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Scott Webb (Host): Peripheral artery disease, also known as PAD is a common condition where narrowed arteries reduce blood flow usually in the legs. This narrowing of the arteries is similar to what happens to arteries leading to the heart. And joining me today to discuss signs, symptoms, treatment options, and what we can do to help ourselves if we want to avoid PAD is Dr. Ankur Aggarwal. He's a Surgeon with Franciscan Health. This is the Franciscan Health Doc Pod. I'm Scott Webb. So, Doctor, thanks so much for your time today. We're going to talk about peripheral artery disease. Also probably shorthanded more often as PAD. And as we get rolling here, what is PAD?

Ankur Aggarwal, MD (Guest): Well, thanks for having me. When I think of PAD, it's basically vascular or vessel disease of the lower extremities. When most people think about vascular disease, they're very familiar with heart attacks and disease of the coronaries or the blood vessels to the heart. PAD is essentially the same thing, except it happens to the lower extremities.

You start to get disease, calcification, plaques within the lower extremities and it can lead to symptoms similar to a heart attack, but as opposed to having chest pain, patient starts to develop leg pain, they start to develop pain in their thighs, pain in their calves, pain in their feet. And there, there's a lot of reasons for developing pain in the lower extremities, but PAD or peripheral arterial disease is one of the most common reasons for that.

Host: Yeah, and I think you're so right. I think that most people do associate arterial disease or artery disease with things in the chest, things in the heart. But as you say, it can be in the legs and it may be an indication of a serious condition like PAD. So it sort of prompts me, how common is PAD?

Dr. Aggarwal: PAD is it's becoming more and more common with diabetes on the rise and the obesity epidemic we have in the United States. PAD is ranged to be about 2% of the population around the age of 30 to 50. But once we get to about 50 years of age, the incidence usually rises to around 15 to 20%. And that number can vary depending on where in the United States you live, whether you smoked or not, other risk factors. But the average overall incidence is about 15% of patients who are ranging in age from 50 to 70. And as you get older, that number does increase.

Host: You mentioned risk factors, smoking, perhaps genetics, family history doesn't sound to me like PAD is something that, you know, is really tested for, unless people are having some signs and symptoms. Right? So is that when people might expect, if they're going to develop PAD would be sometime after the age of 50?

Dr. Aggarwal: Yeah. I think that's definitely a good way of putting it and, you know, some patients, if they have really bad genetics or if they were very unhealthy in their early part of their life or their diabetes was uncontrolled, they may develop those symptoms earlier. But I would say that's correct that most patients are older in age as they start to develop those symptoms. And the majority of patients don't really get screened for it. It's kind of like coronary disease or cardiac disease. Most patients don't know they have it until they have a heart attack or they have a problem. While there are certain parts of vascular disease that are screened for like carotid disease and aortic aneurysms, we don't really screen for PAD unless patients come in with symptoms or if they happen to be in the hospital for some other reason to get imaging done, sometimes we'll get called if PAD has been seen on some other imaging modality.

Host: Yeah. And so what specifically causes the leg pain? Is it the calcification? Maybe you can kind of take us through that. I know would probably be easier if you had some graphs and charts and things in the office to show us, but specifically, like if we're experiencing this leg pain and it is due to PAD, what's causing the pain?

Dr. Aggarwal: I think of vascular disease in the extremities as sort of having three stages. The first stage is called claudication. It basically means pain in the legs and the pain can vary on the location based on where the disease is. So if people have disease within kind of their abdomen or higher up in the leg vessels, you start to have pain within the thighs. They start to walk a certain amount of feet and they'll notice you know they walk 50 feet or 100 feet or 200 feet and every time they get to that distance, they start to have pain within their legs and it may feel like a cramping sensation and maybe kind of a sharp pain. Usually within the back where the more thicker muscles are and they stop, they rest, the pain goes away and once they rest, they start walking again and they get back to that same distance, they start to have pain again.

If the disease is within the thighs, in terms of the arteries, then they start to have pain within their calves. And they notice after a certain distance, the pain in their calves gets worse, they stop, they rest, the pain goes away. If the disease is within the calf vessels then they start to have pain in their feet. They walk 200 feet, 100 feet, and they started to have pain in their feet.

