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Prakash Chandran: Peripheral arterial disease or P A D affects eight to 12 million people in the United States. So it's important to understand signs and symptoms of the disease and factors that might put you at risk here to talk to us about it is Dr. Irfan Imami, a board certified vascular surgeon and general surgeon at Health First in Melbourne Florida. this is Putting Your Health First, the podcast from Health First. I'm your host, Prakash Chandran. So Dr. Imami, thank you so much for joining us today. We truly appreciate your time. I wanted to get started by understanding what exactly is peripheral arterial disease.

Dr Imami: Well, I appreciate it prakash. The definition of peripheral arterial disease is essentially hardening of the arteries of the blood vessels. As we get older, we all develop some hardening of the arteries. Calcium, cholesterol buildup that restricts blood flow to the end organs, let it be muscle or solid organs, and restricts flow, causes problems down the road.

Prakash Chandran: Okay, so you mentioning kind of the hardening of the blood vessels, what causes this and who's at risk?

Dr Imami: So the best example I give, it's similar to the water pipes in your house. You cut the pipe 20 years later, you look inside at home, it's full of debris. The water pipes in the house are very similar to the pipes in our body or arteries as we would say. So we develop in our body, calcium, cholesterol buildup over time, and those buildups become significant blockages then which restrict flow, which is peripheral arterial disease.

Prakash Chandran: I Got it. And so when you have this restriction of flow, are there symptoms that tell you that it's happening?

Dr Imami: Absolutely. So as an example, if we have restriction of blood flow going to the legs, we start developing leg pain. When we start to walk as the restrictions or blockages get worse, we start to develop wounds and sores, at that point. And then that puts us at limb threatening ischemia where we could lose our leg if it goes untreated. If it's similar blockage in our neck, for instance, in the carotid artery that could increase our risk for stroke.

Prakash Chandran: Okay, so I'd love to understand a little bit more around who is at risk for getting this disease. Is it all of the population? Is it people over a certain age? Talk a little bit about that.

Dr Imami: Majority of the population, yes, they develop age appropriate arterial disease. Everybody gets it, but the people we're more concerned about are people who have associated risk factors that'll accelerate the process. So the patients are typically over 60 years old, and the number one culprit is tobacco. Somewhere in our life, if we've smoked tobacco, it's built up over years, and then we see the effects as we get older. In the blood vessels, it's tobacco, high blood pressure, high cholesterol, diabetes, and kidney failure. Those are the top risk factors we're looking for. Then there's of course, a family history, which comes in family history can get us at a younger age. Typically in our fifties, we might see family history come in.

Prakash Chandran: And what about screening? Do you have a certain screening regimen that you recommend, or do you only have them come in when they are experiencing symptoms?

Dr Imami: So majority of people, again, are over 60 years old. Screening is a pretty good study. It's a very easy non-invasive vascular study. We can just check the blood pressure down at the ankle level and compare that to your arm. Since. Similar blood vessels and flow throughout the body. If there's a significant discrepancy in blood flow at the ankle that's going to tell us that there's a problem or blockages, so that then warrants additional testing. But if the screening studies come back fine for the most part, then really wouldn't be too alarmed about it.

Prakash Chandran: So if it turns out that someone has peripheral arterial disease, can you talk a little bit about the steps taken after the diagnosis and also some of the treatment options?

Dr Imami: We'll start with the legs as an example. So if somebody has symptoms of leg pain when they walk it could be arterial disease. So we do the basic screening study of the blood pressure cuff tests. Then we can go further and get better imaging of the blood vessels by having a CAT scan performed. CAT scan can tell us exactly where the blockages are and to what extent. That's diagnostic. That gives us a great answer, but if we wanna go forward further, we need to do intervention. Intervention is a catheterization.

Very similar to how a cardiologist does a heart catheterization to put stents in as vascular surgery. We can go down into the legs and put stents and balloons down into those blood vessels to restore flow, and that typically takes about 30 to 45 minutes to do all done as an outpatient. That's the first line of therapy. If we cannot do that because the disease is so bad, then we can proceed forward with a potential bypass of that blood vessel. So that's your legs. Regarding other areas which is equally important, or say the carotid arteries in the neck.

If you've had a history of tobacco use or a family history of strokes, then an ultrasound of your neck will tell us are we able to have significant blockages that need to be managed? Because the symptoms of carotid disease are many strokes or what we call TIAs, transit ischemic attacks. Or it leads to a permanent stroke, which is obviously what we need to avoid. So if there's any inkling of a family history of carotid disease or strokes, or a history of tobacco abuse and you're over 60, then I'd say, Hey, listen, let's get a carotid duplex done and take a look at your carotid arteries.

