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Challenges and Evolutions in Limb Salvage

Updated: Aug 13

Achieving a high success rate of limb salvage in patients with critical limb ischemia (CLI) depends primarily on extreme dedication. Interventional cardiologist Dr. Jihad A. Mustapha and interventional radiologist Dr. Sabeen Dhand discuss some of the biggest challenges with building a limb salvage program and treating CLI. They also examine the advances in tibial-pedal access and the use of extravascular ultrasound for optimal chronic total occlusion (CTO) crossing in limb salvage.

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

The BackTable Brief

  • Building a successful limb salvage program requires dedication and work hours that fall outside of the 8 to 5 schedule. Having a team of multidisciplinary partners who will support you and strong mid-level support is critical.

  • Limb salvage success rates can be as low as 40%. However, with new advances in pedal access as well as the use of extravascular ultrasound (EVUS), patients can stay on the operating table for less time and experience better results with fewer intraprocedure complications.

  • With the evolution in pedal access, CTOs can be crossed from below if they cannot be crossed from above through the groin. With EVUS, an arterial Doppler or venous evaluation for DVT is used as a tool for intervention during the limb salvage procedure. Access, sheath placement, and CTO crossing are all achieved using EVUS without the need for any radiation or contrast.

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.

Challenges of Building a Limb Salvage Program

To build a successful limb salvage program, Dr. Mustapha notes you must have extreme dedication, be comfortable with long work hours, and have partners who will support you. In addition, he discusses three main challenges. These include not having adequate mid-level support, unsuccessful crossing of the CTO, and groin and intraprocedure complications.

[Sabeen Dhand]

You mentioned how Dr. Saab would be the only one that stayed with you until midnight. I think it's so important to note that complex limb ischemia requires dedication. Do you agree with that?

[Jihad Mustapha]

I super agree with that. We hear the word “limb salvage program” and “multispecialty limb salvage program” a lot. I've got to tell you, when you dive into limb salvage programs, you've got to be dedicated 100% because you can never predict when your day is going to end. You might be able to control the beginning of your day if there is no acute limb, but you can never predict when your day is going to end? If you're not dedicated and you don't have the passion for it, you get burned out quickly and you quit. This is the love of my life to do this kind of work, so before you know it, it’s midnight. And this is how you do a limb salvage program. You can't do it 9:00-5:00.

[Sabeen Dhand]

Yeah. I've talked to some of my friends and colleagues who have recently graduated. Sometimes, the big challenge they have is that they want to do it, but then their partners have no interest in doing an acute limb on the weekend. You can't do a haphazard approach to someone's life.

[Jihad Mustapha]

You just said the magic word actually. The magic word is partner and support. Those that want to do limb salvage and have the passion for it are willing to do it. But if they don't get the support from their group, especially the senior partners, they might not be able to excel. Maybe they'll dabble in it and do something here and there, but not get to a point where they can tackle almost anything that walks through the door. At our center right now, 90% or more of the consults that we get are limb salvage cases and amputation prevention.

[Sabeen Dhand]

So what are some other challenges with building a limb salvage program?

[Jihad Mustapha]

Let's talk about the top three challenges because there's so many. When someone comes and visits you at your center and they see everything is moving around and cases are being done, the impression is that everything is straight forward. The patient walks in, they get a procedure and they go home. What goes on behind the scenes is really what makes these three steps happen easily. That is failure number one, not having a good mid-level support that helps you behind the closed doors, sits down and examines the patient with you to come up with a good plan. A CLI therapist, interventionalist or surgeon, anyone that can provide revascularization, who spends enough time and understands the complex problem they're facing has to say if they can do it. Once you say you can do it, then that patient needs further imaging done and the patient is scheduled. The second failure is crossing. The patient can go through the initial process of evaluation, make it to the operating room, but the crossing of the CTO does not happen. As you know, in CLI the success rate is between 40-60% and that is not very good. If you only succeed 40% of the time, the patients that you see coming in, getting a procedure, and leaving is going to be very small. Not everybody can cross everything, including myself, but see what your limit is, try to get to it and improve it. You have to improve your limits until you get to a 90% crossing rate. Then you're good. The third obstacle is dealing with groin complications and also intraprocedure complications. We have complications like everyone else, but ours are extremely low because we use ultrasound every step of the way. We evaluate the access point before we get an access. And when we close, if we use a closure device, we do the ultrasound as well. If we're trying to cross and we can't cross, we use ultrasound, then we cross. And finally, we use retrograde access, tibial access or pedal access. If you don't master these challenges, your failure rate is going to be very high, 40-60%. If you master what I just mentioned to you, your success rate will be in the 90s. We have a very high success rate considering that the patients that we get are amputation prevention or limb salvage.

