was really nice talk and you're very kind to share with us some of the early experiences on and if I can have the rest of the panel on Laurie. Uh Yes, thank you, Jason Jason on board. So um I want to uh you know, we have 10 minutes or so. So I'm just gonna have some questions that I think some of the members of the audience please feel free to oppose any more questions. But my first question to you, dr Griffin is, you know, I realized early on that I share a lot more with my interventional radiology colleagues and my vest a surgery colleagues that treats cli patients. I have a lot more in common with them as interventional cardiologist than and some of my regular cardiology colleagues because we tend to speak the same language. Um and I also discovered that not all uh interventional radiologist, not all interventional cardiologist and not all vascular surgeons are created equal when it comes to cli therapy. Now as a person that's both skilled and endovascular and surgical approaches. Can you comment a little bit about your thought process in terms of tackling cli patients, specifically patients with Infra Pop It'll disease and tibial disease. Like the beautiful case that you shared with us. Because I can assure you that those patients uh unfortunately in significant portion around the country will not get any any of the work that you've shared with us and the amazing results that you've shared with us. So can you can you just elaborate a little bit on your approach as a vascular surgeon surgical versus in the vascular for some of those cli patient, especially with infra pop material disease and and planted disease? Yeah. No, I know a great, great question. Uh Yeah. I mean if you ask me personally and how we do it uh Yeah, I mean, you know, I would definitely say for papa till disease, you know chronic limb ischemia is you know, first step is now in the vascular and I agree with you. There are people in town, both cardiology, radiology, etcetera that want to attack these kind of things and should. So our approach is always an endovascular approach. And when I meet an intravascular approach, you know, we initially you would start with just what we call, you know familiar approach right cross over. Just come from the contra lateral growing and come up and over. But these things get so complex that you want to have all this whole military um in your In your hands. So we would do what we call anti greater approaches to where we actually stick the artery on the same side as the leg and go down, which was kind of taboo maybe 12 years ago or so. So we'll do those things. We'll do papa till approaches. We'll stick the papa to artery itself if we need to and go down. The reason being, as you know, doctor find the closer you are to the the occlusion, the more success you have crossing that inclusion would do things is what we call peter artery sticks to where we go down at the ankle and the foot and stick the artery income retrograde. Come back up. And sometimes you've been meeting in the middle to where you're coming from above and below, uh, to get these things open. So we're very aggressive with all these things. Uh, you definitely have to be careful when you started doing some of these advanced techniques. You you don't want you don't want to go in there and make things worse. And that that's one of the things that when you have these kind of programs, these things are spoken about very early on. So um no, we go full board from an endovascular standpoint. And then of course if you can and you know, then we would do a surgical uh bypass or and or even a hybrid. Right? Sometimes you you can't do all of it, it just doesn't work. You need the surgical bypass. That said you just can't get through a severely calcified, you know, femoral artery which is common. But you can get down, you know, you get down to the tibial where you can do the bypass. And then while you're in the operating room we have hybrid operating rooms. Now, right. We have you have sterile X ray equipment in the rooms where we'll stick the graph and and do a tibial angiogram and then do the a threat to me, the angioplasty etcetera. So we like to just give our patients full bore. And by the way, some of those hybrid cases are done with an individual cardiologist in the operating room with this. So our radiologist that is as well. So it's a, it's a multi team approach. I mean there's no everyone's humbled. If you're doing this for a living, you have to be humbled because just when you think you have this thing nipped in the bud boy, that case comes at you right away and two or three right behind it, you know, So that's probably the best spare assessment that I could give to you how we practice. Uh, thank you. That's that's a great point. Uh, joseph. So, uh, my next question is to Laurie, I was, I like something that you said earlier, he said, you know, they call me the quarterback. And let's, let's ask a frank question. You know, there is, there is uh, uh, there's fatigue, that's the only way I can describe it. Sometimes there's fatigue from the health care providers and these are the people that care and passionate about the patients. And like the doctor Griffin said, it's not only health care providers, it's the patients, it's a family members, its uh, its function, that's uh, that's had a very important task, which is, you know, keeping the morale up and identifying the people that are really interested in being a part of this multidisciplinary group. And Laurie, I know I know that you are that person within, within your group. Sorry, Jason. Nothing against you. But uh, um, can you comment on some of the techniques or some of the things that you do to make sure that you have a stakeholders remain engaged, you know, the infectious disease doctors, you won't care specialists, your podiatrist the family members of patients. What are some of the tips and tricks that you can share with our attendees in terms of keeping, you know, uh, shareholders engaged in this process. Um, that's a great question because it does get, it can be overwhelming. Um, so from a from a provider standpoint so that we can meet the needs of everybody. We've we've really started to expand and and find people like Dr Griffin said that that