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Dr. Michael Smith (Host): Peripheral arterial disease is a common circulatory problem in which narrowed arteries reduce blood flow to your limbs. If this develops, your extremities, usually your legs, don’t receive enough blood flow to keep up with demand. Welcome to The GW HealthCast. I’m Dr. Mike Smith, and today’s topic diseases of arteries. It’s not just about your heart. My guest is Dr. Salim Lala. Dr. Lala is the assistant professor of surgery at the George Washington University School of Medicine and Health Sciences and is affiliated with The George Washington University Hospital. Dr. Lala, welcome to the show.

Salim Lala, MD (Guest): Thank you for having me Dr. Mike.

Host: We know, for most of my audience probably, the minute we say arterial disease or anything like that, they think of the heart, right? Probably rightly so. But it’s more than just that, correct? So, tell us a little bit about what peripheral arterial disease is.

Dr. Lala: Yes. So basically, patients who present to the hospital, most commonly if they have family members, they think about the heart first because they think about arteries in the heart having disease in them that needs to be unclogged. As you correctly pointed out, that that diseases exists elsewhere in the body and can also exist in the arteries that supply the leg. What it is basically is as we age, peripheral arterial disease is a chronic disease in which you have what’s called plaque, which causes the blockages that tend to build up in the arteries. Not just in the leg, but anywhere in the body.

When patients develop these blockages in the arteries supplying the heart, that’s when patients develop heart pain, or what we call angina. That’s what prompts them to go to their cardiologist. In a similar fashion with the arteries that supply the leg, when they start building up plaque and these blockages, then patients will exhibit pain in their legs. That’s when these patients need to be referred to a specialist, which is a vascular surgeon.

Host: So that’s interesting right. I think that’s an important point that you bring up that phrasing arterial plaque. I think most listeners are somewhat familiar with that. The key thing here is that that can actually happen in any artery really throughout your body. Here’s an interesting thought though. If somebody was to come in and see you, Dr. Lala, with this peripheral arterial disease, some of the symptoms you mentioned in the lower legs, does that make you worry a little bit about other arteries? Like the arteries in the heart. Is there a connection there?

Dr. Lala: Yes, absolutely. In fact, disease in the arteries of the leg is an indicator for having disease in the arteries or plaque in the arteries elsewhere in the body, most commonly the heart. What happens is that patients who have heart pain or angina know that that’s a problem because obviously it’s everywhere. Patients and their families go to the hospital to get that fixed. However, when patients have pain of their leg, that could be due to a multiple host of different factors. So, they don’t tend to clue in that this actually may be a problem with the arteries of my leg. But conversely, you’re right. When a vascular surgeon or another provider correctly identifies that these patients have plaque buildup in the arteries in their leg, it is definitely an indicator that they may have more disease in their heart.

Host: Well how would someone know then. Let’s talk a little bit about average American 30/40/50 years old. What are some of the signs and symptoms that we should look for that might tell us hey I need to go get the arteries in my legs checked out?

Dr. Lala: Yeah so just like in the heart when patients exert themselves and the heart muscle isn’t getting enough blood, they will have heart pain in a very similar fashion when patients have blockages in the arteries of their leg. When they walk, most commonly, and the muscles of their leg aren’t getting enough blood flow because of the blockages, they will exhibit pain in their muscles. We classically describe that phenomenon as intermittent claudication. Basically, the strict definition of that is pain in the muscles of your leg, most commonly your calves, that occurs when you walk a certain distance. When you stop, once that pain occurs, the pain is actually relieved by rest. That is a very good indicator to tell me, as a surgeon, that there might be disease in the arteries supplying that leg. That will be a good time to get a referral and to get further workup and treatment done.

Host: Well what is some of that workup? If I were to go in and kind of present some of these symptoms to my primary care physician, is there something that they can do first to maybe rule out peripheral disease? Or do they get referred right to you?

Dr. Lala: No. I think in the primary care setting there’s definitely a few things that can be done on basic history and physical examination to kind of delineate whether this is truly an atrial problem. Again, when someone talks to these patients, they would be able to tell if they had these classic claudication type symptoms. Also, on physical examination, you can examine the leg and do what we call a peripheral pulse exam where we check the pulses in your leg. So, we check the pulses in the groin where there’s a big artery there called the femoral artery. There’s the popliteal artery that’s behind the knee, and then there’s the arteries in the feet that you can listen to or you can feel with your hand. If you actually can feel the pulse in the foot with your hand, just like you would feel a pulse in your wrist, you probably don’t have any significant blockages.

