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BackTable / VI / Article
Building an Acute Limb Ischemia Program: Focus on Referrals
Melissa Malena • Oct 8, 2023 • 67 hits
Washington University faculty member and expert interventional radiologist Dr. Alexander Ushinsky shares his experience in building a thriving peripheral vascular practice with a successful acute limb ischemia (ALI) program. WashU has a mixed practice with University and community hospital vascular patients, and both inpatient and outpatient care. In cases of acute limb ischemia, Dr. Ushinsky is referred patients from the ER, inpatient and outpatient locations.
Common symptoms indicative of ALI are acute pain, cold limb presentation, and motor and sensory loss. Upon initial workup, Dr. Ushinsky recommends a detailed patient history and physical exam to determine diagnoses.
This article features transcripts for the BackTable Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Brief
• The peripheral vascular practice at WashU provides an excellent example on vascular practice management and expanding patient volume.
• Emerging treatment includes a shift towards treating some acute limb ischemia cases in outpatient settings or with shorter inpatient admissions.
• Classic symptoms of acute limb ischemia include acute pain, sensory loss, motor weakness, and cold limb combined with a common history of peripheral vascular disease.
• The key elements to focus on in an initial patient workup are a comprehensive history and physical exam to ascertain acute limb ischemia.
Table of Contents
(1) Expanding Peripheral Vascular Care: Patient Referral Insights from WashU's Practice
(2) Acute Limb Ischemia Patient Presentation & Hallmark Symptoms
Expanding Peripheral Vascular Care: Patient Referral Insights from WashU's Practice
Dr. Alexander Ushinsky explains the burgeoning growth of the peripheral vascular program at WashU. Amidst an expanding academic and community practice landscape, the WashU team, including Drs. Ushinsky, Guevara, and Sauk, have diligently cultivated a robust peripheral vascular practice, expanding both elective and emergency care across university and community hospitals. Dr. Ushinsky underscores the significance of building and maintaining relationships with referrers as a pivotal aspect of this expansion. Their concerted efforts have resulted in a remarkable increase in case volume, from virtually zero to 300-350 cases annually within just a few years, reflecting the impactful transformation in peripheral vascular care delivery at WashU.
[Dr. Chris Beck]
If you don't mind me asking, I just want to know a little bit about the WashU program. How many IR docs is it? How many facilities, just ballparking?
[Dr. Alexander Ushinsky]
We have a pretty large practice. In the academic core, we have 15 faculty, so 15 IR docs. Then in addition to that, there's two or three IRs who work in the community practice who staff a couple of the outlying hospitals, which the academic practice occasionally goes out to and have been expanding our services. For example, my colleagues in neuro IR now cover stroke at those satellite hospitals. It's a little bit of a dynamic process that I'm sure my colleagues who are in academics also have now experienced with the university's extending their presence in some of the community hospitals.
[Dr. Chris Beck]
With 15 IR docs, a lot of good work to be done, no doubt. Whenever you came on to WashU as faculty, did you know that this was an area that you wanted to dig into?
[Dr. Alexander Ushinsky]
I'd had a little bit of limited experience in residency, especially at a VA doing peripheral vascular, which I really enjoyed. When I did my fellowship early on at WashU, we had almost no volume of peripheral vascular. We were doing what was being done at the university where I did my residency at, which was mostly salvage on-call cases, acute limb ischemia, lysis catheter replacements, and not many or any elective peripheral vascular cases at all. Since that time, my partner, Carlos Guevara, myself, and a third partner, Steven Sauk, have really worked hard to practice, build, and build up a pretty extensive peripheral vascular program at WashU across all those sites that I mentioned before.
[Dr. Chris Beck]
All right. In a given week, just to give our audience an idea of what the practice is looking like now, how many cases of PAD? What do the cases look like? Are you getting all the dogs? Are you getting some of the good cases longitudinal? Is it one-off? What is it?
