The Circle of Care: The Multidisciplinary Approach to Limb Salvage, Acute Limb Ischemia: Case Presentation

Purpose: Acute limb ischemia (ALI) occurs with an abrupt interruption of blood flow to the extremity and a sudden decrease in limb perfusion, threatening the limb viability. The  incidence is 1.5 per 10,000 and requires immediate revascularization. Prompt diagnosis and revascularization with thrombectomy is critical to minimize the risk of limb loss. Here, a 29-year-old man presents with ALI with cold left lower extremity and severe pain. He underwent emergent angiogram with mechanical thrombectomy with repeat attempts at revascularization, then was referred to vascular surgery for an open attempt that also yielded no success, leaving the treating team with only the option of major amputation. The critical limb ischemia (CLI) team and committee were critical in favor of limb preservation.

Materials and Methods: This case shows the importance of a multidisciplinary approach to limb salvage in ALI. It discusses the vascular intervention and the surgical procedure and advanced wound modalities used to achieve healing. We also will introduce the CLI team and CLI committee process that allowed for a committee review of this case prior to amputation and allowed for a formal second opinion process to provide all options before a major amputation. A 29-year-old man with ALI presented to another hospital where he was treated with many failed attempts and worsening tissue loss. Orthopedics was consulted and referred the patient to be transferred to a CLI center of excellence for treatment by the CLI team. Through a CLI committee process he was referred to be evaluated by limb preservation specialists who determined that he warranted an attempt at conservative transmetatarsal amputation vs below-knee amputation and repeat vascular evaluation. Successful limb preservation and minor amputation was achieved.

Results: The progression to wound healing and limb preservation, even after failed attempts due to a formal CLI committee review and second opinion leading to a successful revascularization and conservative wound management. The multidisciplinary approach from vascular intervention to surgical intervention and wound care that led to healing a wound where the only option was major amputation as recommended by all other specialists on his case.

Conclusions: The authors portray the importance of a team approach and coordination of care essential to bring all disciplines together for optimal wound healing and limb preservation.