Scott Webb (Host): Peripheral artery disease, or PAD, is a common and underdiagnosed disease that can cause leg pain and may be a sign of a more severe medical condition. I'm joined today by Dr. Neal Ramchandani. He's a board-certified vascular surgeon practicing with the Franciscan Physician Network. And he's here today to stress the importance of early diagnosis of PAD and discuss the various treatment options.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, thanks so much for your time today. We're going to talk about peripheral artery disease or PAD and the leg pain that's associated. And I got a whole bunch of questions for you. So as we get rolling here, at what age do people normally start showing signs of PAD and how common is it?

Dr. Neal Ramchandani: It's actually quite common. I think it's actually underevaluated, to be honest with you. Usually, people start experiencing symptoms around the age of 65 or older, but often we've seen from 50s onwards. So, it just depends also based on your family history and also your smoking exposure, as well as if you've developed early onset diabetes.

Host: Right. So family history, genetics, if you will, smoking, you know, all the greatest hits that contribute to things like this. So, do we know exactly what causes the leg pain?

Dr. Neal Ramchandani: Absolutely. I always tell my patients, arteries are like streets and highways. So, your main pump is the heart, off of the heart comes the aorta, and that's the main highway, like I-65. And as it comes down, it provides alternative highways, whether it be 74 or 465 East or West, subsequently providing blood to the Intestines, the upper extremities, and then subsequently the lower extremities. And the main thing we focus on is the lower extremities because that's the furthest thing away from your heart. You know, it's an amazing process in that the body has to provide the blood flow to the tip of the nose to the tip of the toes. And so in order to do that, it has to make some accommodations.

But, you know, let's say that going on I-65, you have four lanes, and then again, 465 East or West, you have four lanes. Well, as atherosclerosis or some plaque builds up in the arteries, those lanes may narrow to maybe two lanes or even one lane. What happens when you have one lane on a highway? Well, traffic builds up. And so, what ultimately results is a decrease in blood flow. And that's what I mean by traffic building up. And so, when the muscles see a decrease in blood flow or otherwise decrease in oxygen, it feels like you're running a marathon when you're merely walking to the mailbox. And that's, you know, where that leg pain comes from. It's just a cramp without the strenuous activity that you would normally see.

Host: Yeah. And those of us familiar with the highways in Indiana, when all the lanes aren't open, especially on 65, we can totally understand. So, obviously vascular is an all-body thing, an all-body disease, right? So, is vascular disease sometimes a sign of another underlying health issue?

Dr. Neal Ramchandani: Oh, yeah. Vascular disease is heavily associated with high cholesterol, high blood pressure, diabetes, like we talked about. And all the while if you have peripheral arterial disease, so too do you have coronary disease. It's all the same distribution. And honestly, if you have peripheral arterial disease, you probably have just as bad, if not worse, coronary disease. So, it's also very important to be evaluated for heart health as well.

Host: So, you mentioned smoking earlier, so let's talk about that. How does smoking and uncontrolled blood sugar affect the arteries in the legs?

Dr. Neal Ramchandani: Yeah. I briefly mentioned, you know, this thing called atherosclerosis, which is a fancy way of saying stuff that's built up in the arteries. So, you know, our arteries are just big tubes, right? They're like the PVC pipes. But of course, they're a little bit more pliable in that they have multiple layers. They actually have three layers, an inner, a middle, and an outer. And as we age, our vessels are used. You know, as we get to 80, 90, certainly we have seen some years. But just as stuff would build up in your kitchen sink and the pipes in your kitchen and in your house, so too does stuff build up in our arteries. And, of course, diet and smoking, unfortunately, hastens the process. So instead of maybe experiencing a mild atherosclerotic disease as we age normally, you may see that sooner, maybe at the age of 55, 65, as the process of atherosclerosis hastens due to smoking, because smoking and also diabetes affects that narrowing or the buildup of "stuff" in the artery. Atherosclerosis kind of increases the buildup in the middle layer. And then, diabetes really affects the inner. And, you know, diabetes is tough because it affects the arteries and the smaller arteries below the knee, whereas smoking affects the arteries above the knee and in the groin.

Host: Okay, yeah. As you were saying earlier, you know, some of this may be family history, but also behavior, lifestyle, diet, exercise, or lack thereof, as you say, can sort of hasten all these things. Are there some conditions that you rule out before making the diagnosis of PAD?

Dr. Neal Ramchandani: That's an excellent question. You know, I think PAD is often difficult to diagnose early on, meaning that, you know, we always like to rule out things because once you've diagnosed peripheral arterial disease, there's a lot of management strategies that you can pursue. So, I think that it's important to make sure that we have the diagnosis of PAD and also prompt diagnosis and accurate diagnosis. That's very important because a lot of people who complain of leg pain often also have back pain. And so, there's things called neurogenic claudication, and claudication meaning pain with activity and resolution with rest. And so, like I talked about with vascular claudication, you have pain with activity due to the traffic building up, right? Traffic backing up such that the blood flow is limited, thus producing these cramps in the muscles. But neurogenic claudication is maybe due to some back issues, some nerves that have been compressed by chronic back issues. May have had had an injury in the past that has now produced such issues, but that's something we certainly like to tease out during our physical examination.

