Building a Multidisciplinary Limb Salvage Program
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Building a Multidisciplinary Limb Salvage Program

Critical Limb Ischemia (CLI) is a complex disease with an average lifespan of 2.1 years after diagnosis. It requires complex outpatient care and meticulous follow-up. Interventional cardiologist Dr. Jihad A. Mustapha and interventional radiologist Dr. Sabeen Dhand discuss the essentials of building a successful amputation prevention center and the importance of a multidisciplinary approach.


We’ve provided the highlight reel below, but you can listen to the full podcast here.


The BackTable Brief

  • Dr. Mustapha emphasizes that preventing amputation is the most important aspect of a limb salvage program. Saving a limb so that it can be maintained beyond three months is part of the definition of limb salvage, as is the ability to live independently, maintain decent quality of life, and return to work.

  • A limb salvage program operating in an amputation prevention center is different from an office-based lab (OBL). Limb salvage procedures can oftentimes be longer than 45 minutes and less straightforward. General working hours are also longer, especially with acute limb cases.

  • Having a mid-level practitioner and multispecialty team allows for collaboration and time savings. When CLI patients are treated through a combined group effort, outcomes are significantly improved.


Image Courtesy of Sabeen Dhand MD


Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.


Defining Limb Salvage


Saving a limb is just as important as maintaining it once it has been salvaged. The ability to maintain the limb beyond three months, have a good quality of life, return to work, and complete activities of daily living independently defines a successful limb salvage.


[Sabeen Dhand]

For trainees who are listening, what's your definition of limb salvage?


[Jihad Mustapha]

A limb salvage is a limb that is saved from amputation. It allows the patient to be independent of others, have a good quality of life, and return back to society to work and contribute. It’s also the ability to maintain the limb beyond three months. I say that because patients with critical limb ischemia, you can save their limb, but if you don't maintain it, it's not a limb saved. What happens after the procedure, what really counts the most as a limb salvage or limb save, is the maintenance of it. And we have patients now out to 8 or 9 years post limb salvage and they still have their limbs on.


[Sabeen Dhand]

Wow. Amazing. That sure beats the 2.1 year average lifespan of someone who's diagnosed with critical limb ischemia.


[Jihad Mustapha]

I'm glad you said that because that’s actually the reality we face. When we discuss the issue of mortality associated with critical limb ischemia, there's a lack of comprehension or refusal to comprehend the seriousness of critical limb ischemia. Many don't want to accept that having critical limb ischemia is deadlier than having an acute MI. But this is the reality. This is why we're talking and this is why we have to work together to raise awareness about the seriousness of critical limb ischemia.



Starting a Limb Salvage Program


Dr. Mustapha shares how he started a critical limb salvage program by building a CLI center. Currently, he operates out of both his CLI center and the hospital. Dr. Mustapha also discusses the differences between an office-based lab and a limb salvage center.


[Sabeen Dhand]

Tell us about your current practice. Where are you now? Is it hospital-based or part of a group?


[Jihad Mustapha]

For almost 12 years, I was hospital-based and built a really great CLI program. That's where Dr. Saab joined me. We worked together side-by-side for almost five years doing some of the most exciting limb salvage procedures. And we got to a point, that we actually outgrew the hospital because the number of patients that needed procedures was beyond the amount of cath lab time available to do the procedures. This is when we elected to work in the hospital, but also open our own CLI Center. And we started doing that. Right now, we have three operating rooms outside of the hospital and are still working in the hospital. And with that, we are not able to keep up with the CLI volume. We've hired five physicians in the course of two years. CLI is not a simple disease. It's a very complex disease and requires a lot of support.


[Sabeen Dhand]

Totally agree with you. I can't believe you have increased to five operators in the past two years. That's still probably not enough.


[Jihad Mustapha]

No, it’s not enough. We had four vascular surgeons join us and they're our partners now. I'm a big believer in having a multidisciplinary team. It's got to be one of the best things I've ever done in my life, seeking colleagues that have similar interests. Now, together we're doing some amazing advances in critical limb ischemia therapy.


