When PAD advances to the extreme stage, the lower limbs become susceptible to Critical Limb Ischemia (CLI).
JD Corl,MD, discusses Peripheral Artery Disease and Critical Limb Ischemia, and when to refer to a specialist.
Selected Podcast
Critical Limb Ischemia-CSI
Featured Speaker:
He grew up on the east side of Cleveland where he graduated from West Geauga High School in Chesterland, Ohio. Dr. Corl moved to Cincinnati in 1987 to study engineering at the University of Cincinnati. As an engineering student, Dr. Corl worked at General Electric Aircraft Engines and the Danis Construction as part of the University of Cincinnati co-op program.
Learn more about John D. Corl, MD
John D. Corl, MD
John D. Corl, MD, is an Interventional Cardiologist with The Christ Hospital Health Network.He grew up on the east side of Cleveland where he graduated from West Geauga High School in Chesterland, Ohio. Dr. Corl moved to Cincinnati in 1987 to study engineering at the University of Cincinnati. As an engineering student, Dr. Corl worked at General Electric Aircraft Engines and the Danis Construction as part of the University of Cincinnati co-op program.
Learn more about John D. Corl, MD
Transcription:
Critical Limb Ischemia-CSI
Melanie Cole (Host): Welcome to the show. Our topic today is critical limb ischemia and my guest is Dr. J. D. Corl. He’s an interventional cardiologist with the Christ Hospital Health Network. Dr. Corl, what is critical limb ischemia and when does it sort of come into the peripheral arterial disease play?
Dr. JD Corl, MD (Guest): Thanks Melanie. I appreciate you having on the show. Critical limb ischemia is the high-risk end stage form or peripheral vascular disease characterized by very poor circulation to the legs. The patients have severe pain and non-healing wounds and ulcers on their feet and lower legs.
Melanie: What’s the prevalence of it? Are you seeing more of it or less?
Dr. Corl: That’s a good question. You know peripheral artery disease affects 18 million Americans, one in twenty Americans over 50, one in seven over 70, one in four over 80 and one in three diabetics over 50, so peripheral artery disease is very common and critical limb ischemia affects a small minority, about 2% but that percentage is growing and we expect exponential growth of critical limb ischemia by 2020 to affect close to three million Americans.
Melanie: Dr. Corl, are you seeing peripheral vascular disease and critical limb ischemia trending up together as a curve or is critical limb ischemia going up more sharply by itself?
Dr. Corl: Yes. Peripheral artery disease is increasing. If you look at the risk factors obviously age is one of the big risk factors and Americans are living longer or collecting more risk factors like diabetes, hypertension, hyperlipidemia, coronary disease, tobacco use etc. These risk factors drive up the prevalence of peripheral artery disease and ultimately critical limb ischemia. In fact, tobacco use increases peripheral artery disease risk by 400%. Yes, with the increase in these risk factors and the prolonged life span, I think we are just getting more patients into this condition of peripheral artery disease and then again, critical limb ischemia where you have that high-risk end-stage form where the limbs are threatened.
Melanie: So, what’s the clinical presentation? What do you notice or what might the patient notice and how important is it to get treatment pretty quickly?
Dr. Corl: Yeah, so good question. So, peripheral artery disease in general, we know the classic claudication symptoms with leg pain with activity, fatigue, heaviness etc. Unfortunately, that’s only present in 10-35% of patients with obstructive peripheral artery disease. Many of these patients up to half, have an atypical presentation and many are asymptomatic. When it gets to the critical limb ischemia stage, these are patients with ischemic rest pain, they have to hang their leg out of bed to get gravity to help with perfusion. They often present with ulcers, sometimes small ulcers or wounds that just won’t heal because of the poor circulation. So, that’s often when they present for help at the wound clinic and then of course, they need further treatment to treat all their risk factors and improve circulation to their legs and feet.
Melanie: Tell us about some of the trends first in medical intervention. What are you doing in medication wise?
