Interventional practice has evolved, with new technologies, treatment guidelines and even practice environments for IRs. This is especially true of interventional treatments for PAD, as some treatments leave the hospital setting and gradually become more common in outpatient settings. IRs have shown that they can successfully provide high-quality PAD patient care in a variety of practice settings.
To provide perspectives from different settings, IRQ brought together a panel of PAD experts from varying practice environments to discuss several common questions regarding PAD treatments, including clinical tips, marketing strategies and more.
EU: Erika J. Ugianskis, MD – Indiana University Health Arnett Hospital, Lafayette
JB: James F. Benenati, MD, FSIR – Miami Cardiac and Vascular Institute
KM: Kumar Madassery, MD – Rush University Medical Center, Chicago
TC: Timothy W.I. Clark, MD, FSIR – Penn Presbyterian Medical Center, Philadelphia
What are the biggest advantages and challenges of your practice model?
EU: Our biggest advantages include our 24/7 availability to the community we serve, West Central Indiana, a predominantly rural region with a population of about 300,000. My partners and I are very collegial and are always available to one another to confer on cases. We enjoy doing this work and are virtually identical in our techniques, leading to consistent PAD care. We also assume responsibility for the longitudinal surveillance and care of our PAD patients. Our model’s biggest challenge is that our volume has grown markedly during the 8 years we have worked together, leading to a demanding caseload—which in the grand scheme of things is a good problem to have.
JB: Our model allows us to treat very complex patients, including those with CLI, claudication and AAA. We have five vascular surgeons in our practice so we can work as a team for very complex cases and do combination cases with both open and endovascular therapies at the same time. We also collaborate closely and work in harmony with our cardiology colleagues, so we share costs, ideas and devices on complex cases. We take a comprehensive approach to PAD, so we have a very mature office practice and follow all of our patients. For example, we often initiate statin therapy and or anticoagulation/antiplatelet therapy on our patients. We commonly initiate medical therapy and exercise programs in our patients in the office. We rely heavily on our noninvasive laboratory for pre- and post-testing and follow-up testing. In fact, this is probably the cornerstone to the PAD and venous practice. We read and interpret these studies daily. We currently do not have an outpatient facility for PAD, which is limiting because many patients prefer this setting and because of the streamlining efficiency that we can’t always achieve in the hospital.
KM: Our readiness to help any patient, anytime, has helped grow our PAD service, as has immediate and consistent communication with all care providers involved in the patients’ care. Although not always possible, having strong leaders who have helped pave the way for this process, such as our chief, help this process tremendously. Having access to our clinic to evaluate, follow-up and refer patients to has been one of the best assets we can have. In clinic, we can handle noninvasive evaluation, coordinate patients’ multifaceted co-morbidities, and the documentation necessary to be thorough in PAD care.
In our setup, our outpatient imaging and labs are down the same hall, so everything we need for the patient is a few steps away. Our very learned and comprehensive nurse practitioner fights hard alongside us to give our CLI patients the very best chance of limb preservation. Having time in the wound care clinic at our second hospital allows us to be ever present in our CLI population and perform our own wound care. This has drastically improved our quality of care and referral pattern.
Personally opening and eventually closing wounds, many of which need potential arterial, venous, infectious or other interventions, is possibly the most rewarding part of the CLI practice. Communication improvements and consistency has helped patients referred from other areas, other states, or as second and third referrals. After each case, images from the case with diagrams, expectations and plans are sent directly to the referring care provider, often accompanied by a phone call.
TC: IR brings a number of advantages to the care of patients with PAD. It must be emphasized that one cannot have a successful PAD practice without providing longitudinal clinical care, and ensuring all patients are receiving optimal medical management. This includes smoking cessation, blood pressure and glycemic control, antiplatelet therapy, and ideally medium- to high-intensity statin therapy. IRs who treat PAD are often making the initial diagnosis of PAD and this provides an opportunity to ensure patients are also assessed for coronary and neurovascular disease. This also enables creation of two-way referral pathways, further growing the PAD practice.
From a technical standpoint, IRs have a competitive advantage through mastery of CTO crossing, re-entry and alternate access techniques such as tibiopedal approaches. From a workflow perspective, IRs usually control their IR suite scheduling so that, if a complex revascularization procedure requires some additional time, they can accommodate it within their schedule. In contrast, vascular surgeons who are allocated fixed blocks of operating time may be less willing to perform certain PAD procedures (e.g., pedal arch recanalization) because of the additional time required to do so as they need to also use that time for their other aortic and carotid cases. This gives IRs a subtle but important advantage in treating complex CLI patients.
Another advantage is CTA, MRA and vascular ultrasound provided within radiology departments, particularly when the IRs participate in interpretation of those studies; this enables IR to provide guidance to other clinical colleagues seeking treatment options for PAD patients.
How do you market to your target patient population?
EU: We are very customer service oriented, with our customers being not only our patients but also the referring services. We take a direct personal approach in promoting our services to the hospitalists, primary care physicians, podiatrists and wound care clinics by communicating directly to the referring physicians and advanced care providers. We make every effort to reassure them that we will evaluate their patients and treat them accordingly. We also have a physician liaison within our local regional system who visits outpatient offices and educates physicians and advanced care providers as to the breadth of PAD services we provide: screening, imaging, endovascular interventions, surveillance and follow-up.
JB: We have many marketing strategies including letters to referring physicians, lunch-and-learns, educational dinners, and working with marketing specialists to distribute materials about our group and advertise on our behalf.
KM: Marketing is always at the forefront of our PAD discussions. I think what matters is first understanding all the clinical aspects, management and co-morbidities involved with PAD. Then comes the process of reaching out to your medical community.