[Sabeen Dhand]

Totally. Do you guys only focus on peripheral vascular disease? Do you do any cardiac intervention as well or are you guys focused on limb salvage and CLI?


[Jihad Mustapha]

In the CLI Center, we primarily just focus on CLI and we just make Dr. Saab go do the coronaries. The rest of us, we are full-time just doing CLI. Even Dr. Saab has gotten to the point now where he's doing less and less coronaries because CLI practice is not allowing him anymore to do coronary. On a serious note, we’ve sat down and discussed where we are making the most difference in terms of patient's improvement and quality of life and possibly actually reducing mortality. We’ve found that if you have critical limb ischemia, your average lifespan is about 2.1 years after you've been diagnosed with it.


[Sabeen Dhand]

What about starting a limb salvage program? How does one start to build one?


[Jihad Mustapha]

Starting a limb salvage program was harder than I thought because of the responsibility that you're taking on. If you're going to say you have a limb salvage program, you're going to find yourself in the mix of many, many sick patients that require really complex care in an outpatient setting. The perception out there is that if you're in an outpatient setting, you're not going to be able to provide this complex care to those patients that are extremely sick. In the beginning, we actually took the sick patients to the hospital and treated the rest of the patients in the office. But, we found that we didn't have what we needed and we didn't have the support that we needed in the hospital. Then we actually shifted and switched. Now we're doing the more complex cases in the outpatient centers and the less complex in the hospital because of the time and space. Having a limb salvage center, opening one is very tricky. You cannot just open the door like everyone tells you and everything will be fine. It requires daily hard work and extensive, meticulous follow-up. Of course there's a lot in between, but if you do that, you save a limb, but maintaining the limb is what is most important in the limb salvage program.


[Sabeen Dhand]

Going back to limb salvage, what about social media? Does social media play a role into starting a center or anything like that?


[Jihad Mustapha]

Social media is a phenomenal thing and like everything else, there's always ups and downs, but in general, it helps tremendously. We share with each other the good cases and the bad cases, and we get advice from each other. Those that are trying to open a limb salvage program or an outpatient center, in general, they can get a lot of advice from everyone in the media. The other day, I had a question about a device and how to use it. I sent a question and got a thorough response. I pretty much got the answer that I needed. It was extremely successful.

[Sabeen Dhand]

Definitely agree with you, too, and I think it's a nice way to network. I think probably my first interactions with you were on social media before I met you in person, and I learned so much from you there. Is there anything else you would say that we didn't really cover about developing or starting a limb salvage program that you want others to know?


[Jihad Mustapha]

There's a big difference between an OBL and a limb salvage program. An OBL, you can do a lot of straightforward procedures that will take you 45 minutes and there's a lot of us that can do that and those that are doing it. If you really want to open a limb salvage program, think twice about it and make sure that you're up to the task. It takes more work, more effort. The hours are much longer. This idea of finishing at 3 o'clock if you have an outpatient center, we have not seen one day like that. For limb salvage, it's a whole different beast. Financially, it's not as lucrative as other things, but it is rewarding in terms of fulfilling your passion towards limb salvage. It takes you a year before you feel comfortable. You build your practice to shape it to your needs. For that one year, you just have to be able to ride it out and get to the point where you're comfortable. I wish everyone the best because I would like to see more limb salvage programs. They are very helpful to our patients.


[Sabeen Dhand]

I admire your dedication. I think we're just at the beginning of what we'll see of limb salvage and in five more years, there's going to be so much more technology and so many more limbs that we can save.


Building a Multidisciplinary Team


Collaboration with other disciplines helps patients with CLI. By working with a multidisciplinary team of surgeons, physicians, and other interventionalists, Dr. Mustapha notes patient outcomes improved by as much as 90% with a combined specialty group effort. A mid-level provider as well as direct communication with vascular surgery, infectious disease, wound care, and podiatry helps ensure that CLI patients receive the best care.