Also, some primary care physician offices have these otherwise you actually are referred to a vascular surgeon to get ABIs, which is, again, this is a technical term. It’s called ankle brachial indexes. It’s a non-invasive test where they measure the blood pressure in your ankle and compare it to the blood pressure in your arm, and they’re looking to see what the difference is. Usually any number less than 0.9 indicates that you have some sort of disease in your arteries that may warrant a referral to a vascular surgeon.

Host: That’s interesting. So just for my listeners to understand that a little bit more, what you're saying with the blood pressure test is that in general the blood pressure throughout our body should be even or equal, correct? So, if there’s a drop, there’s a blockage, there’s going to be less pressure in the ankle. Is that kind of a way to think of it?

Dr. Lala: Absolutely.

Host: So, there’s a certain number that you look at and you say yes, that’s a drop-in pressure. That’s a sign. If that happens… If let’s say I’m with you Dr. Lala and you do that check and it turns out that my pressure’s a little too low in the ankle, what’s the next step at that point?

Dr. Lala: Yeah, that’s exactly right. So usually at that point, you're usually talking to someone like myself, like a vascular surgeon. Then at that point, we have to investigate and marry the symptoms that the patients are exhibiting, their physical examination findings, and objective measurements such as the results of an ABI to see what the best course of treatment is. The reality is that most patients who have claudication, again which is just pain while walking a certain distance, would actually benefit from conservative management first. Because most patients who have claudication will actually still have their legs in five years. The mortality or the problem with these patients actually comes from underlying disease elsewhere in the body, most commonly in the heart.

So usually patients who have pain in their legs that isn’t really interfering with their life that much but is kind of an annoying cramping pain to the supermarket or if they walk to their mail box, usually we tell those patients that risk factor modification is the first and most essential step. So, if they have high blood pressure to make sure that’s managed well. If they have diabetes, to make sure that’s managed well. To exercise regularly three to four times a week. If they're a smoker, to definitely stop smoking. If they can engage in weight loss programs to engage in a weight loss program. So, I think all of that together, especially exercise, helps to increase the amount of blood flow to the legs while also minimizing the disease that tends to build up and is the first step in treatment actually for these patients.

Host: Then so in those cases where maybe it has to go to the next step of treatment, is this surgery? What’s the process or the procedure at this point if you feel like those lifestyle modifications are not working or they're just too hard for that patient?

Dr. Lala: Yeah, another excellent question. So, then the next step is when patients actually have more pain. It’s just not pain while walking. It’s when they’re sitting down, or they have a wound on their foot that they’ve noticed about three weeks ago that has not healed. So, in those cases, those patients actually have what we like to call critical limb ischemia, which is basically the tissues, or the muscles and the skin of the leg is not getting enough blood flow, even at rest, to do the basic function. So those patients, yes, would warrant an intervention. There are a variety of means by which we can accomplish this. Similarly, we can do it both by using minimally invasive surgical techniques, which is endovascular repairs, and also open surgery where we can do similar to a heart bypass, open leg bypasses.

Host: Right. Yeah. So, I guess let’s, in summary Dr. Lala, let me have you take the reign here and just give us a nice summary of what you would like people to know about peripheral arterial disease?

Dr. Lala: Yeah so patients who have peripheral arterial disease. If you are having pain in your legs, especially while walking, you want to seek a referral from your primary care doctor to a vascular surgeon to see if you do have blockages in the arteries of your leg. Usually if you just have pain while walking, you can manage that with risk factor modification, as we mentioned before. If the pain is interfering with your life or if the pain has gone to the point where you can't even move and the pain is in your foot even while not walking, then we can definitely offer interventions at that point. Usually now that the technology is so advanced, we can put stents in the arteries using wires and casters and even balloons to open up blockages. Such that these blockages can be managed on an outpatient basis. Even if it comes to a point where the blockages are so severe that we cannot manage it with endovascular means, we are very well equipped to do open bypasses to bypass the blockages and reestablish blood flow to your feet.

Host: Great summary Dr. Lala, and I'm going to thank you for the work that you're doing. Thanks for coming on the show today. I want to thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Lala or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.