Dr. Corl: That’s a good question too. The treatment of these patients because they have all these risk factors, and comorbid conditions; you have to treat the whole patient. You have to treat the diabetes, the heart disease, the cholesterol, the hypertension, the tobacco abuse etc. If you don’t treat all those things, it’s unlikely that you are going to heal the wound even with good wound care. And then the other thing we touched on earlier, is these patients need better circulation, better blood flow to the foot to heal the wound. An ulcer or wound needs four times more blood flow to heal than you just need to maintain integrity of tissue. So, that’s one component, a very important component but you have to treat the whole patient, to treat al those comorbid conditions to help improve the chances of healing that wound and saving the leg.
Melanie: And when does it become surgical where you are going to look at endovascular procedures?
Dr. Corl: Well, the trend is moving more aggressive early treatment. So, when the ulcer is present, and it is not healing, that can proliferate quickly, and the trends are to get these arteries open and restore circulation to the foot sooner to improve that chance of healing so, the trends are going towards endovascular approaches, early aggressive approaches and trending away from the surgical approaches. These are high-risk patients for surgery, so often they are better suited with an endovascular approach. An endovascular approach can ultimately restore multiple arteries, blood flow to multiple arteries in the lower leg to improve chances of healing.
Melanie: So, what are some of your revascularization strategies? What are you doing?
Dr. Corl: So, that’s a good question. The strategies for revascularization have come a long way in the last five or ten years. In the old days, we would approach these blockages from above and try to get through, starting in a large artery and trying to reenter in a small artery. The trends now are to enter the vascular system with sheaths and catheters from below the blockages, often in the small arteries of the feet, the pedal arteries of the tibial vessels in the ankles and come up across these blockages from below and above attacking these blockages, these chronic little occlusions from two directions and trying to get across and then we have more tools to open these arteries with atherectomy devices of course, balloon angioplasty with some drug coated balloons and the stent technology continues to get better, so we have more tools to work with from an endovascular approach and it’s improving our procedure success and then ultimately, the durability of the procedure and then ultimately wound healing and amputation prevention.
Melanie: Dr. Corl, as far as research and clinical management in CLI, looking forward to the next ten years in the field; what do you feel will be some of the most important areas of research?
Dr. Corl: Well, the biggest need is better durable treatment options for the vessels below the knee. These are small arteries compared to the arteries in the thigh and then the pelvic area and of course, the aorta. These vessels as you get farther down the leg, get smaller and unfortunately, the disease seems to get more diffuse. There is a lot of calcium. These are difficult vessels to treat and our treatment options are somewhat limited. We don’t have good stent technology for down there, in fact there is no stents approved below the knee for critical limb ischemia patients. Atherectomy devices are getting better, but we need better atherectomy devices, better balloon results. I think the real advancement need to be below the knee in these smaller vessels to get better durability, better patency.
Melanie: So, in summary Dr. Corl, please tell other physicians what you would like them to know about recognizing critical limb ischemia and when to refer to a specialist.
Dr. Corl: Well, I would recommend referring early if you have suspicion of peripheral artery disease in the setting of rest pain or ulcers. The reality is most of these patients are grossly under treated. About 54% of these patients don’t have an angiogram prior to an amputation, 67% of Medicare patients do not even have an attempt to revascularize these vessels prior to amputation. We need more aggressive, more comprehensive treatment for these patients and these critical limb ischemia programs like we have put in place at Christ Hospital have been proven to reduce these amputations. If a patient presents to a hospital without a critical limb ischemia program, their amputation rate is around 64%. If they get to a hospital with a comprehensive critical limb ischemia program, the amputation rate goes down to 14%. So, if we can get these patients into the system, get them worked up properly and get them treated properly, we can significantly reduce the amputation rate.
Melanie: That’s excellent news and doctor, tell us about your team at the Christ Hospital Health Network.
