CLI Perspectives
Defining CLI From the Front Lines of Care

Dr. Eric C. Scott is a very involved CLI operator and has dedicated a large portion of his career to CLI. I am happy to have this chance to share his thoughts and experience with you.
J.A. Mustapha, MD: Dr. Scott, without looking at any published data or journals, how would you simply define CLI today?
Eric C. Scott, MD: I define CLI as ischemic rest pain, non-healing wounds in the setting of peripheral arterial disease (PAD), or frank gangrene of the lower extremity. Of these three entities, I find non-healing wounds are really the only component that often require some additional history taking and interrogation to accurately define as CLI or not. Neuropathic ulcers in diabetics, for example, are often identified in the absence of any degree of PAD and do not constitute CLI. However, a foot wound in a diabetic that is not healing, with clinical evidence of PAD, is CLI. The “clinical evidence” of PAD is where perhaps where we have historically gotten tripped up.


Dr. Mustapha: Based on your definition, will you be able to superimpose what you described onto the recently published task force consensus paper1 from the Society for Cardiovascular Angiography and Interventions (SCAI)?

Dr. Mustapha: Do you get the sense that CLI is receiving plenty of attention today because of its associated cost and the focus on how to lower that?

We already know that amputation is not an appealing therapy for most patients with CLI nor is it cost effective. This puts increased pressure on vascular specialists to perform often complex endovascular or surgical therapies in an attempt to save limbs. So I think for many of us, CLI has our attention because of the magnitude of the problem and the difficulty in providing clinically beneficial therapies to these challenging patients.
Dr. Mustapha: CLI is on the radar of governmental bodies such as the FDA and CMS, as you noted. Do you believe that what is currently being done is helping to move the CLI field forward?
Dr. Scott: I think the field of CLI is moving forward on multiple fronts. First, the medical device industry, working in conjunction with numerous vascular specialists, continues to push the development and testing of new therapies for below-the-knee (BTK) disease. Drug-coated balloon technologies for BTK, “specialty” balloons, and novel atherectomy devices come to mind first and may each push the field forward. Second, there is hardly a national or international vascular symposium that does not devote considerable time and attention to the evaluation and treatment of CLI patients. Through these symposia, valuable therapies, technical details, and data are disseminated worldwide. And finally, over the next five to ten years, the collection of clinical data in multiple, ongoing CLI data registries and clinical trials will hopefully produce a wealth of new information to guide us on selecting the right therapies for the right lesions in the right patients.
Dr. Mustapha: We all use the term “multidisciplinary CLI team”. Accordingly, 1) Do you have such a team at your institution? 2) How much support do you get from your administration? 3) Has this team made an impact on your CLI patients?
Dr. Scott: I am fortunate to have such a team assembled at my institution. CLI patients require an extraordinary amount of care initially, as multiple related issues often need to be addressed simultaneously to optimize wound conditions and prepare for revascularization procedures. Regular and frequent follow-up has also been shown to be essential in achieving good outcomes. Honestly, it is too much work and beyond the scope of most physicians to provide all facets of CLI care alone. So a team is essential. What that team looks like though — like politics — is local. In my clinic and hospital, I work very closely with numerous podiatrists who provide excellent care to the entire foot, from wound care to minor amputations. We communicate regularly about challenging patients or acute problems, and do so by phone or secure text to avoid delays in communication. We also utilize the input of infectious disease specialists for detection and treatment of foot infection, and internists for assistance with medical management of diabetes and other vascular risk factors.
Dr. Mustapha: Dr. Scott, if there is one thing you wish CMS would do today to help you and your CLI patients, what would it be?
Dr. Scott: I don’t have any major concerns with current CMS policy, but I would certainly caution against additional bundling of tibial and pedal interventions in CLI patients. This could conceivably dissuade interventionalists from pursuing multiple tibial interventions in one setting when certain patients may actually benefit from the additional intervention and circulation.
Reference
- Klein AJ, Jaff MR, Gray BH, Aronow HD, Bersin RM, Diaz-Sandoval LJ, et al. SCAI appropriate use criteria for peripheral arterial interventions: An update. Catheter Cardiovasc Interv. 2017 May 10. doi: 10.1002/ccd.27141. [Epub ahead of print]
Disclosure: Dr. Scott reports no conflicts of interest regarding the content herein.
Dr. J.A. Mustapha can be contacted at jihad.mustapha@metrogr.org.
Dr. Eric C. Scott can be contacted at escott@iowaclinic.com.