Prakash Chandran: Okay, so if you are able to do that proactively, right? Like you mentioned, if you're over 60, maybe you are a smoker, you have that family history and you find a blockage, is there a way to proactively flush out those arteries before something more severe happens?

Dr Imami: Correct. So regarding the carotid arteries, the proactive treatment is to have either a stent placed or undergo a endarterectomy, which is where we physically core out the blood vessel from the inside and clean it out, put a new patch on it, and we're done with it. Obviously, we don't want the carotid arteries to become symptomatic because if they do, those symptoms are stroke-like symptoms and you don't want to be in that position. So you wanna avoid being symptomatic. We'd rather get to it before it gets to be a problem.

Prakash Chandran: Yes. Now you mentioned legs at first, and then mentioned kind of the other areas of the body. Did you mention legs because it's a more common form or representation of PAD?

Dr Imami: So legs I mentioned because people mistake leg pain for a whole slew of other reasons. A lot of patients say, Hey, listen, I'm just getting older, and it's just part of the aging process. Well, It really doesn't have to be that way, we can get your quality of life better. It's just a matter of identifying the disease process and let's get to it and get your walking again better, out of pain.

Prakash Chandran: I wanna talk a little bit about prevention now, based on the risk factors. I'm assuming you do things like don't smoke and stay active, but are there any other things that people can do to best avoid this disease?

Dr Imami: Avoidance is very difficult. Again, just we all get age appropriate arterial disease. Agreed. Number one reason, stop smoking. That's critical. Next is maintain blood pressure control and maintain your sugar level or a hemoglobin A1C. Keep those in check. The best you can do for me is, walk, walk, walk. I tell patients just walk. It increases collateral circulation around blockages, and it will avoid having need for potential bypass or intervention if you just walk a lot.

Prakash Chandran: Now I wanna actually unpack that a little bit. When we say walk, what does that mean? Does that mean walk around the block? Does that mean walk for a couple miles? Do you have like a certain regimen that you, prescribe people?

Dr Imami: So I tell patients who wanna walk indoors, walk around the mall, it's great. It's air conditioned. They just make a little circle. I've got a lot of patients that just love walking in the mall. Other people, they walk in their neighborhood in the subdivisions. They walk one to two to three houses down or maybe end of the block, and they start gradually increasing their distance on a month basis. Today we're walking two houses tomorrow we'll walk three houses. So that's how I sort of encourage them to get out and about or walk their dog.

Prakash Chandran: Yeah, that's great advice. So one more thing I wanted to ask is, given all of your experience treating patients with PAD, what is one thing that you know to be true that you wish more patients knew before they came in to see you?

Dr Imami: I wish they were educated a little bit more about the effects of tobacco and how to manage tobacco. So, If you are a diabetic smoker, the risk of limb loss is extremely high, from not only the diabetes affecting the blood vessels, but the continued use of tobacco. So diabetic smokers, I always say, Listen, you've gotta stop. Otherwise we're gonna end up at some point losing your leg. We won't be able to manage the disease process. So if we can help curtail folks patients tobacco use, that would really help us out.

Prakash Chandran: Yeah, and we actually didn't talk about extreme or severe cases of PAD, but you mentioned leg loss or limb loss. Can you just talk broadly about when it gets to that point and when a limb is needed to be removed?

Dr Imami: Right. So there are different gradations of arterial disease. It can start as mild, where we're starting to see some pain in our legs when we walk, say to the mailbox, and then it stops. Then we gradually, Get pain at rest where we're just getting pain as we're sitting in our chair. The next step is we stub our toe on the door, for instance, or on the side of a bedrail at night. Then you develop a wound or sore that you've inflicted that doesn't wanna heal because there's not enough blood flow.

The last case scenario is when you develop a sore spontaneously, you did nothing and a sore or wound pops up on your foot, ankle, or calf. That is what we consider limb threatening eschemia. then we really have to hustle to get blood flow in order to heal that wound, otherwise infection sets into the skin, into the bone, and then through the blood. And then we're well behind, the eight ball at that point.

Prakash Chandran: Okay. Understood. So I've learned a lot here, today, Dr. Imami, I really appreciate your time. Is there anything else that you'd like to share with our audience before we close?

Dr Imami: No, absolutely. I think just notify your physicians, let them know about leg pain and exercise, walk, healthy diet. Those are some of the, preventative measures that you can do. And as vascular surgeons, we're all here to help out.

Prakash Chandran: Beautiful. Well, thanks so much for your time, Dr. Imami.

Dr Imami: Thank you so much. Thank you.

Prakash Chandran: That was Dr. Irfan Imami, a board certified vascular surgeon and general surgeon at Health First in Melbourne, Florida. Thanks for listening to Putting Your Health First. For more information, you can visit hf.org. Thanks again for listening. My name's Prakash, and we look forward to you joining us again.