That's sort of the first stage of vascular disease. The second stage is rest pain, where the disease within the vessel is so poor, it's so bad, that when they go to sleep at night is sort of the classic time, they don't have the help of gravity bringing the blood down to their toes, down to their feet, down to their calves and thighs; so they wake up with pain because of that lack of blood flow, getting to the muscles. They wake up, they dangle their feet over the side of the bed. Gravity helps to bring the blood down to those locations and they start to feel a little bit better. So that's sort of the second stage. It's a little bit more severe than claudication, cause it's not just exercise that's causing the pain; it's actual just laying in bed and not having the help of gravity.

Third, the sort of worst level is tissue loss where especially in patients who are diabetics who have numbness or tingling in their toes, they bump their toe, they hit it, something falls on it, they get a wound and the lack of blood flow is so poor, they can't actually heal the wound anymore because of that. So, those are sort of the ways I think of peripheral vascular disease and the severity of the disease.

Host: Yeah. And I'm so glad we're doing this because as you say, PAD is not talked about that much, you know, you're not going to see much on Facebook or Tik Tok about PAD. It's just not something that folks are really talking about. So, I'm really glad that we're doing this today. I've already found this to be really educational. And I know what we're dealing with here is really a sort of an all body disease, you know, vascular disease and is vascular disease sometimes a sign of another more serious underlying health issue?

Dr. Aggarwal: Yeah, peripheral artery disease is really common with patients who have coronary disease. The two kind of go hand in hand and the numbers are around 75% that if you have diagnosed coronary artery disease, you probably have some level of peripheral vascular disease. And the vice versa is also true that if you're diagnosed with peripheral vascular disease, you probably have some level of coronary disease also that's going on. Now, whether you have enough disease that requires intervention, can vary from person to person, but, the majority of patients who have coronary artery disease will have vascular disease that they probably don't know about until it actually becomes an issue for them. Some studies quote, as high as 90% of patients with significant coronary artery disease, will have vascular disease. They just don't know about it because they're asymptomatic.

Host: Yeah, I see what you mean, but that's a pretty big number, 90%. But as you say, if they're asymptomatic, how would they know? You mentioned a couple of times we've talked about risk factors, genetics, family history. But when we talk about the things that we all sort of do to ourselves, things that we can control, but many of us don't. How, do smoking and uncontrolled blood sugar affect the arteries in our legs?

Dr. Aggarwal: Those are by far the two most common risk factors that are associated with PAD. And, you know, I tell my patients that when you're in that first level of disease, you can get yourself out of that first level of disease. We don't operate on patients who only have pain with walking because we can actually do more harm than good.

So, patients who have pain with walking, unless it's significantly impacting their life, they can't do their job, they can't go to the grocery store and shop, things like that. Patients who have PAD who are either smokers or diabetics or have high cholesterol or high blood pressure, all those risk factors can be modified. And patients can actually get themselves out of a point where they're having pain symptoms, but it really requires good management and an aggressive approach by the patient. It really requires five real things that they need to do. They need to stop smoking, if they're smoking. If they're a diabetic, they need to control their A1C and try to get it below seven. If they have high cholesterol, they need to be on medications for that and get their cholesterol down to as low as an LDL of less than 70 if they're a diabetic, but less than 100 in everyone else. They need to control their blood pressure. And then the fifth is they need to have a walking program.

That's probably the most important one and the hardest to do. But if patients walk for 30 minutes a day, you know, they walk to the point of having pain. They stop, rest a little bit, let their pain go away. Start walking again to the point of pain, maybe even a little bit further, if they can, stop, rest. And they do that for 30 minutes a day, 90% of patients who are having rest pain will notice in six months so they can walk significantly further than they did before.

If they continue to do that, those patients, their pain will go away and they don't require any operative intervention. The problem is the majority of patients don't do that. They continue to smoke. Their diabetes is uncontrolled, which is why we end up operating on such a high percentage of these patients.

Host: What other conditions do you have to rule out before making a diagnosis for PAD?

Dr. Aggarwal: The The most common problem that PAD can be mistaken for is what's called neurogenic claudication is patients who have spinal stenosis or a nerve related issue that's actually causing their symptoms. A lot of times we can figure that out just based on the history. If a patient says that they are having pain with walking, but then they do things like leaning over a cart or something that's going to open the spinal canal and their pain seems to go away.

