Written by Kymberlie McNicholas, Founder of The Way to My Heart

“Having a team approach and a one-stop-shop in evaluating a patient makes all the difference in the world,” explains Co-Director of the University of California at San Francisco Center (UCSF) for Limb Preservation, Dr. Alex Reyzelman 

As part of our ongoing Vascular Innovation Series in conjunction with The Way to My Heart, Emmy Award-winning Journalist Kym McNicholas interviews the Co-Director of UCSF’s Center for Limb Preservation, Dr. Alex Reyzelman, about how his team has successfully implemented the Toe and Flow model to save life and limb. This is the second of a two-part series focusing on the Toe and Flow model. In Part I, USC Keck School of Medicine Professor of Surgery and American Limb Preservation Society President Dr. David Armstrong discusses how the origination of this model, its implementation, and challenges in scaling around the world. 

Part I: Limb Saving Toe and Flow Model | Dr. David Armstrong: https://youtu.be/dX86Mjrazhc 

PART II: Lim Saving To and Flow Model | Dr. Alex Reyzelman:


Every 20 seconds someone around the world loses a limb due to underlying conditions like diabetes and advanced peripheral artery disease (PAD). While most patients are treated by a single specialist, leaders in limb preservation have shown that successful wound care requires a multidisciplinary approach that integrates multiple specialties. This approach specifically includes a highly trained vascular specialist to restore flow to the small vessels below-the-ankle and a podiatric specialist highly trained in wound care to ensure more perfusion in the tissue surrounding the wound. Dr. Alex Reyzelman briefly describes the importance and impact of the Toe & Flow Model to UCSF’s Center for Limb Preservation and the patients it benefits. 

Before adopting a Toe and Flow model, what gaps did you face in the care of patients at risk of limb loss at UCSF?  

We found that vascular surgeons and podiatrists tend to work in their own silos and there’s valuable time that is lost when trying to get a patient from a vascular surgeon to a podiatrist and vice versa. 

Describe how the “Toe and Flow” structure for treating patients with Peripheral Artery Disease and Diabetic Foot Ulcers has filled the gaps in patient care and additions you have made that are unique to UCSF.  

Having a team approach and a one-stop-shop in evaluating a patient makes all the difference in the world. The patient gets a comprehensive evaluation of their circulation and their foot wound at the same time. Decision is made via a team approach without wasting valuable time. 

How does the Toe and Flow structure impact patient compliance with critical lifestyle changes such as diet, exercise, and smoking cessation which has a low overall rate with patients globally?  

The toe and flow team pays close attention to follow-up and surveillance. Once the foot is saved, it’s important to follow the patient to make sure that we minimize the recurrence of foot injuries. This close surveillance allows the team to continue educating the patient regarding the lifestyle modifications and lowering their risk factors. 

How do you see this model scaling to include implementation in the growing number of Office-Based Labs and Ambulatory Surgical Centers?

The key to saving limbs is a “Team Approach”. The team of dedicated vascular and podiatric surgeons who specialize in limb salvage is what’s needed in order to scale and implement limb salvage centers throughout the United States and the world. 

What data do you have that show the successful implementation of a Toe and Flow structure that would inspire other facilities to follow suit?  

We have our own 10 years of experience at UCSF. Our outcomes have been published in peer-reviewed journals.

Literature References:

  • Rogers LC, Andros G, Caporusso J, Harkless LB, Mills JL Sr, Armstrong DG. Toe and flow: essential components and structure of the amputation prevention team. J Vasc Surg. 2010 Sep;52(3 Suppl):23S-27S. doi: 10.1016/j.jvs.2010.06.004. PMID: 20804929. https://pubmed.ncbi.nlm.nih.gov/20804929/ 
  • Armstrong DG, Bharara M, White M, Lepow B, Bhatnagar S, Fisher T, Kimbriel HR, Walters J, Goshima KR, Hughes J, Mills JL. The impact and outcomes of establishing an integrated interdisciplinary surgical team to care for the diabetic foot. Diabetes Metab Res Rev. 2012 Sep;28(6):514-8. doi: 10.1002/dmrr.2299. PMID: 22431496. https://pubmed.ncbi.nlm.nih.gov/22431496/ 


This interview was produced by The Way To My Heart in partnership with Vascular Cures. Neither The Way To My Heart nor Vascular Cures endorse any specific products, entrepreneurs, companies, organizations, drug or device trials, and/or healthcare professionals, including diagnosis or treatment programs. The information, advice, and views shared in this interview are that of the individual speakers and are offered for educational and informational purposes only.

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