BackTable / VI / Podcast / Transcript #60

Podcast Transcript: Building A Limb Salvage Program

with Dr. Jihad Mustapha

CLI fighters Sabeen Dhand and Jihad A. Mustapha discuss the essentials of building a successful Limb Salvage program, including the importance of a multidisciplinary approach, broadening skill sets such as pedal access, and meticulous patient follow up. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Starting a Limb Salvage Program

(2) What is Limb Salvage?

(3) Multidisciplinary Efforts in Limb Salvage

(4) Challenges of Building a Limb Salvage Program

(5) Evolution of Pedal Access

(6) What is Extravascular Ultrasound?

(7) Using Social Media to Build Your Limb Salvage Program

(8) Arteriovenous (AV) Flow Reversals in a Limb Salvage Program

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[Sabeen Dhand]
Hello everyone. Welcome to the BackTable podcast. Your source for all things interventional and endovascular. If you are a regular listener, welcome back and thanks for tuning in. We have a great show for you today with a special guest, Dr. Jihad Mustapha. Welcome Dr. Mustapha and thanks for being here.

[Jihad Mustapha]
Thank you for the great opportunity.

[Sabeen Dhand]
Before we dive into our topic today, just want to say a quick word from our sponsor, RADPAD. RADPAD is developed by physicians for physicians, clinically proven radiation protection during cine and digital subtraction angiography. Don't bet your career or your health on anything less. Trust RADPAD radiation protection shields for all your fluoro-guided interventions. See RADPAD.com for more information and contact info@RADPAD.com for a free radiation evaluation and a No Brainer radiation protection cap.

[Jihad Mustapha]
I wanted to reiterate what you said. Anything that is made by physicians for physicians is always something that has significant value because the physician has built that tool to protect him or herself. RADPAD, the way it's designed, it's designed for someone who has actually worked in a lab, so they're hands are under the fluoroscopy. So we use it exactly the way the designer designed it, the physician for physician without even asking the inventor. So yeah, it's a major part of what we do every day and as you know, the amount of scattered radiation that comes from the patients are tremendous.

[Jihad Mustapha]
So that's a major player in our lab and I recommend it for everyone.

[Sabeen Dhand]
Oh yeah. I completely agree with you. The fact that it's designed by a physician, those things totally just have a different point of view than someone who's not in the lab. So it's a great point. Many people don't know it, but you have a pretty unique background. You actually gave a TED talk many years ago about being a go-getter. They described you having $80 in your pocket and two pairs of pants when you came to the US as a teenager. How did you go from that to being a key leader in limb salvage?

[Jihad Mustapha]
Oh, Sabeen. I came to the US when I was 15 and had $80. I landed at 4:00 p.m. in New York. I came to the airport. And I started working the second day at 6:00 a.m. and today, I still have the $80 with me and I continue to work. I have not stopped since then. The first thing I learned actually being on Broadway and 20th Street and working is that everyone's walking fast and doing something. I decided that I was going to go ahead and make something out of my life, and I did. I worked during days selling umbrellas, among other things. At night, I went to school.

(1) Starting a Limb Salvage Program

[Sabeen Dhand]
That's an amazing story. That's an amazing accomplishment. Where did you do your education and training? And where's your current practice?

[Jihad Mustapha]
Actually this is my favorite part of my life. You know how when you finish high school in the United States and you look for the best college or university there is to go to? This is an exciting time for everyone. I have twins. Right now, they are going through it and they got accepted to a couple elite schools and other universities, etc. And they're very excited and happy.

The way I did mine, actually, back in the day, I went and looked for the cheapest school there was, and that is a true story. So I went to the cheapest school I could find and it was called Wayne County Community College. I started there. The credit was only $18 the first year and went up to $20 the second year. I was not happy about that.

[Sabeen Dhand]
Wow. Yeah.

[Jihad Mustapha]
From there, I went until I got to my cardiology fellowship at Louisiana State University and then did peripheral intervention and I did coronary intervention in vascular medicine. They have a program for vascular medicine and peripheral intervention. So I spent an additional couple of years actually doing that. The one thing that definitely stuck with me and I found to be extremely interesting is the tibial-pedal anatomy and how afraid everyone was to come near it or even advancing a wire into the tibial artery.

