An appropriate staff is the critical component of a multidisciplinary program. The team must share a dedication and passion for the goals as outlined above and create and maintain open lines of communication. The staff includes the physician team, administrative support, physician extenders, nursing team, and secretarial support. A medical director who has the authority and initiative to bring together other team members should lead the physician team. The background of the medical director can vary but is most often drawn from vascular surgery, podiatry, or plastic surgery. It is important to have representatives from both the vascular and soft tissue perspectives in leadership roles, and therefore co-director positions can be created. Although there is not only one model regarding the multidisciplinary PAD team, certain applicable guidelines begin with the importance of “provider champions” in leading a clinical program. A vascular specialist (vascular surgery, interventional radiology, interventional cardiology) and a soft tissue specialist (podiatry, plastic surgery) are the typical “champions,” often involving orthopedics, general surgery, vascular medicine, diabetology/endocrinology, infectious disease, nephrology, and rehabilitation medicine. The team should also include wound nurses, nutritionists, occupational therapists, orthotists, pharmacists, physical therapists, prosthetists, and social workers.

There should also be an administrator dedicated to the program with time available to guide the project on a daily basis. The administrative director can be either a physician (medical director) or someone trained in medical administration. The administrator should know the clinical and business aspects of the program and be facile with interaction among the hospital, physicians, staff, and local community. Physician extenders such as nurse practitioners or physician assistants play a crucial role in the success of the program. These practitioners initiate the medical evaluation of each patient and coordinate the complex care required for an optimal outcome. These providers can often run clinics independently with supervision from treating physicians. This includes wound care, preoperative preparation, and prescription of medications used in the treatment plan. The physician extenders must work closely with trained wound nurses, medical assistants, and secretaries. The wound nurses or technicians are the focus of the clinic setting. These specialized personnel perform much of the wound care and dressing changes and important patient education required to involve the patient in their own care. Coordination of visiting nurse visits is also coordinated by the wound nurses. The ideal complement of such personnel to optimize patient flow is approximately three physician extenders/wound nurses for each doctor involved in the clinic setting. Staff support should also include a receptionist and medical assistants. The medical assistants aid in moving patients through the clinic and completing initial demographic and historical data in the electronic medical records and may help in the removal and application of dressings under the direction of the wound nurse or physician. Ideally, case managers and prosthetists form part of the program. Case managers assist in the volume of work involving rehabilitation centers and insurance issues, which patients often require, while a prosthetist with familiarity with the patients and direct communication with the limb team greatly enhances the functional results of the patients.

A dedicated, identifiable outpatient space is important. The space should be accessible to those patients who have mobility problems. The outpatient space should be in proximity or connected to the hospital, as limb patients require frequent hospital services. The space for exam rooms is also important, as patient flow is important to program viability and patient satisfaction. Ideally, six rooms for every 30 scheduled patients would allow for the optimization of the physician and physician extender team. A designated inpatient hospital ward for limb patients when they are admitted is also preferred. The nursing staff on an identifiable ward should be familiar with the medical issues surrounding the PAD patients. Wound dressings and other medical materials can be centrally located in proximity to the admitted patients. The identifiable limb ward fosters the team approach and continuity of care from outpatient to inpatient setting and back to outpatient wound or rehabilitation centers as needed.

When intervention is deemed necessary by patient history, exam, and vascular lab studies, then arterial imaging is required to plan the appropriate revascularization, including CT angiography (CTA), MR angiography (MRA), and catheter-based arteriography. CTA allows 3D reconstruction while demonstrating calcium and the calcium load in the arterial tree. Unfortunately, CTA involves contrast with the timing of the injected bolus critical to image quality. Heavily calcified arteries can also impact image quality. MRA is a flow-dependent analysis, and while non-invasive without the need for standard contrast, the best images are obtained with the administration of gadolinium, which is problematic in patients with renal insufficiency due to the chance of nephrogenic systemic fibrosis. Additionally, MRA images can overestimate the degree of stenosis due to signal dropout, and certain patients cannot tolerate the time required to acquire the images in the enclosed space. Catheter-based arteriography continues to play an important role in diagnostic imaging for limb preservation, especially in terms of the precise definition of distal tibial disease. A primary intervention can be performed at the time of the initial arteriogram; however, obtaining quality images of the lower leg and foot with subsequent planning of complex revascularization procedures is often appropriate. This approach allows collaboration and communication among providers of varying skills and experience in the different modes of revascularization.

Although the goal of a PAD program is limb preservation, primary amputation may be required in varying clinical scenarios, such as lack of tissue for reconstruction, sepsis, non-ambulatory status, and/or being demented and unable to cooperate with rehabilitation. The goal of PAD management should be to maximize the functional length of a biomechanically sound limb. Proper limb biomechanics is the key to successful amputation. To optimize biomechanics, anatomy must be appreciated, and the procedure performed with technical care. Viable tissue should be maximized especially along the plantar surface of the foot as this tissue is often used for forefoot reconstruction. Skeletal stability is also important. The patient should not be left with any pressure points or potential areas of decubitus ulceration after amputation. Several amputations can be considered to obtain an optimal result. Minor and below-ankle amputations include digital (ray) amputation, transmetatarsal amputation, and midfoot (Lisfranc), hindfoot (Chopart), and less commonly ankle amputation (Symes). The goal of these procedures is to maximize the length and ambulatory status. Major or above ankle amputations are classified as above- and below-knee. All amputations can be technically challenging to obtain long-term function, but the below-knee amputation must be done especially carefully to design a well-constructed posterior flap with maximal length from the tubercle of the tibia. Tenodesis (the anchoring or fixation of a tendon to a bone) to the tibia helps maintain function and diminish deformity postoperatively. Advances in prosthetic technology have greatly contributed to maintaining ambulatory function after a well-done major amputation. Peer support groups can also help assist the amputee in a successful recovery.

A limb preservation program should also include a patient support group, as there is a significant emotional component to limb loss or living with a foot ulcer. A patient support group can be very important both preoperatively and postoperatively in helping patients deal with the burden of their clinical situation by maintaining functionality and a positive outlook. Education can be incorporated into the program in the form of seminars for patients and referring physicians. Education is critical to achieving the goal of limb preservation through the reduction of amputation and enhancement of the QOL of patients. The limb program also provides a format for multidisciplinary research that is increasingly important to the healthcare system. Both education and research are a reminder of the importance of a patient-centered approach when initiating and maintaining a multidisciplinary limb preservation program.

RN: Writing – review & editing.

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