Melanie Cole, MS (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole. And joining me today is Dr. Andrea Um. She's a vascular surgeon with Bryan Heart Vascular Surgery, and she's here today to tell us about peripheral artery disease or PAD.

Dr. Um, it's a pleasure to have you with us today. Can you tell us a little bit about peripheral artery disease? Explain a little bit about it, how common it is. What is it?

Andrea Um, MD: peripheral basically just means that it's arteries that are excluding the arteries of the heart. And when we're talking about arterial disease, that's plaque buildup in the arteries that happen in all various parts of the body, including the legs, arms, as well as in arteries that go to the intestines and the kidneys and also the neck.

the plaque that's in the arteries is made up of various things including fat, cholesterol, calcium and kind of fibrous-type material. The plaque, once it builds up, can create narrowing or even complete blockages of the arteries where it's affecting. when that happens, that can affect the blood flow to those parts of the body, which is what really creates the parts of the disease that we're more worried about.

Melanie Cole, MS : So, tell us a little bit about the risk factors that would contribute to this.

Andrea Um, MD: The worst thing for arteries is smoking, unfortunately, and that's something that a lot of patients are surprised to hear, because it's not something that's often shared in commercials. Usually, the commercials talk about how smoking affects the lungs and cause cancer and various things like that, but smoking is by far the worst thing to do for the arteries. And smoking damages the arteries, which causes that plaque to build up. So that's the number one and worst risk factor.

But then, there's also some more common ones, such as high cholesterol, patients with diabetes. And then sometimes, it's just as patients get older, the parts of their body get older, including the arteries. And so, that can build up some wear and tear. genetics can certainly be an important factor as well.

Melanie Cole, MS : Well, thank you for telling us about all of that. Now, the big question, how would somebody know if they have peripheral artery disease? How is it identified? Are there some symptoms, things we would feel, pain in the legs, that sort of thing? Tell us a little bit about what we would notice.

Andrea Um, MD: there can be patients who have disease and plaque buildup in their arteries and not have any symptoms at all. And there can also be more concerning symptoms. So if we're talking specifically in the legs, the first symptoms that patients will experience will be pain in their calves or their thighs when they're walking. once they walk a certain distance and it pretty much happens every time they walk that same amount of distance, that their calves or their thighs or both will cramp up on them and get really sore. when they stop walking, that pain will get better. that's the first symptom. That's the most common symptom as well. And that can be a symptom of less severe disease.

As the disease gets more severe and there's worsened narrowing or blockage, patients can develop pretty bad pain in their feet that happens at night. this is because the feet are the farthest away from the heart. so at night, when the legs are up, the body doesn't have the help of gravity to get the blood flow down into the foot. the lack of blood flow getting to the foot at night can cause significant pain for patients. the thing that will relieve that pain is if they dangle their foot off the side of the bed. So, that's another symptom.

the final symptom is wounds in the feet that aren't healing. If they're taking longer than a normal wound to heal, more than a couple weeks, or if they're continuing to get worse, that could certainly be a concern that there's underlying disease of the arteries that are making it hard for those wounds to heal. those can be some symptoms.

There's also different tests that can be done. The most basic test is actually taking a blood pressure cuff and measuring your blood pressure in your ankle and comparing it to the blood pressure in your arm. And if there's a decrease there, that can signal that there's some narrowing or blockages getting down into that part of your leg.

the next test that's often done is something called an ultrasound which can look at the arteries and can give us a really good idea if there's narrowing or blockages. we use this ultrasound to look at the blood flow both in the legs for disease. We look at it to look in the neck if there's disease there, which symptom of disease in the neck would be a stroke. And then, also looking at the blood flow in the belly, including the arteries that go to the kidneys and the intestines. If there's narrowing there, the ultrasound can also pick that up. there's more tests beyond that that are often ordered once you've seen a vascular surgeon, including CAT scans, or sometimes we can do a procedure to get even better pictures to understand what's going on.

Melanie Cole, MS : Wow, that was an excellent explanation, Dr. Um. So, what screenings does Bryan offer or should a person seek out in order to determine if they do have peripheral artery disease? I mean, obviously, early diagnosis is important so you can catch it early in the disease process and take action. So, speak a little bit about screening.

Andrea Um, MD: certainly, if anyone is concerned that they could have these symptoms or if they know someone who has these symptoms and they want to make sure they don't have this disease, Bryan offers screening both for the carotid arteries, which are the arteries that go to the neck. And if there's plaque development there, like I mentioned earlier, that can lead to a stroke. we have an ultrasound that the screeners can do to get a good idea if there's any plaque development in those arteries, and that can be a really good assessment to figure out what your risk of stroke would be from the neck arteries.

the other screening test that's done is what I mentioned before where they use the blood pressure cuff at the ankle. if that's abnormal, then a patient would get referred either back to their primary doctor or to us as vascular surgeons to do further workup and testing.

Melanie Cole, MS : Dr. Um, I'd like you to speak about managing the disease because there's always ways that we can treat peripheral artery disease to a degree. I'd like you to speak about some of the noninvasive things, what role exercise plays and what if that leg pain, that claudication, causes pain with exercise because that seems to contradict each other. I'd like you to speak about some of the noninvasive ones first, like nutrition, exercise. What are we doing? Obviously, smoking cessation since that's the hugest risk factor. And then, get into some of the surgical options available.