[Sabeen Dhand]
Oh yeah. So true.

[Jihad Mustapha]
So I fell in love with the tibials because nobody else wanted to mess with them. So I decided, well, I'll mess with them and I started then.

[Sabeen Dhand]
That's amazing. When did you start in your own practice? What year was that?

[Jihad Mustapha]
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, the usual thing. And the reason I got in trouble was because I saw a patient in the office 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 because I opened the posterior tibial artery. That was in Grand Rapids, Michigan, and I continue to live in Grand Rapids, Michigan, right now and am associated with Michigan State University.

[Sabeen Dhand]
It's always amazing, in any kind of field, whether it be medicine or even just industry, 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]
What about your current practice? Where are you now? Is it hospital-based or part of a group?

[Jihad Mustapha]
For many, many years--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 where we actually outgrew the hospital because the number of patients that needed procedures was beyond the number of cath lab time available to do the procedures. This is when we elected to work in the hospital, but also open our own center, 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 and we've hired five physicians in the course of two years.

[Sabeen Dhand]
Wow. You guys have five now.

[Jihad Mustapha]
CLI is not a simple disease. It's a very complex disease and requires a lot of support.

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

[Jihad Mustapha]
No. Actually we hired primarily vascular surgeons. And I don't like to use the word hired. We had four vascular surgeons join us and they're our partners now. As you know, Sabeen, 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, seek colleagues that have similar interests and now together we're making 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 do the coronaries. The rest of us, we full-time just doing CLI. And even Dr. Saab has gotten to the point now he's doing less and less coronaries because actually, CLI practice is not allowing him to do coronary anymore. On a serious note, when we sit down and discuss it in terms of: where are you making the most difference in terms of patient's improvement and quality of life and possibly actually reducing mortality? This is all probability. Sabeen, we found that if you have critical limb ischemia, your average lifespan is about 2.1 years after you've been diagnosed with it versus if you have an acute MI, you can live for another 50 years. It depends on what kind of lifestyle you have.

So based on that concept, I shifted already to completely CLI. I stopped doing coronaries a year ago and Fadi is slowly shifting to CLI.

[Sabeen Dhand]
You have a very strong partnership with Dr. Saab. He's awesome. How do you guys know each other?

[Jihad Mustapha]
Dr. Saab came from Tufts University to work in Grand Rapids and he had a great interest in peripheral vascular disease. You can tell that he's got great skills. He's the only one that would stay with me until midnight every day. We built that relationship and basically, we think alike. We do the same work together. We have the same approach to the same problems, but occasionally, actually we have different approaches which helps. This is how we came out with many things that we do, like with AV reversal, which we've been doing actually for about eight years now. This is the ninth year.

And we've been doing arterial bypass, venous-to-artery and venous-to-artery. So basically, the desperation and unmet need forced us into doing things outside the box, and the limb salvage rate that we have with these types of procedures has led us to become more excited and confident in doing more of these kinds of procedures.

[Sabeen Dhand]
You mentioned how he would be the only one that stayed with you until midnight. I think it's so important that this disease requires dedication. Just doing a superficial pass, trying to delve into it, is really not the way to start a limb salvage program. Do you agree with that?

[Jihad Mustapha]
I super agree with that. We hear the word limb salvage program a lot, 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 will 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 give up quickly and you quit.

So Fadi was extremely passionate and dedicated, and as you know, this is the love of my life to do this kind of work. So before you know it, it was midnight. And this is how you do a limb salvage program. You can't do it 9:00-5:00.

[Sabeen Dhand]
I've talked to some of my friends and colleagues who have recently graduated and 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. We don't talk about this a lot because they're sensitive issues and sensitive topics.

[Jihad Mustapha]
Some want to do limb salvage, have the passion for it, and 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 and probably won't be able to have a complete limb salvage program. 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, education and prevention.

(2) What is Limb Salvage?

[Sabeen Dhand]
Just so we don't get too ahead of ourselves, for trainees who are listening, what's your definition of limb salvage?

[Jihad Mustapha]
Limb salvage, at the end of the day, the way I look at it is as the following: A limb salvage is a limb that is saved from amputation, allows the patient to be independent of others, have a good quality of life, return back to society and work and contribute, and be able to maintain the limb beyond three months. The reason I say that is because for patients with critical limb ischemia, you can save their limb, but if you don't maintain it, it's not a limb salvage. And finally there are medications.