are passionate about this. And we added two more nurse practitioners to our team. So they help, um, you know, with the reach and being able to see the patients. But the training and the passion within each of them is very important because we all have to be very vested in salvage and making sure that we're catching any little thing that's going on with the patient. Um but that allows you to me to also be more available to the other providers for phone calls, for triaging, for helping take within the Amputation Prevention Center. We now have um three nurses to nurses and and a an assistant who are, you know, we're training and we're working with them constantly to be able to answer the call phone during the day and be able to treat Ege the questions that come in from patients um to be, you know, our our one of our nurses um you know, the other day shared with me, he saw that a patient did not receive their wound back quick enough from the home healthcare company. We have to be very passionate and and we have to demand a high quality of care from the people we're working with. You know what I'm hearing from you, Lori is um this is not an automated answering machine. Human that's answering there is, you know, Mr smith did not show up to their appointment today or I'm worried about them. You know what? It's not it's not a new thing. Every cli program, every one of my colleagues that I speak to, they have someone that's knows the patient calls them in talks with them. It's not an answering machine. Artificial intelligence did not did not crash the party of cli multidisciplinary team yet. Um so I love what you said about that people need to be engaged. You need to hire and have the right people that will call and follow those patients. So I think that's very important. Uh Jason, I'm gonna I'm gonna have a question for you and I think um it's kind of a leading question I apologize for putting you in the in this position, but I need to ask because me and dr Griffin, I'm sure Laurie in this situation, thank you for sharing some of those pictures Because you know 90% of the pictures that you showed when they come to our office or they came, you know, they were sent to us, uh the overwhelming majority of people that don't deal with cli they say this is too far gone. Why are you even attempting this? So you know, and I appreciate you sharing some of those really glorious efforts that you you do to say some of these limbs, what's what do you say to physicians that say you know this is just too far gone or just cut it and you have a new leg on and you're gonna move on um do you ever say like this is just too far gone? And I'm not talking about, you know, septic patients and you know, infections and and we're amputation is necessary, needed. Obviously we're not debating this year, but I'm talking about significant issue laws because some of those pictures that you showed them, the amazing results that you got clearly shows that this is possible. This is feasible. So what are some of your strategies to some of these physicians that do not believe and limb salvage this takes too long? Well, that's a great point. Um you know, dr Saab and I think we do see it a lot here and I think Lori can agree with me. It's funny because kind of the goals, you know, they it's an accepted norm um where below the knee amputation is the way to go. Um basically what I do is I got to get a clear picture for the patient first and foremost. How is the vascular status? Okay. Is there is there to vessel run off? Is it three vessel runoff? Is the infra popular deal Pop? Little disease so severe. So that's the first thing I look at is the vascular status because it doesn't matter. You know what I do if the vascular status isn't improved. So for me that's the first thing I look at. The second thing I look at is infection. Okay I typically get an M. R. I. Um to look at whether um there's an abscess whether the bone is involved. So for me doing my due you know due diligence in the beginning, assessing the vascular status, looking at infection and at that point I can determine you know whether you know and at what level is the is the limb salvageable? Okay. And it also also has to do with the patients and I do have this conversation with my patients upfront. I said okay Mr Doe. Okay we have two options here. Okay. We can we can be a team, We can work together for the next 4-6 months. It's not going to be easy. Okay I need your commitment. You may need multiple surgical debridement. You may have to go back to the cath lab a time or two but I'm all for it or it ends today. We can have a below the knee amputation and guess what life goes on. But I think the important thing is to educate the patient on the sequel a on the consequences of a below the knee amputation, How difficult it is going to be for them to tabulate. How um you know, the the complications and the challenges and getting to in fitting into a prosthesis. Like I said, you know, a lot of my patients, they are mobile morbidly obese and it's challenging for them to tabulate. So um those physicians, obviously I look at the whole picture starting with the vascular status of the patient, I look at infection and obviously whether the patient is motivated to proceed with a with limb salvage efforts. So for me personally, those three components are important. Um I know I'm motivated and the Lord is motivated and you know, dr Rogers definitely motivated. So, you know, in most cases, you know, patients got to be on the same page. So yeah, thank you. That's that's a nice summary of some of the things that you can you need to have to save the limb and ultimately really save the life of the patient. Absolutely. Uh you know, I want to I want to thank the steam panel with me here today, Laurie Henderson, Jason mandible and thank you Griffin and I want to thank our sponsor from phillips uh uh medical for putting on this series, uh great series that we have um and you can go on phillips lead academy and view them again. My name is Farah sob. Thank you very much for staying with us tonight. And uh I want to thank all my colleagues also and have a nice evening everybody and uh good night. Good night everyone. Thank you everyone. Thank you for tuning in helpless. Mm mm.