Helen Dandurand (Host): Hello listeners and welcome back to the Well Within Reach podcast, brought to you by Riverside Healthcare. I'm your host, Helen Dandurand. And joining me today is Dr. Hussain, vascular and endovascular surgeon at Riverside Healthcare, to discuss peripheral artery disease or PAD.

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Host: And we are back with Dr. Hussain. Thanks for joining us today.

Dr. Syed Hussain: Thank you for having me, Helen.

Host: Of course. So, this is your first podcast with us. So, could you just go ahead and tell the listeners a little bit about yourself?

Dr. Syed Hussain: Sure. My name is Syed Hussain. Born and raised in Chicago, Illinois. I went to medical school at Loyola University. After finishing medical school training, I did some of my General Surgery training at University of Illinois, followed by my Vascular training at Southern Illinois University in Springfield. And then, I stayed in the central Illinois region. After that, I practiced in Peoria and also in Champaign. And now, I'm practicing here.

I've been in practice a little over 20 years. And I love to do all types of vascular work, both surgical and minimally invasive endovascular work, which means putting in stents in angioplasties and things of that nature gives us a lot of fun toys to play with to help our patients.

In my spare time, I enjoy watching sports. I'm particularly fond of football and baseball, and enjoy going to the beach, riding my bike and things of that nature.

Host: Awesome. Well, sounds great. Very well-rounded person. Well, so jumping into our topic at hand today, could you tell us a little bit about what peripheral artery disease is?

Dr. Syed Hussain: So, that's a good question to start off with because peripheral artery disease initially on a broad spectrum was defined as any atherosclerotic process or a thrombotic process, meaning that any type of clotting disorder or plaque buildup that occurs in arteries, that affects any artery outside the heart or the brain, and that's how it was defined. So, arteries in the neck, arteries in the chest, the abdomen, or pelvis, the arms, legs, that was all called peripheral artery disease.

What we focus mostly on peripheral artery disease now is disease that affects the legs, which means pretty much from the abdomen down to the toes. And that's how PAD is defined now is atherosclerosis, plaque buildup, clotting disorders of the arteries in the legs.

Host: Okay. Could you explain why the legs and lower extremities are primarily affected?

Dr. Syed Hussain: Well, actually, they're not so much that they're primarily affected, it's that the definition has changed a little bit, purely because we focus a lot on cardiovascular disorders, meaning that we focus a lot on the heart. When people are having a heart attack, that's what we're trying to prevent them from having, because we're worried that they're going to die. Same thing with stroke. You know, we put a lot of emphasis on stroke. So, peripheral artery disease is almost a second thought. It's sort of an afterthought, you know, of looking at the legs as being a problem.

So, focusing on the carotid arteries, which can affect the risk of having a stroke, for example, or a coronary artery disease, which can affect you from having an MI and things of that nature, the legs are kind of an afterthought. And so, people don't really think about that as being a major issue until it becomes a major issue.

Host: Yeah. So, could you explain then what kind of the typical symptoms are for PAD and maybe how they would differ from other leg pain such as arthritis or nerve issues?

Dr. Syed Hussain: Sure thing. And I think that's a really good question because most people do mistake PAD for arthritis or nerve issues and things of that nature. So typically, PAD affects the lower extremities when people exert themselves, and that is the key thing to remember. It's when you have pain or cramping or getting a Charlie horse in your calf muscle or your thigh muscle, or sometimes in your buttocks, when you exert yourself and walk a certain distance. The minute you stop walking, that pain goes away or that sensation goes away, and that's how you resolve yourself.

The other side of things is when patients have pain in their feet at night. So, not cramps at night in their calves, but pain in their feet or numbness in their toes that causes them to wake up out of bed and have to put the foot on the floor, and that relieves their pain. So, that is all symptoms of PAD.

Host: Interesting. Those are very like specific things. That's super interesting. What are kind of the main risk factors then for developing that and who's most at risk?

Dr. Syed Hussain: So, the main risk factors for PAD is, number one, any history of diabetes mellitus, and the underlying history of smoking. So, those are the top two causes right there. So if someone has smoked more than a hundred cigarettes in their lifetime, or somebody has diabetes, somebody who has kidney disease. For example, patients who are on dialysis or patients who are at risk of being on dialysis are at the highest risk on the spectrum for peripheral disease. When you talk about other patients, those would be people of the elderly class. So, patients over the age of 55, patients who tend to be more males than females. But generally speaking, it could affect both sexes relatively equally. Obviously, underlying history of heart disease, high blood pressure, high cholesterol, all of those are risk factors for PAD. But if you were to ask me what are the three top risk factors, it would be diabetes, smoking, and kidney disease.

Host: Okay. So, how is it typically diagnosed? Are there certain tests or tools that you commonly use to do that?