Host: Yeah. And we talked a little bit here about behavior and lifestyle. Wondering if you can give us maybe an example of a patient who made some significant lifestyle changes and really saw some relief from PAD.

Dr. Neal Ramchandani: Oh, absolutely. That's one of the most important things we focus on. And I think that getting the diagnosis of PAD doesn't necessarily relegate you to undergoing an operation or an intervention. I've had many patients that have already, you know, shown in the last three months marked improvement with just smoking cessation and overall increase in activity. You know, the body can do amazing things. If you have a blockage in your leg, let's say your body can naturally make a detour, right? And that detour can widen. Instead of being maybe one lane detour, the body over time can make it four lanes

just with more activity. But if you continue to smoke or your diabetes is not under strict control, then unfortunately, that may not be the case.

Host: Doctor, let's talk about venous disease, venous insufficiency, varicose veins, all that sort of stuff.

Dr. Neal Ramchandani: Yeah, absolutely. As the blood comes back to the heart, it's brought back via the veins. And so, we have deeper veins that are within our muscles. So as we use our muscles, the blood gets propelled via the contraction of those muscles through the deeper veins. However, superficial veins have valves. And I like to think of these valves like elevators. And so when you have an elevator that goes up floor by floor, that brings blood back to the heart, if you have let's say elevator number one that unfortunately keeps dropping to the first floor, hopefully, this never actually happens to anyone, but you know, it stays on ground level. It can't go up due to the lack of valves. If those valves become what we call as incompetent, then veins can no longer bring blood back up and, unfortunately, veins then pool. When veins pool blood, it results in varicose veins or bulging veins. And then, it can also result in lower extremity swelling and also some fatigue in the legs at the end of the day.

Host: Yeah. We could probably do an entirely separate podcast just on the veins, but good to just kind of scratch the surface today. So, let's talk about if you need to do surgery. I know you're a surgeon, right? So if and when you need to do surgery, what's that like for folks? Do you use stents, you know, that sort of thing?

Dr. Neal Ramchandani: We like to take a very individualized approach in determining who would be best suited for what. You know, we use anything and everything from stents to special catheters and wires, balloons. We use certainly open surgery. I think it all is patient-dependent on what they come in with and what problem we're trying to treat. In addition, I think we also are very good at trying to determine the longevity of therapy that we're trying to provide. So whether it be stent versus stent plus an open surgery or versus open surgery itself, like a bypass, I think that's all very patient-dependent and also situational that we take things into account.

Host: Yeah, definitely not one-size-fits-all, but always good as a patient to know that the surgeon has a bunch of stuff in their toolbox, right?

Dr. Neal Ramchandani: Oh yes, absolutely.

Host: Yeah, that's great. So, how do you actually determine if it's PAD? Is there certain tests that you do or is it a patient history, family history, you know, all this stuff we've talked about?

Dr. Neal Ramchandani: If you have lower extremity pain such that you have calf cramping or foot pain, certainly that should prompt a workup of peripheral arterial disease, especially if you have a history of diabetes or longstanding tobacco use. In addition, if you ever have developed a foot wound, I think that also prompts the diagnosis of PAD or the evaluation for PAD.

The first step is getting an ankle-brachial index. Like I mentioned, the blood flow, the heart likes to pump blood from the tip of your nose to the tip of your toes all at the same time. And so, in order to do that we certainly have made some compensatory changes in our body in order to do that. But all things considered, if you have a ratio or a comparison of blood pressure in the arms to the legs, it should be relatively the same. And so, that's what's the ankle-brachial index, meaning that the pressure in your ankles over the pressure in your arms. And so, that is said to be normal when it's greater than 0. 9. If it's less than that, then certainly a further evaluation must be done. On the flip side, if it's greater than around 1.3 or 1.4, then you also should be evaluated for heavily calcified vessels. And so, you know, it's always good though to start with that initial workup.

Host: Well, I really appreciate your time today. These types of things are great for me and I'm sure listeners as well. I just find them really educational. And if folks are suffering from some of the signs and symptoms, they obviously reach out to their own providers, have things done like the ABI, the ankle-brachial index to find out exactly what's going on, and is there a diagnosis of PAD and so forth. So, thank you so much.

Dr. Neal Ramchandani: Oh, absolutely. Happy to talk with you. We're certainly here to help anytime.

Host: And to learn more, visit franciscanhealth.org and search peripheral artery disease. 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.