From Theory to Practice: Creating a limb Preservation Center Krishna Jain MD, John Munn MD, Mark rummel MD, Dan Johnston MD, Syed Alam MD, Chris Longton RN OEIS 2015

Mission Prevent amputation of a limb and maximize independence and mobility

Causes of limb loss Diabetes (ulcers and infection) Arterial ischemia Atherosclerosis Diabetes Dialysis Venous Trauma Congenital Other

Conditions needing Treatment Arterial Claudication Rest pain Ulcer Gangrene Venous Ulcers Insufficiency and obstruction Diabetic ulcer Trauma Others

Planning Essential services Multidisciplinary team Office based endovascular suite Wound clinic Vascular lab Easy access to hospital Rehabilitation Vascular screening Registry

Planning Desirable services Diabetic clinic Vascular medicine clinic Cardiology Rheumatology services Access to gym Dietitian Neurology services Nephrology services

Essential Services Multidisciplinary team Vascular surgeon (endovascular and open ) Interventional radiologist or cardiologist ( if Vascular surgeon does not do endovascular procedures) Podiatrist Infectious disease specialist Plastic Surgeon Orthopedic surgeon (desirable)

Office based endovascular lab Only way to achieve rapid and timely endovascular intervention is in an office based endovascular lab Hospital systems are too cumbersome and expensive

Wound Clinic The center should be affiliated with a wound center that provides all modalities of wound treatment for dedicated management of all types of limb wounds.

Vascular Lab IAC certified Vascular lab Easy access to lab Vascular lab registry

Access to hospital Admissions for intravenous antibiotics Open procedures Major debridement Reconstruction

Rehabilitation After discharge patients need proper rehabilitation services In case of an amputation appropriate prosthesis

Desirable services Diabetic clinic Diabetes expert Nurses Early referral

Vascular Medicine Clinic For comprehensive management of risk factors Diabetes Hypertension Hypercholesterolemia Nicotine addiction Obesity Exercise Others

Rheumatologist In cases of unusual ulcers and limb threatening conditions the consult and work up is helpful

Patient Management Quick referral system Procedures to be performed in expedient manner Patient education Prevention

Evaluation Clinical exam Podiatry consultation Noninvasive Vascular Lab CT, MRI, Radio nucleotide scan Angiogram Cultures Neurological exam

Management Medical management of risk factors Podiatry management Debridement Treatment of infection Physical therapy and rehabilitation

Advanced Therapy Endo Vascular procedures Open procedures Angioplasty, Stent, atherectomy Open procedures Bypass vein and prosthetic Endarterctomy Hybrid procedures Bypass and endovascular Foot sparing amputations Reconstruction of deformed foot Grafting Thrombolysis Venous procedures Ablation Microphlebectomy Dilatation and stenting

Research The center should participate in national protocols of limb preservation

Business model Start free standing units For existing facilities bring essential services together Create a registry of all patients Maintenance of essential services by constant monitoring and periodic review Marketing

Conclusions Calling an office based lab a limb salvage center is not desirable Most medical communities have most of the services required to be a limb preservation center Goal is to bring everyone together