Dr. Syed Hussain: Yes. One of the easiest tests to diagnose PAD is to do an ABI and toe pressure. So, what is an ABI? Well, an ABI is basically putting a blood pressure cuff on the foot and measuring the blood pressure in the foot, and then also measuring a blood pressure in the arm. And then, what we do is we take the pressure we get in the foot, divide that number by the pressure in the arm, and that gives us an index. And if the index is really low, that tells us the person has PAD. So, it's a very simple exam, non-invasive.

Host: That's so interesting. What would you say are the current treatment options if somebody gets diagnosed, then where do you go from there?

Dr. Syed Hussain: So, this is where a lot of controversy occurs because patients have pain when they walk or when they have those kinds of symptoms where the symptoms only occur with exertion, but they're fine when they're sitting at home and resting, in those patients, the number one therapy is to put them on a walking program. So, you have to get them on a walking program where they're walking regularly. Because the more they walk through the pain, not up to when they have pain, but when they walk through the pain, their symptoms will actually start to get better by themselves.

That's not the only thing. The other thing we need to do is make sure their diabetes is tightly controlled. So, patients who have hemoglobin A1cs of over 8, for example, those patients need to get better, tighter control of their diabetes to help treat their PAD, getting them on the appropriate antiplatelet medications, things like aspirin and Plavix, or clopidogrel or Brilinta. Those are the types of medications in addition to a baby aspirin that can make all the difference.

And last but not least, we would try to make sure that our patient's blood pressure is well controlled and their cholesterol levels are are at the norm levels. And so for that, putting them on a cholesterol-lowering medication is always very helpful. So, those things almost go hand in hand. The walking program, the aspirin, the cholesterol medication, and blood pressure control, and oftentimes all four of those things controlled together, really you can keep the patient out of a procedure for a long time.

Host: That's awesome. Do you find that, a lot of patients, because it is pain when walking that they start with like going to ortho and saying, "Hey, this is happening," and then you get patients that way?

Dr. Syed Hussain: Yeah, that's kind of a good question because we do see referrals coming not just from primary care, but we also see them coming from Neurosurgery or from Orthopedics or from Podiatry, you know, when people think maybe they have arthritis in the foot or they think, "Oh geez, my lower back pain is acting up and that's why I'm having pain in my buttocks or in my calves," or "Yeah, you know, maybe I threw my hip out because I slipped and fell the other day. So, maybe that's what's causing it." But it's amazing how people misdiagnose PAD.

Host: That's so interesting. Okay. So, you kind of touched a little bit before on some of the basic treatment options, but when should a patient with PAD consider surgical treatment? And what are the risks and benefits for that?

Dr. Syed Hussain: So currently, vascular surgery has really evolved, because I'm able to do surgical procedures and do minimally invasive procedures, it really gives me kind of a unique subset to be able to tell patients and their families the benefits and the contraindications to both procedures. It's one thing if I can only offer one option, and that's what I offer the patient. And so, I kind of feel lucky in the perspective that I can manage them medically, but I can also manage them interventional, or I can manage them surgically.

So when these patients come to me, typically what I will do is I will tell them, "Have you done a walking program?" If you've not done any of the things we talked about earlier, getting them on the right medications, the right counseling, et cetera. Then, we always try that route first. Once those things fail and the patient is still continuing to have worsening symptoms, then the next step would be to do an angiogram first. Because you have to get a lay of the land to say what kind of anatomy are you dealing with? And that's basically a catheter-directed x-ray to get a good roadmap of the arteries in the legs. And once we figure out the roadmap and what's blocked and what isn't, then we can decide what the next step is, whether we do surgery or we offer stents or angioplasties and things of that nature.

Host: Okay, cool. We are going to take a quick break to talk about primary care at Riverside.

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All right. And we are back with the podcast here. So, could you tell us a little bit about what lifestyle changes that patients can make to prevent PAD or slow its progression?

Dr. Syed Hussain: So, lifestyle changes obviously to prevent PAD is, one, stop smoking. So if you're a smoker, that is number one most important thing, is to try to quit and completely stop smoking, if at all possible. And also, that means trying to not inhale secondhand smoke either. So, you want to try to avoid environments where you are able to inhale secondhand smoke as well, which increases your risk just as much as if you were to smoke yourself.

So, that's number one, lifestyle change. I think as far as eating healthy, obviously we want to avoid saturated fats, we want to try to avoid too much red meat. You know, we want to add more fruits and vegetables, whole grains, legumes, those kinds of things to our diet that obviously help us to bind cholesterol appropriately and decrease some of our lipids in our body as well. Minimize our salt intake, those kinds of things.

But the most important thing after that is exercise. And you got to find a way to exercise. I think for PAD, like I mentioned earlier, a walking program is really important. So when people ask me, what is a walking program? Well, a walking program is 30 minutes of walking three times a week.