Sometimes some of the procedures you do to save a limb could be, I don't want to say easy, but could be easier than the norm. But what happens after the procedure, what really counts the most as a limb salvage or limb saved is the maintenance of it. And we have patients now out to eight-to-nine years post limb salvage and they still have their limbs on.

[Sabeen Dhand]
Amazing. That sure far beats the 2.1 average lifespan of someone who's diagnosed with critical limb ischemia.

[Jihad Mustapha]
I'm glad you said that Sabeen because that is actually the reality that we face. And 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. The fact is that 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 and make everyone aware about the seriousness of critical limb ischemia.

(3) Multidisciplinary Efforts in Limb Salvage

[Sabeen Dhand]
So speaking about 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 members of the CLI Society board members. “Leave your specialty at the door” came after many long discussions about the contribution of the different specialties toward the patient's outcome. And we found that when you combine the effort of the multispecialty approach toward a single patient, there's a 90% improvement in outcome of any patient that you treat.

Because of that, 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 that will treat a patient by himself or by herself. So “leave your specialty at the door” is to push us to work together more. You know, Sabeen, any one of us might get to a point where you hit just a brick wall and you 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 it's so good and you'd be like, "Wow. That is simple. I can't believe I didn't think of it.”

So this is how it was born, basically in discussions behind closed doors. And we found if you combine the specialty effort together, the outcome for the patients is better. And we published a nice, large manuscript 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's all involved?

[Jihad Mustapha]
Today is a good day, actually to answer that question for you because now that we have our own independent limb salvage or amputation prevention center, we have this direct relationship with our partners, the vascular surgeons that work with us side-by-side every day and podiatrists, as well. And then we have these deep relationships with Infectious Disease, wound clinics, Endocrinology and any other primary care physicians that offer care for patients. So we have this deep relationship with all of them together.

And it's similar to the paper that we published in JACA at one point. And not just the relationship, but what I've found to be extremely important, is to pick up the phone and call someone and let the Wound Care know that you just opened the artery, and it's a good idea if you do something this week--and the same thing with the podiatrist. I'm not sure if the operators of the surgical operation and vascular operation communicate with the primary care physician or a wound care specialist as often as they should.

Because we are physicians, we found that we are unable to do everything, so we created a midlevel provider who is with us at the end of every case, and we make a quick summary and send it to everyone. And I really recommend this for everyone to do. Primarily, it was just sent to the wound care clinic and the podiatrist and the Infectious Disease doctor if they're involved. And then, we decided finally to just send the message to everyone who was involved in the care of the patient. So right now, we just send a message to everybody.

(4) Challenges of Building a Limb Salvage Program

[Sabeen Dhand]
Excellent. I think your approach is a streamlined approach that anyone starting a limb salvage program can hope to attain. Like you said in your paper, multidisciplinary approach results in 90% improved results, so they can only hope to learn from that example. What about starting a limb salvage program? How does one start to build one?

[Jihad Mustapha]
I'm not going to say impossible, but it's harder than I thought. And the reason why it's hard 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 who 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.

So 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 in the hospital. We didn't have what we needed and we didn't have the support that we needed. 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, etc.

So having a limb salvage center, opening one is very tricky and not easy. So I don't want to make it sound like it's extremely easy and you just open the door like everyone tells you and everything will be fine. No. It requires daily hard work and extensive, meticulous follow-up. If you do that, of course there's a lot in between, but if you do that, you save a limb, maintaining the limb is what is most important in the limb salvage program.

[Sabeen Dhand]
Yeah. You hit it spot on. It's not an easy thing to say, “Okay, I'm going to do a limb salvage program.” For our listeners, I think it's important to know that, like we discussed before, it takes dedication and it's a challenge. 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. How does that help or hurt a program?

[Jihad Mustapha]
Thank you for bringing that up because unfortunately in 2020, competition and turf war still exists, despite the fact that we know that collaboration also exists. You have to choose. You have to make a decision that you are not going to fall into this trap of primitive behavior and get side-tracked and sucked into the vortex of the he-said, she-said things that go on, especially within institutions. And you need to actually stop, rise above it all and focus only on what's important and that is the patients. This is how we fought our war, actually.