Primary care, family medicine, endocrinology, nephrology, PM&R, podiatry and infectious disease specialists are just some of the care providers who come across these patients with whom an IR should establish good relationships. It is very important to help educate and develop a collaborative method of identifying these patients and making it easy for the other providers to reach out to you and receive prompt feedback. Also, by being collaborative with the other specialists who perform surgical or endovascular procedures in PAD, you can increase your referral patterns and opportunities to help patients.
By understanding the management of diabetes, anticoagulation, pain medicines and the other parameters that these patients commonly have together, you can be an active participant in the care of the patient and help your providers keep on top of their patients, which they will appreciate. Also remember, once you touch a patient, that patient should be your patient for life. The goal is not to be a procedural moment for these patients, but rather part of the lifelong management team for them and their families.
TC: In our practice, we also market our IO, UFE, PAE venous and spine services. Compared to these areas, PAD therapy is probably the most challenging to market. We regularly perform outreach to regional wound care centers, podiatry practices, clinical cardiologists, internists, vascular medicine specialists, nephrologists, and plastic and orthopedic surgeons who perform limb salvage.
A close feedback loop of information to the referring physician is essential. Any new referring physician gets a phone call thanking them for the referral and discussing the treatment plan.
We don’t currently use a lot of social media for marketing PAD therapies although many IRs have done this aggressively (or what some might characterize as relentlessly) with what appears to be a lot of success; in the COVID-19 era this strategy may become indispensable.
What patients would you not treat in your setting?
EU: Patients with acute limb ischemia who have an immediately threatened limb are referred for surgical intervention.
JB: In our practice we treat all aspects of PAD and PVD. There is really nothing we would not get involved with if it was indicated. We are very careful to review all studies performed at outside institutions and we are aggressive with exercise programs and medical therapy for all claudicants prior to offering intervention.
KM: In my setting there aren’t really any patients I would not treat. There are few patients who should not be treated in my setting, at least as a first option, including severe fulminant infection of a limb, threatened limbs with motor loss, early claudicants and a few others. Other than that, I have tried to be a place for excellent primary management of patients. However, I’m very happy to be the second or third opinion or even last hope.
I do wish we could do far better globally to address these patients on a preventative level so that they never get to the critical stage that we tend to see a of them at. We need to term CLI as arterial cancer, so that the importance of early detection, management and high level of care is established everywhere. Late-stage PAD is aggressive and undermanaged.
TC: We refer younger patients with severe common femoral disease to our vascular surgery colleagues for endarterectomy. Similarly, younger patients with severe claudication from long-segment SFA disease who fail medical management and want the most durable treatment option may be better off with a reversed saphenous vein graft.
What is your top clinical pearl for PAD treatment in your setting?
EU: Take the time to listen to your patients. Genuinely connect with them and build trust by demonstrating empathy for their concerns and reassurance that you are there to help them.
JB: Proper pre-procedural workup is the key to successful endovascular therapy. A history, physical and noninvasive testing with proper explanation of all options and risks before every procedure will decrease complication, decrease procedure time, and will form strong bonds with the physician and patient that will be lasting. Secondly, an open mind to new technology and new ideas is essential.
KM: There are some pearls to be taken with a grain of salt with PAD patients. First and foremost, it is imperative that you know when not to touch a patient. This is more important than knowing how to do a distal deep vein arterialization. This relies on giving ample time to have a proper initial consult, whether it be in the clinic or if as an inpatient. The biggest disservice that is done is not have a proper workup, whatever that may consist of in one’s practice. Having a consistent system that produces great results and follow-ups is the key.
One issue is that many people preach as to what they think is the best system, but there is not one. These patients are complex and deserve individualized management. Understanding that although ankle brachial index (ABI) tests are part of the gold standard workup, knowing when to get exercise ABIs, toe pressures, wound biopsies and better diabetes/infection management are all important to excel at PAD care. Being patient and knowing when to ask for help or another opinion can all improve care for patients.
TC: Strive to be the best vascular specialist you can be and provide comprehensive longitudinal care in your PAD clinic. Use endovascular techniques and technologies judiciously and based on best available evidence. Look to collaborate with colleagues in vascular surgery, interventional cardiology and vascular medicine. If you bring passion and commitment to the care of PAD patients, you will be successful in growing and maintaining a busy PAD practice.
Is there anything else you’d like to share?
JB: PAD management is within the realm of IR but there must be strong commitment to the clinical management in order to be on par with surgical and cardiology colleagues. It requires an understanding of the disease and commitment to patient care on top of the technical skills required. In our practice, we are involved in clinical research and use as many new devices as we can, but we want to do so in a controlled and scrutinized manner.
KM: Developing and growing a PAD practice is predicated on a strong desire to take some of the most clinically demanding and critically ill patients who have been undermanaged for decades and doing your best to provide an improved quality of life and reduce their mortality. One of the issues is the fragmented care that occurs with many of these patients and even more concerning is the lack of awareness, detection and appropriate referral of patients with PAD.
All too often, we see these patients when they are at dire straits, with terrible wounds, pain and other difficult scenarios. A lot this falls on each of us. The main issue for IRs is that we have yet to establish widespread clinical and technical high-level training in this disease process. We focus heavily on oncology, which is fantastic, and we are making great strides in that area. However, the importance in PAD of understanding the data, fully bringing treatment into the clinic, and continually innovating complex vascular procedures and wound care is not a focus … yet. It is growing and, with the interest from newer young #IRads, we are seeing an increase. With the dedicated residencies, we hope this becomes the standard.