[Dr. Alexander Ushinsky]
Between the three faculty who are doing peripheral vascular, there's a little bit of different practice mixes. For example, I do maybe about 30% of my practice is peripheral vascular, same with my partner, Dr. Sauk. Carlos Guevara is probably 80% to 90% doing peripheral vascular.
[Dr. Chris Beck]
Wow. All right.
[Dr. Alexander Ushinsky]
He's really dedicated all of his, let's say, elective clinical work. He doesn't really support many other service lines other than placing the routine IR practice G tubes and drainages and things that we all do on call. Between the three of us, I think in the last academic year, we've done between 300 and 350 peripheral vascular cases, with I think Carlos probably doing in the 60% to 70% range of those given his practice mix.
We are doing these at both the university hospital and the community hospitals. The community hospital is more in an OBL-style practice mix, meaning it's mostly outpatient, prescheduled, relatively rapid turnaround. These are smaller hospitals. Then the university and one of the community satellites where we've been increasing our footprint, we are doing quite a bit of both inpatient and outpatient peripheral vascular work.
[Dr. Chris Beck]
Man, that's really impressive. When you think about the number of cases and you said like three years ago?
[Dr. Alexander Ushinsky]
Zero.
[Dr. Chris Beck]
Golly. That's incredible. Well, I know this isn't a practice-building podcast, it's not the topic. I want to get you back on, you and Carlos, to talk about how you built this machine. That's great.
[Dr. Alexander Ushinsky]
To be honest, Carlos started building it up while I was in my fellowship. I think the most useful thing I learned in my fellowship was that practice-building aspect of it and how to make these relationships with the referrers, maintain the relationships with the referrer. I'm sure you've had other guests speak about that in the past, but that's something that we don't learn very well as interventional radiologists is really how to run those aspects of a practice and maintain that culture.
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Acute Limb Ischemia Patient Presentation & Hallmark Symptoms
Navigating the intricate pathways of acute limb ischemia (ALI) begins with a nuanced understanding of patient presentation and workup. A patient with ALI may arrive through diverse routes, including the emergency room, inpatient, or outpatient settings. Despite the variance in presentation, classic symptoms like acute pain, sensory loss, motor weakness, and a cold limb often emerge as common denominators. Notably, Dr. Ushinsky highlights the changing dynamics in ALI treatment, with some patients now being managed in an outpatient or sub-24-hour inpatient admission, showcasing the evolution and adaptability in approaches to ALI care.
[Dr. Chris Beck]
All right. Getting into the topic, we're going to be talking about acute limb ischemia, if that wasn't clear. This disease can rear its head in a couple of different ways, but the first broad category is to talk about workup. It's a little bit artificial. We might just select a clinical scenario that best fits it. How do you start your workup maybe for an inpatient on acute limb ischemia? What's the typical presentation for you guys? I know that we're ignoring a lot of the nuance.
[Dr. Alexander Ushinsky]
Sure. I think when we get called, we get a consultation about acute limb ischemia. The patient usually arrives either through the ER or on the inpatient side. Occasionally, we'll actually get called from outpatient. We have a couple of OBLs in the community that are former alumni or former faculty at WashU. We've had a couple of calls from them. I have a patient who just called me up, has acute limb ischemia. They're at home. Can we send them over to you?
I think you and I, maybe we'll touch on this in the future, but more recently, we've been able to treat a few of those patients in a more of an outpatient or less than 24-hour inpatient type admission given some of the changes that are going on in the acute limb ischemia world. To go back to your initial question of how are these patients presenting, we're being called about patients presenting with these classic symptoms, acute pain, sensory loss, sometimes motor weakness, and cold limb. A lot of these patients carry some history of peripheral vascular disease in a more chronic setting, but not all.
Podcast Contributors
Dr. Alexander Ushinsky
Dr. Alexander "Sasha" Ushinksy is an interventional radiologist and assistant professor with Washington University in St. Louis.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2023, April 24). Ep. 315 – Arterial Thrombectomy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com 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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