Yes, we do have our battles. We do have the competition, but quickly, everyone realized that really, 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. So since that actually has resolved and there is the realization that we're just treating those that were scheduled for an amputation, we have less resistance. The turf war, it basically comes back to more of a claudicant patient population and those we tend to manage again, by using the same method.

[Sabeen Dhand]
So what are some challenges that people talk about when building a limb salvage program? You have a lot of international and local people that can learn from you, from your center. What are some of the things they say that they've noted as challenges of creating a program, other than the ones we talked about?

[Jihad Mustapha]
Let's talk about a few of them because there's so many. Let's talk about the top five challenges. When someone comes and visits you at your center, they see that everything is moving around and cases are being done. Patients come in the morning, get their procedures done, and get discharged. The impression that the observing physician sees--this is straight forward. The patient walks in, they get a procedure and they go home.

So what goes on behind the scene is really what makes this set of nice three steps happen easily. Failure number one is not having a good mid-level support that supports you behind the closed doors, where you and the mid-level sit down and examine the patient and form a good plan. And you--as a CLI therapist, interventionist, surgeon, or anyone that can provide revascularization--need to spend enough time and understand the complex problem they're facing and they can say, “I can do it or I can't do it.” You know, Sabeen, that is one of the hardest parts. Once you say that I can do it, then that patient goes into a path where further imaging is done and the patient is scheduled.

The second failure that we hear a lot about is the patient actually goes through the initial process of evaluation and makes it to the operating room, and the crossing of the CTO did not happen. As you know, in CLI the success rate is between 40-60%, and that is not very good. It depends on who you are. If you only succeed in 40% of the time, the patients that you see coming in, getting a procedure, and leaving is going to be very small. So the second thing is crossing.

The third obstacle that we hear a lot about is how to deal with groin complications and also, intraprocedural complications. We just presented our data at ISET recently for 1500 patients. We had a third party evaluate our patients. We have complications like everyone else, but ours were extremely low, and the reason they were low is because we use ultrasound in every step of the way. So we evaluate the access point before we get an access. And when we close, if we use a closer device, we do the ultrasound, as well. And if we're trying to cross and we can't cross, we use ultrasound and then we cross. And finally, we use retrograde access, tibial access or pedal access.

So these are the top five that in my mind, if you don't master those, your failure rate is going to be very high, like 40-60%. If you master what I just mentioned to you, your success rate will be in the 90s. I am never going to say we have a 100% success rate, but we have a very high success rate considering that the patients that we get are amputation prevention or limb salvage.

So I would like to say for those that are thinking of the obstacles, they should accept the fact that not everybody can cross everything, including myself, Fadi, and you. Everyone is going to face one of those, but see what your limit is and then actually 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.

[Sabeen Dhand]
Completely agree. We touched on earlier about how 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. So that's another reason why collaboration and more people who are highly involved can really help with that as well.

[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. So we don't mention it that much anymore in our practice here because now we have multiple specialists. So they can come in probably, in your scenario for example, they can just come in, put a PVL sheath for you, pass the wire up and walk away and they just saved you an hour of hard work, right? So we have to get to that level of telepathic combined work effort so the patient can get the best care from two physicians that combine their effort together.

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

[Jihad Mustapha]
Absolutely. Thank you. Leaving your ego is much better than leaving your specialty. Leaving both would be better.

(5) Evolution of Pedal Access

[Sabeen Dhand]
I wanted to touch on two technical aspects that I think you and your group have really, 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 our ninth year of doing pedal now.. And initially, we went through the normal thing that everyone goes through and I'd like to say that we did get the letters of reprimand and sit in front of a community just to find why we stuck a tibial artery or a pedal artery and the normal things, right? Defending ourselves. Then we did trials after trials and then we showed safety. So once we went through this and then we started to look what else can we do with pedal access? And actually pedal access did evolve significantly to the point that in the paper that Dr. Saab published, he showed almost 70% access reversal success rate. So when you fail to cross from above, you can go from below and the success rate is significantly higher and quicker, right?