Dr. Corl: Yes, so we have launched a critical limb ischemia program at Christ Hospital. We continue to build it. It’s an ongoing process and will continue with improvements. But the main goal of the program is to pull specialists together to coordinate the care of these complex patients and then navigate the patient through the treatment process to improve outcomes. You know like I said, if we can get these patients into a comprehensive program, their chances of healing those ulcers and saving their leg is much higher.
Melanie: Thank you so much. What an interesting topic. You’re listening to Expert Insights Physician Views and News with the Christ Hospital Health Network. More information on Dr. Corl and all of the Christ Hospital physicians is available at www.tchpconnect.org that’s www.tchpconnect.org . This is Melanie Cole. Thanks so much for tuning in.
Critical Limb Ischemia-CSI
Melanie Cole (Host): Welcome to the show. Our topic today is critical limb ischemia and my guest is Dr. J. D. Corl. He’s an interventional cardiologist with the Christ Hospital Health Network. Dr. Corl, what is critical limb ischemia and when does it sort of come into the peripheral arterial disease play?
Dr. JD Corl, MD (Guest): Thanks Melanie. I appreciate you having on the show. Critical limb ischemia is the high-risk end stage form or peripheral vascular disease characterized by very poor circulation to the legs. The patients have severe pain and non-healing wounds and ulcers on their feet and lower legs.
Melanie: What’s the prevalence of it? Are you seeing more of it or less?
Dr. Corl: That’s a good question. You know peripheral artery disease affects 18 million Americans, one in twenty Americans over 50, one in seven over 70, one in four over 80 and one in three diabetics over 50, so peripheral artery disease is very common and critical limb ischemia affects a small minority, about 2% but that percentage is growing and we expect exponential growth of critical limb ischemia by 2020 to affect close to three million Americans.
Melanie: Dr. Corl, are you seeing peripheral vascular disease and critical limb ischemia trending up together as a curve or is critical limb ischemia going up more sharply by itself?
Dr. Corl: Yes. Peripheral artery disease is increasing. If you look at the risk factors obviously age is one of the big risk factors and Americans are living longer or collecting more risk factors like diabetes, hypertension, hyperlipidemia, coronary disease, tobacco use etc. These risk factors drive up the prevalence of peripheral artery disease and ultimately critical limb ischemia. In fact, tobacco use increases peripheral artery disease risk by 400%. Yes, with the increase in these risk factors and the prolonged life span, I think we are just getting more patients into this condition of peripheral artery disease and then again, critical limb ischemia where you have that high-risk end-stage form where the limbs are threatened.
Melanie: So, what’s the clinical presentation? What do you notice or what might the patient notice and how important is it to get treatment pretty quickly?
Dr. Corl: Yeah, so good question. So, peripheral artery disease in general, we know the classic claudication symptoms with leg pain with activity, fatigue, heaviness etc. Unfortunately, that’s only present in 10-35% of patients with obstructive peripheral artery disease. Many of these patients up to half, have an atypical presentation and many are asymptomatic. When it gets to the critical limb ischemia stage, these are patients with ischemic rest pain, they have to hang their leg out of bed to get gravity to help with perfusion. They often present with ulcers, sometimes small ulcers or wounds that just won’t heal because of the poor circulation. So, that’s often when they present for help at the wound clinic and then of course, they need further treatment to treat all their risk factors and improve circulation to their legs and feet.
Melanie: Tell us about some of the trends first in medical intervention. What are you doing in medication wise?
Dr. Corl: That’s a good question too. The treatment of these patients because they have all these risk factors, and comorbid conditions; you have to treat the whole patient. You have to treat the diabetes, the heart disease, the cholesterol, the hypertension, the tobacco abuse etc. If you don’t treat all those things, it’s unlikely that you are going to heal the wound even with good wound care. And then the other thing we touched on earlier, is these patients need better circulation, better blood flow to the foot to heal the wound. An ulcer or wound needs four times more blood flow to heal than you just need to maintain integrity of tissue. So, that’s one component, a very important component but you have to treat the whole patient, to treat al those comorbid conditions to help improve the chances of healing that wound and saving the leg.