Or the pain is not always reproducible. It seems to vary with the amount of distance that they're walking. You can usually try and figure that out just in the office, by talking to them. We do have studies that we will also do where we actually look at the blood flow to the leg, and basically quantify the amount of blood flow to the leg and that can help us differentiate between them. But a lot of times it's just talking to the patients and getting a true sense of their history and what it is that ails them, and when it happens; you can figure out whether their problem is related to the vascular disease or whether it's related to something else.

Host: Yeah, it is really amazing how important our medical history is. And you've mentioned that we can really help ourselves if we're suffering from PAD before we would get to surgery, maybe you can give me an example of a patient who made a lifestyle change and you saw that significant relief from PAD that we're all striving for.

Dr. Aggarwal: Yeah. I've had a few different patients that I can think of pretty easily. I have one patient that I saw back when I was a Fellow and this patient has really significant disease. I looked at his CAT scan and I was absolutely convinced that I was going to be operating on him. You know, it was disease everywhere. He had disease in his belly and down his legs. And this was just based on the imaging. Then when I went to talk to him, he was only complaining of claudication, he was only complaining that he had pain when he walked. He was able to still do his job. He was actually working in the post office. He could get around, but he would have to take significant amounts of breaks and he would rest, but just by being careful, you could get through everything. So I talked to him about PAD. He was a smoker, he wasn't a diabetic, but he was a smoker. He did have high cholesterol. His blood pressure was a little bit high. So I just kind of talked to him about how with lifestyle changes and by enacting a walking program, which he did walk a fair amount, but on the weekends, if he tried to just walk truly for 30 minutes, as opposed to walking for a little bit, then resting in his truck, you know, getting the letters together.

If you had a true walking program, there was a chance he could avoid an operation. So I saw him about six months later and it was amazing. He said he was able to get through a day of work without having any more pain. He could go about sort of his life. I saw him another six months later and it was as if he had never had any problems. And I had never seen him again. Peripheral vascular disease is not something that goes away. You can't get rid of the disease within your blood vessels. You can't get rid of that calcification, but when you walk enough and then control these risk factors, your body's pretty smart.

It can develop alternate pathways of getting your blood flow down to your legs, to the point where you may no longer have pain or require an operation. Now, once your pain gets bad enough that you have rest pain. You're having pain at night that wakes you up, or you have wounds that aren't healing, it requires a more aggressive intervention because the chance of you needing something like an amputation because of complications, goes up significantly. So, as a vascular surgeon, we have lots of patients who come in with significant vascular disease.

They have rest pain, they have tissue loss, and we treat this by doing a bypass the same way, the cardiac surgeons bypass vessels around the heart. We bypass those vessels around the leg, or we put in catheters and stents to try and open up those vessels and we can get patients to the point where they're no longer having pain. They have wounds that have healed. But again, none of these interventions can last forever and some of the responsibility and the onus is on the patient that once we can get you to the point where the pain is no longer there, that's where lifestyle changes, risk factor modifications, and those walking programs are important to keep you to the point where the bypass doesn't fail or the stents don't fail. And we're trying to look at, you know, last ditch options for how to treat you.

Host: So I want to switch gears just a little bit. And have you discuss venous disease, venous insufficiency and varicose veins if you can.

Dr. Aggarwal: Venous disease is a kind of a different phenomenon from peripheral arterial disease, as opposed to PAD where you have plaques and you have true obstructions that are preventing the blood flow from getting where it needs to. Venous disease is a little different because when PAD the heart is there to pump the blood down to the toes. And there's an obstruction there that's preventing the blood from getting where needs to go. With venous disease, there's no heart behind it. You know, the blood is getting from the arteries, from the muscle and the toes. And it's trying to get back to the heart through the vein. So, it relies on muscles to actually squeeze the veins and get that blood back up to the heart and to prevent the blood from coming backwards because we're not using our muscles all the time, we're not walking 24 hours a day, seven days a week; there's little valves within the veins that prevent the blood from going backwards and try to keep it going in a forward direction. The problem with venous disease is if those valves start to not work as well as they need to, if a person is either overweight or inactive and the muscles aren't squeezing the blood back the way it should, blood starts to pool within the veins, you start to get leg swelling. You can start to get wounds and ulcers. Leg swelling is by far the most common complaint with patients, but they start to get fatigue in their legs. They start to get tired, they can start to get pain. Again, they can start to get wounds or ulcers, and it's very difficult to treat venous disease.