Andrea Um, MD: You mentioned a lot of the things that we start with. the first and most important thing is really working on smoking cessation or not smoking anymore. And again, that's because that can help the symptoms, it helps the disease from getting worse. And if we ever get to the point of having to do any procedure, if a patient's not smoking anymore, that will help any work that we do to open up the blood flow from lasting much longer. that's by far the biggest thing I stress with patients if they're still smoking.

The other main thing with patients who are having that pain in their legs when they're walking, which the medical term for that is called claudication, the first thing we do to treat that is actually doing walking therapy. So, it sounds counterintuitive because when you're walking and you have these symptoms, you'll start to develop severe pain. And so, a lot of patients think they're hurting their legs more or causing harm by having that pain. But what walking therapy does is you walk until you can't walk anymore because the pain is so bad, and you do that over the course of 30 minutes. So, you walk until the pain is really bad, you stop, let yourself rest, get up and walk again as soon as you can. And what that's doing is that pain is signaling to your body that your muscles aren't getting the blood flow they need, and then that causes your body to create new smaller blood vessel channels. So, it doesn't open up the main system necessarily, but it helps create smaller channels. I like to think of blood flow like a road system. So if the main highway is blocked or congested, then it's like the city is putting out road crew workers to create some side roads to get around that congestion. And that's what your body's doing when you go out and do that walking therapy. So, that's another very important lifestyle change to do.

there's also some medications that we can try for patients when they're having that pain with walking, that can sometimes help improve their symptoms as well. most patients who just have pain with walking actually never need to get to the point of needing a procedure, which is the really nice thing because they don't have to go through the risks of a procedure.

in more severe cases, if they are having that pain at night in their feet or wounds that aren't healing, the first step that we do is something called an angiogram, which is a minimally invasive procedure done in our cath lab, where we work from the inside of the blood vessel to take pictures, and then that's where we can use techniques like balloons and stents to help open up narrowings and blockages. there are times where we have to do surgery, where we're having to make incisions and doing something called a bypass, where we actually sew in a different channel for the blood flow to get around the blockages and the narrowings. that's how we deal with the legs. for the neck arteries, which is again a big concern for people with the risk of stroke, we make sure they're on good medication. Well, any patient with arterial disease should be on at least a baby aspirin and a medication called a statin. which is a cholesterol medication that also acts like an anti-inflammatory agent on the arteries and it stabilizes plaque. those are two very important medications. anyone with artery disease, we have you on those medications. if there's disease in the neck, we monitor that. And once it gets severe enough where we worry about your risk of stroke increasing, that's where we talk about doing surgery to fix that.

Melanie Cole, MS : So doctor, there are so many options available and, certainly in your profession these days, more tools in your toolbox to help people that have been diagnosed with peripheral artery disease. As we wrap up, I'd like you to please offer your best advice as a vascular surgeon. Can this be reversed? Can it be prevented in the first place? Please give us your best advice and what you would like the listeners to take away from this very important episode.

Andrea Um, MD: I would say it can be prevented in some ways. Again, smoking is the worst thing. And so, not having that history can really help prevent it. And making sure diabetes is well under control. Sometimes patients can't prevent it, even if they do all the right things. They quit smoking. Their diabetes is great. Their blood pressure is good. Their cholesterol is good. Again, sometimes there's just that age factor and that genetics factor that isn't the patient's fault and this just happens to the arteries as well. So, it's a little bit of a both to that question.

There's not a great way to say that peripheral arterial disease can be reversed. Unfortunately, once somebody has plaque buildup in the arteries, that's a disease that's present in their arteries in multiple parts of the body pretty much the rest of their life. When we do procedures where we clean out that plaque, a lot of times that will prevent that plaque from building back up. But even in some instances, things can re-narrow or re-scar or even new plaque can form. once somebody is diagnosed with this disease, we basically want to make sure they're being followed and monitored and treated for this pretty much for the rest of their life. Although a lot of times the procedures that we can do can really help prevent them from having worsened symptoms and keep them in the best place we can for as long as we can.

my best advice going forward as a vascular surgeon, not to keep hammering it, but really I can't stress the importance of not smoking. unfortunately, right now, we don't have quite enough information out about vaping or even marijuana, but any sort of substance that you're inhaling and ingesting like that, that has different chemical properties and effects to your lungs, can also go in and affect the blood vessels. And so, I would just really caution anyone to avoid those things to prevent their risk of developing arterial disease. again if you feel that you have any symptoms that line up with what we discussed today, it would be best to either go get screened or go touch base with your primary care doctor to see if you need any further testing or evaluation done.

Melanie Cole, MS : Thank you so much, Dr. Um, for joining us today. What an educational episode this was. Thank you so much for all of your great information and sharing your expertise. I would also like to thank our Bryan Foundation partner, Union Bank and Trust.

To listen to more podcasts from our experts, please visit bryanhealth.org/podcasts. That concludes this episode of Bryan Health Podcast. I'm Melanie Cole. Thanks so much for joining us today.