So this almost goes back to our point earlier that the success rate is only 40% in some centers to cross a CTO. So without the pedal access and evolution, which now it's not just an access to cross, but evolved access to cross, shortened the time of the patient on the table, radiation reduction, contrast reduction and now, we deliver therapy through it. And the fact that we have slender sheaths now and RADPADs again, this has become very valuable, we can deliver the entire therapy from below and the patient can go home within 45 minutes. It depends on which size sheath and what you did.

So imagine Sabeen, eight years ago we were being reprimanded for doing pedal access and today, our patients actually come in and say, “Don't go through my groin today. Dr. Mustapha went through my foot last time and that was much easier.” So we hear that now. We're starting to hear that more. I've got to tell you, right now, most of the time when I have a limb salvage, I start with the pedal access, then with the groin access. And 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.

(6) What is Extravascular Ultrasound?

[Sabeen Dhand]
I like it. I can't wait to hear about that. That's interesting because a lot of people have questions about #primarypedal and that's really going to be an interesting insight. When I came to your course about a year and a half ago or two years ago at your center, I was really impressed with something called extravascular ultrasound. 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, right? Extravascular ultrasound. It's basically an ultrasound that is historically used for diagnostic imaging where you do an arterial Doppler, venous evaluation for DVT, or venous insufficiency. But what we decided to do, actually use it as a tool for intervention. So the way we look at EVUS, extravascular ultrasound, we look at it as a tool of intervention during the procedure. So if you remember last year, Sabeen, when you were here, we didn't do anything without it. And sometimes, we would go for about 10 minutes without using any radiation or any contrast.

We get access under it, put the sheath under it, cross the CTO, do the exchange and everything that we need without using any radiation or contrast. So today, it's very hard for me to watch someone gain access under fluoroscopy or palpation and also, I feel bad for somebody struggling to cross a CTO, especially during a live case where they're just looping the wire and the wire is not going anywhere. In our center, we just put an EVUS or an ultrasound probe and within two minutes, you can see where you're stuck and you go around it and then you cross. And literally, Sabeen, it's just basically two to three minutes and you can go through what you're struggling with.

So 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 and possibly efficacy someday.

[Sabeen Dhand]
Totally great. It's amazing. I think the biggest challenge for people to get EVUS started is that it does require a second pair of hands.

[Jihad Mustapha]
Absolutely.

[Sabeen Dhand]
So you have to have a vascular tech or someone else who's very familiar in that setting. But you guys have it down. And 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. We're going to be doing a big trial soon and you're going to be part of it, but we won't discuss it here now. But part of the discussion about that trial was would you consider doing EVUS-guided access versus palpation-guided access? And I said, "No. It's unethical today to do that."

[Sabeen Dhand]
Yeah.

[Jihad Mustapha]
So we declined to do such randomization because how could you, today, do a blinded stick into an artery where you actually can see exactly where you're going to get in, you can see what is going on with the artery and that will actually affect the safety of that artery. So therefore, we declined to randomize that part of the study.

(7) Using Social Media to Build Your Limb Salvage Program

[Sabeen Dhand]
Kudos. I completely agree. Going back to limb salvage, what about social media? Does social media play a role in starting a center or anything like that? That includes Twitter, Instagram, Facebook.

[Jihad Mustapha]
Social media is a phenomenal thing and like everything else, there's always ups and downs, but in general, social media helps tremendously. We share with each other the good case that we had and the bad case that we had 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, Sabeen, I had a question about a device and how to use it. And I sent a question and got a thorough response and guess what--I got pretty much got the answer that I needed. This is what I had to do and it was extremely successful.

We're moving toward an age where online in general, electronics or web, etc., is going to be part of our daily practice. And I look forward to the day where we all wear some sort of Google glasses or something and we can see what we're doing and help each other out while you're in California and I'm in Michigan. I'm not promoting anything. I'm saying it could be something someday.

[Sabeen Dhand]
Definitely. 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 learned so much from each other from there.

[Jihad Mustapha]
I learned coiling from Twitter, from you. So thank you.

[Sabeen Dhand]
You're welcome.

[Jihad Mustapha]
You are the master of coiling.

[Sabeen Dhand]
Nice.