There aren't great surgeries or interventions that I can do to a person to make their vein start to work better, or to bypass the way I can with an artery.

Host: Yeah, it sounds like behavior, lifestyle changes, absolute must for venous disease, varicose veins and so on. I'm sure some people have heard of ABI or ankle brachial index, that test. What is that exactly?

Dr. Aggarwal: Yeah. The ABI or the ankle brachial index is basically a test that we do to compare the blood flow to the arms versus the legs where we know the arms while they can have vascular disease, are not nearly as commonly affected as the legs. So, we take blood pressures in both arms. We take blood pressures in both legs, or sometimes even in the thighs and the toes. And we're basically comparing the amount of blood flow that's getting to the arms, that's generating a pressure to the legs and determining if there's a significant difference. And if there is, that gives us an idea that there's probably something between the heart and the toes or the legs or the ankle that's causing a blockage that's preventing the blood flow from getting there and generating a pressure.

Host: Yeah, that's interesting. And you know, I mentioned earlier that I'm glad we're talking about PAD. I feel like it's not talked about enough. I host a lot of these and very few have been about PAD. So, this has been really informative, really educational and Doctor, as we wrap up here, what are your takeaways for folks about PAD, what they may be experiencing, that they may be perhaps dismissing as something else or chalking it up to something else. Well, what would you like folks to take away from this about PAD?

Dr. Aggarwal: I think the biggest points I'd love for people to understand is that it's not normal to have pain in your lower extremities. And while some of that can be chalked up to age or something more chronic, if you're having pretty consistent pain when you're walking or you're doing some little activity, it happens all the time, it goes away when you stop walking and you notice it constantly, it is bothering you; please get evaluated. Talk to your primary care doctor about it. And then, you know, primary care physicians, aren't always keeping this on their radar as well. So, if you are listening to this podcast, hopefully if you hear this and you notice, yeah, I do have pain when I walk a certain distance, it's pretty reproducible, it's happening all the time, or I'm having pain at night that wakes me up, or even if you have wounds or ulcers that aren't healing; you can take it upon yourself to see a vascular surgeon. You know, we like primary care doctors, we follow our patients forever. You know, patients with peripheral vascular disease. We don't just operate on them and then don't see them. We actually consider ourselves to be sort of vascular medicine specialists. So, we follow these patients with peripheral vascular disease for the rest of their life, even if we never operate on them but they have disease that we think merits following, we'll follow these patients in our office every year or two years and make sure that they don't get to the point where they need an intervention by us.

But it's really important to remember that, you know, peripheral vascular disease is a real problem. It's almost as prevalent as coronary artery disease and it can be a real issue. And, you know, you don't want to be that person who sort of ignores it for a while. And the next time you come to see a vascular surgeon, you realize you're gonna be getting an amputation because you just waited too long. And there's nothing that we can do to fix this from an operative standpoint.

The other thing I would just emphasize, is this is something that can be managed medically. It doesn't require an operation right away. Doesn't always require a surgery or a stent or anything else, you know, but it requires a good conversation between, you know, the patient and their vascular surgeon or their vascular medicine specialist to try and get them to the point where just by changing their life, changing their lifestyle and instituting a walking program and exercising, you can get yourself out of pain without having someone like me make a big incision in you.

Host: Which you'll do if you have to, but you'd prefer not to, right?

Dr. Aggarwal: I would, I mean, I'm a surgeon. I went into this because I love surgery. I love operating, but in my mind, I think that surgery is sort of the last option and I try to do everything I can to get my patients better without operating on them. But if they require an operation, if that's what they need, then that's what we'll do.

Host: Doctor, this has been so educational, so informative. I'm so glad we did this on PAD. Thank you so much. And you stay well.

Dr. Aggarwal: You too. Thank you so much. I really appreciate this opportunity and the time.

Host: And for more information, visit Franciscanhealth.org/vascularcare. And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.