Now, if you have a problem doing that, and frankly, if you have a problem quitting smoking, the best thing about being in the community with the Riverside is Riverside has a Peripheral Artery disease Rehab Program. So, they have a PAD Rehab Program here, which will actually bring you in to Riverside three times a week. And you can actually work out with the Riverside people 30 minutes three times a week, and literally get you on a walking program that they can monitor your progress for.

So, yeah, Riverside offers that. But Riverside also offers a Smoking Cessation Program through their PAD Rehab Program. So, that's another thing. So, you're almost getting two things taken care of right off the lifestyle change right there. So, I would encourage people to talk to their primary care physicians about that. If they're having PAD symptoms or anything like that, that's probably the place to start.

Host: That's great. And that's nice that there can be someone there to help you every step of the way. Sometimes it's hard to make those changes just on your own. So, that's great. And my next question was going to be about, you know, different exercises that are good for PAD. Are there others that, beside from walking, or do you feel like walking is the main one that is recommended?

Dr. Syed Hussain: So for PAD, really walking is the main exercise, because obviously it's your legs that have blockages in them. And so, you're trying to increase collateral supply around those blockages. So when people think of a blockage, they're like, "Oh God, I have a blockage. I need it fixed." And that's not the case. People can walk around with blockages their entire life and never need them fixed because they've made enough collateral flow around those blocked arteries.

And so, the way you make those collaterals is basically by walking a lot. And I think walking on a treadmill, walking outside when it's a nice day, frankly in the winter, like right now, because we can't go out walking outside or if you don't have a gym membership, easiest thing to do is go to the mall here in Kankakee and just walk around the entire mall.

Host: I see a lot of mall walkers when I stop in there.

Dr. Syed Hussain: I do that too sometimes.

Host: Yeah. You got to get your steps in somehow. That's awesome. So, what would you say are some of the latest advancements in the treatment of PAD, that give patients some new hope?

Dr. Syed Hussain: So, some of the new interventional techniques, I mean, surgery's been around for a long time. We've been doing peripheral disease surgery since the 1960s, and a lot of those procedures are relatively the same. They haven't really changed a whole lot as far as doing bypasses on the legs and opening up the artery and cleaning them out.

But the area where a lot of the new developments are occurring is in the interventional space, and that is always moving at a rapid pace. I mean, there's so much new technology that's coming out. We can go in with scopes, we can go in with atherectomy devices where we can shave plaque out of the artery. We have balloons that have not just traditional balloons to open the artery up with. Now, we have balloons that we are able to actually use to deliver drug into the artery to minimize the artery from re-narrowing. And the coolest, latest thing is that we have stents now in the leg that we can put that are bioabsorbable, meaning that the stents are gone after 90 days. So once you put the stent in the patient, the stent dissolves, then it's gone. So, the patient doesn't have to walk around with a stent for the rest of their life. So, those are some of the more exciting things coming out.

Host: Yeah, that's neat. We are living in a crazy time, but also what's probably the best time. Obviously, we have the best technology to really help people out in situations like this. So, that's a really good thing for healthcare. And what advice would you give to someone who might be experiencing like the early signs of PAD, but hasn't sought any medical attention yet?

Dr. Syed Hussain: So if you're experiencing early signs of peripheral arterial disease, I would recommend obviously talking to your primary care doctor about it. Hopefully, if they'll listen to this podcast, one of the things that gives them a little bit of knowledge and some power to ask questions of their primary care doctors as well, to tell them, "Hey, I've got this issue. I heard this guy on the podcast and this is what he was recommending." And I think the first thing to start doing is to obviously get a baseline ABI and toe pressure exam. And that's a very simple task. You can get that here at Riverside very easily. It literally takes about 20 minutes to get. The ultrasound tech will do it, and you'll have a result. And then, you can talk to your primary care physician about the results. And then from there, initiate lifestyle changes that need to be done. And if medications need to be added, like the aspirin, the statin medication, the blood pressure control, that getting your diabetes under tighter control, all those things can start from that point on.

Host: That's great. I think this is all really good information, like to get a baseline understanding of what this is. Is there anything else you feel like you need to add today?

Dr. Syed Hussain: No, I don't think so. I hope this is educational for the people listening to it. And obviously, you know, being a vascular surgeon here in the community, I'm excited to always take care of patients that have any issues. If they want to come and see me for some of these questions that we talked about today. I mean, they can feel free to call me at the office here and schedule an appointment to come in and see me as well. I'm happy to talk about some of the risk factors and things that we can do to help modify them.

Host: Awesome. Well, thanks for joining us today.

Dr. Syed Hussain: Well, thank you for having me. I appreciate it.

Host: Of course. And thanks listeners for tuning into the Well Within Reach podcast, brought to you by Riverside Healthcare. For more information about Riverside's Heart and Vascular Institute, visit riversidehealthcare.org/heart.