Melanie: And when does it become surgical where you are going to look at endovascular procedures?
Dr. Corl: Well, the trend is moving more aggressive early treatment. So, when the ulcer is present, and it is not healing, that can proliferate quickly, and the trends are to get these arteries open and restore circulation to the foot sooner to improve that chance of healing so, the trends are going towards endovascular approaches, early aggressive approaches and trending away from the surgical approaches. These are high-risk patients for surgery, so often they are better suited with an endovascular approach. An endovascular approach can ultimately restore multiple arteries, blood flow to multiple arteries in the lower leg to improve chances of healing.
Melanie: So, what are some of your revascularization strategies? What are you doing?
Dr. Corl: So, that’s a good question. The strategies for revascularization have come a long way in the last five or ten years. In the old days, we would approach these blockages from above and try to get through, starting in a large artery and trying to reenter in a small artery. The trends now are to enter the vascular system with sheaths and catheters from below the blockages, often in the small arteries of the feet, the pedal arteries of the tibial vessels in the ankles and come up across these blockages from below and above attacking these blockages, these chronic little occlusions from two directions and trying to get across and then we have more tools to open these arteries with atherectomy devices of course, balloon angioplasty with some drug coated balloons and the stent technology continues to get better, so we have more tools to work with from an endovascular approach and it’s improving our procedure success and then ultimately, the durability of the procedure and then ultimately wound healing and amputation prevention.
Melanie: Dr. Corl, as far as research and clinical management in CLI, looking forward to the next ten years in the field; what do you feel will be some of the most important areas of research?
Dr. Corl: Well, the biggest need is better durable treatment options for the vessels below the knee. These are small arteries compared to the arteries in the thigh and then the pelvic area and of course, the aorta. These vessels as you get farther down the leg, get smaller and unfortunately, the disease seems to get more diffuse. There is a lot of calcium. These are difficult vessels to treat and our treatment options are somewhat limited. We don’t have good stent technology for down there, in fact there is no stents approved below the knee for critical limb ischemia patients. Atherectomy devices are getting better, but we need better atherectomy devices, better balloon results. I think the real advancement need to be below the knee in these smaller vessels to get better durability, better patency.
Melanie: So, in summary Dr. Corl, please tell other physicians what you would like them to know about recognizing critical limb ischemia and when to refer to a specialist.
Dr. Corl: Well, I would recommend referring early if you have suspicion of peripheral artery disease in the setting of rest pain or ulcers. The reality is most of these patients are grossly under treated. About 54% of these patients don’t have an angiogram prior to an amputation, 67% of Medicare patients do not even have an attempt to revascularize these vessels prior to amputation. We need more aggressive, more comprehensive treatment for these patients and these critical limb ischemia programs like we have put in place at Christ Hospital have been proven to reduce these amputations. If a patient presents to a hospital without a critical limb ischemia program, their amputation rate is around 64%. If they get to a hospital with a comprehensive critical limb ischemia program, the amputation rate goes down to 14%. So, if we can get these patients into the system, get them worked up properly and get them treated properly, we can significantly reduce the amputation rate.
Melanie: That’s excellent news and doctor, tell us about your team at the Christ Hospital Health Network.
Dr. Corl: Yes, so we have launched a critical limb ischemia program at Christ Hospital. We continue to build it. It’s an ongoing process and will continue with improvements. But the main goal of the program is to pull specialists together to coordinate the care of these complex patients and then navigate the patient through the treatment process to improve outcomes. You know like I said, if we can get these patients into a comprehensive program, their chances of healing those ulcers and saving their leg is much higher.
Melanie: Thank you so much. What an interesting topic. You’re listening to Expert Insights Physician Views and News with the Christ Hospital Health Network. More information on Dr. Corl and all of the Christ Hospital physicians is available at www.tchpconnect.org that’s www.tchpconnect.org . This is Melanie Cole. Thanks so much for tuning in.