Pedal Access and Extravascular Ultrasound

Dr. Mustapha discusses the evolution of tibial-pedal access in the treatment of complex limb ischemia. Aside from serving as an alternative to groin access, pedal access also allows for shortened operating time and reduction in radiation and contrast. Pedal access provides interventionalists with the ability to deliver therapy from below when they are unable to cross a CTO from above. Dr. Mustapha also discusses the efficacy of extravascular ultrasound in comparison to fluoroscopy and palpation during CTO crossing.

[Jihad Mustapha]

I got to my cardiology fellowship at Louisiana State University, and I did peripheral intervention and coronary intervention in vascular medicine. One thing I found to be extremely interesting is the tibial-pedal anatomy and how afraid everyone was to come near it or even advance a wire into the tibial artery. So, I fell in love with the tibials because nobody else wanted to mess with them. I decided, well, I'll mess with them. In 2003, I finally finished training and started in the summer of 2003. The first week of work, I got in trouble and had to go to the office because I saw a patient with rest pain and I opened the SFA and the posterior tibial artery. That was probably the fourth day being at my practice. The problem was not that I opened the SFA, it was that I opened the posterior tibial artery.

[Sabeen Dhand]

In any kind of field, you've got to find something that needs work on or needs to develop a niche. You've definitely advanced tibial-pedal anatomy and interventions to a great degree. So congratulations on all of that.

[Jihad Mustapha]

Thank you.

[Sabeen Dhand]

I wanted to touch on two technical aspects that I think you and your group have really advanced. Everyone knows that pedal access now has changed the game of crossing lesions from an endovascular approach. How has pedal access evolved in the last five years in your group?

[Jihad Mustapha]

This will be the ninth year right now we've been doing pedal access. Initially, we went through the normal thing that everyone goes through and we did get the letters of reprimand of why we stuck a tibial artery or a pedal artery. We were defending ourselves. Then with trials after trials, we showed safety. We went through this and then we started to see what else we could do with pedal access. When you fail to cross from above, you can go from below and the success rate is significantly higher and quicker. This goes back to our point earlier that the success rate is only 40% in some centers to cross a CTO. With the pedal access in evolution, it's not just an access to cross. It also allows shortened time of the patient on the table, radiation reduction, and contrast reduction. And, now, we can deliver the entire therapy from below and the patient can go home within 45 minutes, depending on which size sheath and what you did. Eight years ago we were being reprimanded for doing pedal access and today, our patients actually come in and ask we don't go through their groin. They say, “Dr. Mustapha went through my foot last time and that was much easier.” We’re starting to hear that more. Right now, most of the time when I have a limb salvage, I start with the pedal access, then with the groin access. I'm not sure if I'm right or wrong, but we're evaluating it in our institution and I'll let you know in about six months.

[Sabeen Dhand]

I can't wait to hear about that. A lot of people have questions about #primarypedal and that's really going to be an interesting insight. I think most of our listeners know intravascular ultrasound when we can look at vessels, but extravascular ultrasound is an entirely different beast. What is that?

[Jihad Mustapha]

We call it EVUS, extravascular ultrasound. It's basically an ultrasound that is historically used for diagnostic imaging where you do an arterial Doppler or venous evaluation for DVT or venous insufficiency. What we decided to do is actually use EVUS as a tool for intervention during the procedure. We get access under it, put the sheath under it, cross the CTO, do the exchange, do everything that we need without using any radiation or contrast. Today, it's very hard for me to watch someone gain access under fluoroscopy or blindly by palpation. I feel bad for somebody struggling to cross a CTO, especially during a live case and they're just looping the wire and the wire is not going somewhere. In our center, we just put in an EVUS or an ultrasound probe and within two minutes, you can see where you're stuck. You go around it, and then you cross. And literally, it's just two to three minutes and you can go through what you're struggling with. EVUS is an extraordinary tool to use during complex revascularization and it makes your life so much easier. But the best part of it is that it has significant value to the patient in terms of safety, possibly efficacy too someday.

[Sabeen Dhand]

Totally great. I think the biggest challenge for people to get EVUS started is it does require a second pair of hands.

[Jihad Mustapha]


[Sabeen Dhand]

You have to have a vascular tech or someone else who's very familiar in that setting. You did note something, too, when you see someone else trying to get access with fluoroscopy, you chuckle to yourself, saying, "Oh no. Just use ultrasound. It's so much better."

[Jihad Mustapha]

Yeah. I do, but it will eventually become the norm.


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

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.