Scott Webb (Host): Peripheral artery disease, or PAD, is common and avoidable for most if we don't smoke and we control conditions like high blood pressure and diabetes. And though primary care physicians can help to identify the signs of PAD, it's best treated by vascular surgeons like my guest today. I'm joined today by Dr. Steven Hoenig. He's a vascular surgeon and founding member of the Vascular Care Group.

 Welcome to Answers in Vascular with the Vascular Care Group. I'm Dr. Scott Webb. Doctor, so nice to have you on. We're going to talk about peripheral artery disease, and we'll probably abbreviate that as PAD because it's a little easier to say, a little faster to say. So, let's start there. What is PAD and who's most at risk?

Dr. Stephen Hoenig: Well, thank you, Scott, for inviting me to share with you some ideas about peripheral arterial disease. First, I'd like to say that PAD seems to be a common word, and PAD encompasses all of the body outside of the heart and head, including the carotid arteries and peripheral arteries in the arms and legs. What I'd like to focus on today is diseases of the arteries involving the legs and circulation to the legs. that really is what I'd like to focus on.

Host : Okay.

Dr. Stephen Hoenig: So, peripheral arterial disease in the legs is blockages of the arteries. And it usually develops over time. The major cause of this is atherosclerotic disease, which people often hear about. When it affects the heart, when people have heart attacks, it usually involves blockages of the arteries in the heart. What we're going to talk about is blockages of the arteries in the leg

So, PAD in the legs can, in the mildest form, cause leg discomfort when you walk and muscles don't get enough blood flow and lactic acid builds up and you get pain in the leg. And then, sometimes it gets even worse than just muscle discomfort. It can lead to tissue discomfort and nerve discomfort where you get pain in the feet and heels and toes all the time. And then, it can actually lead to skin breakdown, and even gangrene is something that we see on a regular basis.

Host : Yeah. Interesting, because I was going to ask you what the symptoms are, but you gave us a sense there of what the symptoms are. And I think, doctor, a lot of times with medical things, medical ailments, if you will, that it could be one thing. It could be another thing. And so, what you're saying about these PAD symptoms in the legs is these things go on all the time and they get progressively worse, if I'm hearing you right.

Dr. Stephen Hoenig: Yeah. You know, people come to see me in my office all the time with leg pain and leg pain has a million different causes. So, you have to inquire and get a good history from a patient. If you are a diabetic, if you are a smoker, if you're older, then you are a setup for this kind of blockage. You know, we sometimes see people who have led pristine lives, but they're 85 years old and these patients may then develop blockages of the arteries. I call it rust in the pipes. It's the same thing when you have an old house, you know, accumulation of rust. And most of the time, that's fine, no problem. But sometimes that rust can totally block a pipe and it can lead to significant pain.

Host : You know, we talk about prevention, right? Is it possible to prevent PAD or is it more about addressing the underlying causes of PAD? You know, as you're talking about whatever it might be, high blood pressure, diabetes, whatever contributes to PAD. Is it more about sort of limiting the effects of those things or preventing those things, or is it possible to prevent PAD?

Dr. Stephen Hoenig: It definitely is. And I would say that the same thing that people are asked to comply with for the heart is the same thing for the legs. So when we talk about heart disease and we talk about PAD, we're talking about controlling blood pressure, high blood pressure. We're talking about controlling cholesterol. We're talking about exercise every day, eat well. Those are really important things. I would say though that in my population of people who come to me with disease, it's not uncommon for people to have poorly controlled diabetes and are heavy smokers. Smoking is a really big, bad problem for patients with PAD.

And so, we spend a lot of time on not only just prevention, because sometimes patients come to me who already have the disease, but we talk about lifestyle modification. That's kind of the big deal here. We talk about somehow getting off of the nicotine kick. You know, nicotine affects people, whether or not you're smoking, whether you have a patch, gum, vape, cigars, pipe, it's the nicotine that really affects the arteries that leads to blockage.

And the good news is that if you have PAD, and you are a heavy smoker, if you quit smoking after a period of time, one to two years, if you are out of trouble at that point, you'll stay out of trouble. In other words, it doesn't necessarily reverse the curve, but it flattens the curve. So, it really is a very effective thing to quit smoking.

And then, also nowadays we have so many different ways to control diabetes, you know, with the insulin pumps and the continuous glucose monitoring. And those are very hard to comply with, but controlled diabetes with a good A1c is something that's very important for PAD.

Host : Right. So, you know, cut back or quit smoking, control diabetes, high blood pressure, all those things, maybe easier said than done, but you do get a sense there that through behavior and lifestyle modification, it is possible to, as you say, flatten the curve. And wondering when we think about who treats PAD, you know, most people have a primary care physician, but I'm guessing it's more vascular types, vascular surgeons that treat PAD.

Dr. Stephen Hoenig: Yeah. You know, I mean, the problem is there aren't that many vascular surgeons in the country, and there's a lot of people with vascular disease. And so, it's really very much up to the primary care doctors to identify the problem and send those patients to the vascular surgeon.