[Sabeen Dhand]

Speaking of amputation prevention, you host an awesome annual AMP meeting in the summer and the slogan is "Leave your specialty at the door." What does that mean?


[Jihad Mustapha]

That is actually the resolution of the discussion between the co-directors and also the members of the CLI Society, board members, about the contribution of the different specialties toward the patient's outcome. Joining forces together allows us to provide a superior outcome to any patient that we treat versus a single entity, single specialty, or single physician. Leave your specialty behind is to push us to work together more. Any one of us might get to a point where we hit a brick wall and we don't have any more ideas or any other options to offer the patient. And, someone could be standing next to you and give you an idea that is so good and you'd be like, "Wow. That is simple. I can't believe I didn't think of it.” We found that if you combine the specialty effort together, the outcome for the patients is better. And we published a nice, large manuscript on that, showing that if patients were treated by any group, as long as they combine their efforts, the outcome is improved by 90%.

[Sabeen Dhand]

I agree, the multidisciplinary approach to saving legs and limb salvage is extremely important. What type of disciplines would you include under this multidisciplinary approach? Who all is involved?


[Jihad Mustapha]

We have our own independent limb salvage or amputation prevention center, and we have this direct relationship with our partners, vascular surgeons that work with us side-by-side every day. We have podiatrists as well. We also have deep relationships with infectious disease, wound clinics, endocrinology and any other primary care physicians that offer care for patients. We have this deep relationship with all of them together. What I've found to be extremely important is being able to pick up the phone and call someone and let wound care or the podiatrist know that you just opened the artery and it's a good idea to do something this week. I'm not sure if the communication between the operators, the surgical operation or in the vascular operation and with the primary care physician or a wound care specialist happen as much as they should. We found that we are unable to do everything, so we created a mid-level provider who is with us at the end of every case. We make a quick summary and send it to everyone involved in the care of the patient. I highly recommend everyone do this. Primarily, it's the wound care clinic and the podiatrist and the infectious disease doc if they're involved.


[Sabeen Dhand]

A second pair of eyes or something can just come up with another idea. Even just yesterday there was a lesion I couldn't cross and one of my partners thought of another idea that worked. Collaboration and more people who are highly involved can really help.


[Jihad Mustapha]

What you just mentioned right now is the reality of a collaborative effort between you and your partner, and your partner could be any specialty. We have multiple specialists in our practice. They can come in, put in a pedal sheath for you, pass the wire up, and walk away, and they just saved you an hour of hard work, right? We have to get to that level of telepathic combined work effort so the patient can get the best care from two physicians.


[Sabeen Dhand]

Yeah. It's leave your specialty at the door and leave your ego at the door, as well.


[Jihad Mustapha]

Absolutely. Leaving your ego is much better than leaving your specialty. Leaving both would be better.


[Sabeen Dhand]

One of the challenges I dealt with starting our program is competition and turf wars. What do you think about that? We talked about collaboration and multidisciplinary approach, but not to ignore the competition that's there.


[Jihad Mustapha]

In 2020, competition and turf war still exists, despite the fact that we know that collaboration also exists. You have to make a decision that you are not going to fall into this trap of primitive behavior and get side tracked. You need to rise above it all and focus only on what's important and that is the patients. This is how we fought our war. Yes, we do have our battles. But, everyone quickly realized that we are not a competition to any of our surrounding physicians because the patients that we're treating are patients that were scheduled for an amputation at each of the institutions around us. With this realization, we have less resistance. The turf war basically comes back to more of a claudication patient population and those we tend to manage, again, by using the same method.


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Podcast Participants:

Dr. Jihad Mustapha is a practicing Interventional Cardiologist and CEO at Advanced Cardiac & Vascular Centers for Amputation Prevention in Michigan.

Host Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.


Cite this podcast:

BackTable, LLC (Producer). (2020, March 28). Ep. 60 – Building a Limb Salvage Program [Audio podcast]. Retrieved from http://www.backtable.com/podcasts


Medical Disclaimer:

The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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