1. 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

2. Mission
Prevent amputation of a limb and maximize independence and mobility

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

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

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

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

7. 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)

8. 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

9. 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.

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

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

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

13. Desirable services Diabetic clinic Diabetes expert Nurses
Early referral

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

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

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

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

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

19. 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

20. Research
The center should participate in national protocols of limb preservation

21. 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

22. 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