Now, we are surgeons, and there is a specialty called vascular medicine, but there are even fewer vascular medicine doctors. You know, different from in cardiology, where they're there are cardiologists, and then there are cardiac surgeons. We don't really have good medical vascular surgery people, doctors. So, we do a lot of managing patients now. I have a large population of people that see me every six months, just because they want a good vascular checkup.

And then, the other thing is, you know, I follow patients who have-- this isn't specific for this podcast-- but who have carotid artery disease. And we're following them for that, and lo and behold, they also have a blockage in one of the other arteries in their body, whether they have a kidney, a renal artery problem, or a leg problem. And then, we start following them for that as well. So, we do sometimes feel like primary care doctors for the vascular system.

Host : Sure. That's interesting. Not just a matter of semantics, of course. Wondering what's your sense, you know, you say there's basically sounds like there's a shortage of vascular specialists or vascular surgeons. What's your sense of why aren't there more of you?

Dr. Stephen Hoenig: Well, you know, there are a limited number of doctors out there in the world, and it's a long training process. I mean, it takes medical school and then a long residency and then specialty training and Vascular fellowship. And it's a long haul to get there. I love what I do. I wouldn't trade it for anything. It's such a privilege to take care of patients and it's an honor to do it, but it's a long road. And I think that whereas maybe the number of Vascular surgeons has stayed flat, the number of patients who need vascular surgery has increased. And that's largely because patients are getting older, you know, and we have more and more diabetes out there in the world. Fortunately, there are fewer and fewer smokers, but certain areas of the country where there still are big pockets of smokers, we're very busy.

Host : Right. Yeah. You gave us a sense earlier of how you diagnose PAD, good patient history, and checking the medicine cabinet, if you will. You know, what things are they? So, they're high cholesterol, high blood pressure, they're smokers. You know, at some point, probably fairly easy for an expert like yourself to diagnose PAD. So, that in mind then, how do you treat PAD surgically, non-surgically, and so forth?

Dr. Stephen Hoenig: So, a patient walks into my office who I'm concerned about PAD. We have a number of tools right at our fingertips to test to see whether or not they actually have it. We do blood pressure cuffs on the legs. These are non-invasive testing with they're called ankle brachial indices, which measure the blood pressure in the legs. That can be a good test to know whether they have or don't have this disease process. We use a lot of ultrasound and all of us in Vascular Surgery now are skilled in using vascular ultrasound, although we're not necessarily the ones in the back room doing the studies, but we all know how to do the studies and interpret them. That's really the frontline test.

Host : For diagnoses, okay.

Dr. Stephen Hoenig: And then, there are tests, there are things like CAT scans and MRIs, which can help with this and diagnosing. But the gold standard of diagnosing vascular disease is what's called angiography, which is where we actually put a needle into the blood vessel and inject something called contrast, which brings out the open parts of the blood vessels and we can see very clearly exactly where the blockage is and then we can prepare for some form of intervention if that's what's needed.

Host : Yeah. So, let's finish up there with the intervention, the treatment options, surgical, non-surgical, you obviously as a surgeon, I always hear from surgeons that, "Yeah, I'm a surgeon and I love doing surgery, but we try some other stuff first," but take us through that.

Dr. Stephen Hoenig: Well, it's an incredibly creative and ever-changing field in Vascular Surgery. I am trained as a surgeon, but now I'm also trained in Endovascular Surgery. It's also surgery, but less . Whereas we used to always do big open operations that would put people out for weeks or months in recovery, now we do procedures that take an hour and a half and they walk out of the office. Not only that, but we used to do procedures fundamentally in the hospital. And now, I do most of my procedures in my office. I have a office-based lab where we do procedures safely and much more efficiently and quickly and easily for the patients.

So, I think that the way to treat patients has become easier from the perspective of the , not necessarily easier from the perspective of the Vascular Surgeon because it takes different types of training and expertise.

Host : Yeah. And as you say, as we finish up here, you know, there have a shortage really of folks like yourself, vascular surgeons, those especially now who are also trained in minimally invasive approaches. Just want to give you a chance, you know, final thoughts, takeaways. It has been really educational. Always great to have an expert on and learn about things. Today, I learned about PAD as listeners did. So, just final thoughts.

Dr. Stephen Hoenig: Yeah, you know, I think that the goal here is to save functionality, to save legs, save limbs. And in this country, there are a lot of patients who end up with amputations of their legs who have never seen a vascular surgeon. And that's, to me, a tragedy. I spend my life trying to save legs. And I think that if everybody was to be aware of the problems with peripheral arterial disease and get people hooked in with vascular surgeons, then there's a much greater chance of living a long, healthy life with their limbs intact.

Host : Right. Yeah, that's perfect. You gave us a sense earlier of the symptoms that folks may be suffering from. So if you've listened to this and you're checking things off that list, time to speak with your doctor, see a vascular surgeon. As you say, your goal is to save legs and that seems like a good thing in all cases. So doctor, appreciate your time and your expertise today. Thanks so much.

Dr. Stephen Hoenig: Thank you very much.

Host : And for more information, please visit our website at thevascularcaregroup.com. Thank you so much for listening to Answers in Vascular with the Vascular Care Group. I'm Scott Webb. Thanks for joining us.