Taking a Multidisciplinary Approach to Peripheral Arterial Disease
Updated: Mar 10, 2019
From podiatry to interventional radiology, peripheral arterial disease (PAD) is managed by numerous medical specialties. A multidisciplinary approach to treating PAD gives patients the best surgical options and ultimately creates opportunities for IRs to take on new cases.
The BackTable Brief
Podiatric patients with poorly healing wounds may need endovascular care; forming partnerships with podiatry can help achieve the same goals- which are healing wounds and saving limbs.
Collaboration between interventional radiology, interventional cardiology, and vascular surgery can also lead to improved patient management by deciding together which cases would be best for a specific treatment.
Below the knee PAD cases can be technically difficult, providing an opportunity for skilled IRs to take on more PAD work that other physicians may not be comfortable with.
Disclaimer: The opinions expressed by the participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Partnering with Podiatry
[Michael Barraza] I've actually learned a ton of tips and techniques from the two of you and others, just through Twitter. It's been a great resource for that. It's part of how we decided to reach out to the two of you.
But one of the things I noted, maybe about a month ago, was that you had posted something about your partnership with the podiatrists at Rush. Is that something that you guys use as part of your practice?
[Kumar Madassery] Yeah, I think the collaboration with podiatry is something that over the last few years has been growing leaps and bounds. Dr Arslan, our director, he's a big aortic and PAD guy, he actually brought the president of the APMA, the American Podiatry Association, to SIR a couple of years ago as a first ever joint session where we kind of talked about how important it is for IR and podiatry to work together, because we both have ultimately the same exact goal which is saving that limb.
I mean, podiatrists are daily battling the non healing wounds, and we are the ones who can help them with kind of the best expertise and capabilities to get them the best help possible, so it's kind of a natural relationship that gives the patient the best options. So, we do a lot of work with podiatrists, a couple of us cover the wound care clinic with them, and then help them on all patients and kind of co-manage them.
It's a beautiful relationship, and I think we try to educate and tell others to work on as well. Actually I give a talk with one of our podiatrist at our medical school because they also have one of the best podiatry schools in the country. So giving those students an understanding early on, the importance of this relationship, I think it's something we need to all extrapolate.
[Michael Barraza] Yeah. Sabeen, what about you?
[Sabeen Dhand] Yeah. I mean the relationship with podiatry I think is very important. It was something that was already established when I came to my group. There's a wound care center that's run by five or six podiatrists and the relationship with interventional radiology was established in endovascular care. They just get so many patients with terrible wounds and they're automatically, in addition to all their medical therapy, they automatically refer to us.
It's been a great resource. Most of our legs come from them. They're great people and we have a great relationship. And I think if anyone's starting to start a PAD practice, just reaching out to the community of podiatrists and showing that you're available would help you a ton. There's so much out there and so many podiatrists that don't have an endovascular specialists that can help them. It's just an unused resource.
Sharing the Case Load with Other Specialists
[Michael Barraza] Did the two of you have many issues with turf battles, with either cardiology or vascular surgery, either involving the podiatrist or otherwise?
[Kumar Madassery] In our platform, in our district, we have what's called interventional platform, where we have 14 rooms. The majority of it's for IR, but there's one or two for cardiac interventional, and then neurointerventional.
And vascular surgery is a very great surgical specialty that we have as well. Once Arslan and Turba came a few years ago, it just demonstrated the capabilities. We started working together with vascular surgery and co-managing all the patients, and deciding together which one would be best for surgical options, which one is not. We can try it first. We're not burning any bridges, because we demonstrated that we had that capability.
It's kind of a unique relationship because they trust us and we always discuss cases together. We have a weekly vascular surgery conference. In between there are some transitions that may come and go, but so far we've demonstrated our capabilities and our outcomes are very good. Working with podiatry is an added benefit. So in terms of turf war, it's not really there. Some of the other specialties are doing some work, but in the grand scheme of things, especially at CLI, we do primarily all of it. I think we keep up our outcomes and everybody's happy. Sabeen and I were actually talking with some other colleagues around the country on Twitter. When you have those battles and you feel like it's difficult to get those patients, you just have to learn how to be the collaborative one, and take on the hard cases but also try to mend a fence. Try to reach out, try to say, "Hey, we can probably work on this patient together," or send the referral when you think it's a better surgical candidate.
Once you open up those doors, which is not always easy, at least you're demonstrating a better multi-disciplinary approach than just trying to do cases that feel like you're being observed.
[Michael Barraza] Right.
[Kumar Madassery] Whether you're cardio interventional or interventional radiology or vascular surgery, you want to develop a system in your institution that gives the patient the best outcome, not just the service line.
[Michael Barraza] Absolutely.
[Sabeen Dhand] Exactly. Even sometimes I'll call the vascular surgeon in the middle of the case, and have them review the films, and ask them, "Do you think this would be better for a bypass?" And more so, I kind of already know the answer, but I'm just keeping them in the loop. And I think just working collaboratively is important just to keep relationships up top, too. Targeting Below the Knee PAD
[Michael Barraza] And for me, here in Nashville, it's primarily vascular surgery and so it's been a bit more of a challenge to go out and get these. And what it appears to me is that the best place for me to start, is to start below the knee, which in my experience tends to be more of the challenging cases.
[Sabeen Dhand] Yeah, definitely. I see it a lot when I talk to other people about turf wars with vascular surgery, and even cardiology. And I think below the knee is definitely a place where interventional radiology can shine because I've also seen vascular surgeons just not really go below the knee. Our cardiologists just are not comfortable with it.
My situation at PIH is kind of unique where we have two vascular surgeons who are a bit older and they're not interested in endovascular interventional stuff. And our cardiologists don't touch legs either. All the care goes to us. Which is unique and I hope it stays like that forever. I know that can change. But it's a good situation for me. I was going to say that below the knee is where I think most interventionalists can really shine. And they are the tougher cases. If you have a good mentorship or something, someone just to teach you how to do it, you can do a lot of good care.
Podcast Participants: Dr. Sabeen Dhand is a practicing interventional radiologist at PIH Health in Whittier, CA. Dr. Kumar Madassery is a practicing interventional radiologist with Rush University in Chicago. Dr. Michael Barraza Jr is a practicing interventional radiologist at Radiology Alliance in Nashville. Cite this podcast: BackTable, LLC (Producer). (2017, August 16). Ep 9 – #StopTheChop [Audio podcast]. Retrieved from https://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. Disclosures: None.