[Jihad Mustapha]
About four years ago, I was a master here in my group, not everywhere else. But it just shows you. You ask questions and you do it all the time, right? The picture you guys gave me, that was phenomenal and now I can pretty much coil anything I need to. So yeah. What you actually get into in terms of Twitter or media in general, it is a phenomenal tool. We have to use it right and educate the young and the old and everyone that is willing to be educated on it.

[Sabeen Dhand]
Exactly and ignore. Sometimes there's a little bit of negativity and trolling on social media, but that's just easy to ignore and move on.

[Jihad Mustapha]
I went back to the old days of the competitive turf wars, and I decided not to fall back into that primitive thinking and I have not actually gotten back into any sort of negative action with anyone because it's not worth it, really.

[Jihad Mustapha]
You're right. It does happen and I'm very grateful to everyone that steps up and says, “Stop that, that's not necessary and let's focus on something positive.” And it's been really nice lately.

(8) Arteriovenous (AV) Flow Reversals in a Limb Salvage Program

[Sabeen Dhand]
Yeah. I agree. You briefly touched on a new technique as far as AV reversal or percutaneous bypass. Do you think this is something we'll be able to do in independent limb salvage centers or is it only something in the hospital?
[Jihad Mustapha]
You know, actually I've got to tell you a funny story, where we sent Dr. Saab to the hospital to do an AV reversal on a patient and he was gone for six hours. We felt bad for him. It must have been a really tough case that he took six hours to do it. He said, "No, it only took me two hours to do it, it's just waiting for the devices to be found to do it." And the problem we learned later on was that hospitals actually don't have everything that you have in your outpatient centers.

Again, this is not by any means taking a cheap shot at any hospitals at all, except that when you have your own center and when you do these kinds of procedures, you're prepared for them and you have all the tools that you need. It's just like what you started with today, building tools by physicians for physicians, right? And now when you build your center, you build it for you, for what you do every day. So now we don't do them enough anymore.

So actually, all of our arteriovenous flow reversals are done here in the center. Actually they are far more efficient, quicker, safer actually, much safer and even the arteriovenous-arterial bypass, we do them in the outpatient center, as well. And those are actually easier than the AV reversal because they have less requirements. A long discussion, but in general, we're going to be actually putting the details in the CLI Global, general couple of cases coming out. Imagine you feel more comfortable doing an in situ bypass in the outpatient center than doing it in the hospital because of the lack of tools that we need.

[Sabeen Dhand]
Yeah. I personally can't wait to read those articles when they come out. It's going to be very interesting and I'll adopt it to my own practice. For our listeners, is there anything else you would say that we didn't really cover about developing or starting a limb salvage program that you want them to know?

[Jihad Mustapha]
I just want everyone to be realistic. There's a big difference between an office-based lab (OBL) and a limb salvage program. An OBL, you can do a lot of straight forward procedures that will take you 45 minutes. there's a lot of us that can do that and those that are doing it, and I congratulate them and wish them the best. If you really want to open a limb salvage program, I would like you to think twice about it and make sure that you're up to the task and also, the financial task. Financially, it's not as lucrative as other things, but rewarding in terms of fulfilling your passion towards limb salvage.

So it's doable, Sabeen, but it takes more work and 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, me and Fadi. I don't know who has that. I would love to be part of them. For limb salvage, it's a whole different beast. And as you can see, I'm not saying it's easy and I can't say it's easy. It's complex. It's doable. Just to be committed and to be ready to go through all the obstacles that you're going to face. There are so many of them.

It takes you a year before you feel comfortable because in that year, you build--like we said earlier--Sabeen,yYou build your practice to shape it to your needs to the things that you're going to do and you're going to be doing. So that year, you just have to be able to ride it out and get to the point where you're comfortable. And I wish everyone the best because I would like to see more and 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. So thank you so much for everything that you do and thanks again for speaking on the podcast today. That pretty much wraps it up on my side. So I'd like to thank our sponsor, RADPAD, and thank all our listeners for listening. Jihad, keep on doing what you're doing. I really look forward to seeing what the next year or two holds for you.

[Jihad Mustapha]
Thank you so much, Sabeen, and you keep doing the same thing.

Podcast Contributors

Dr. Jihad Mustapha

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

Dr. Sabeen Dhand

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 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.