Scott Webb: Diabetics and those suffering from peripheral artery disease are at risk of losing limbs, and it's important for them to speak with their providers when they experience symptoms. And joining me today to discuss things, including the signs and symptoms, like foot pain and treatment options, is Dr. Anahita Dua, she's a vascular surgeon with SolutionHealth.

This is your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Doctor, thanks so much for your time today. It's great to have an expert on. And as we get rolling here, why is foot pain so common in patients with diabetes? You know, what's causing those issues?

Dr. Anahita Dua: Basically, patients that have diabetes have a significantly elevated blood sugar, which essentially means that some of the areas of their body that normally would function with breakdown and upkeep of blood vessels don't happen in the same way that a normal patient's leg would.

So specifically, diabetes affects the end organs. So, what happens is the teeny tiny blood vessels that feed your toes, feed your eyes, feed your kidneys get badly impacted by having high blood sugar, otherwise known as diabetes. And slowly over time, these itty-bitty vessels start getting eaten away. As they get eaten away, we no longer have enough blood flowing to a particular area. And ultimately, you can end up with things like gangrene, so breakdown of skin tissue and dead areas. You can end up with blindness. You can end up with kidney disease, which is why a lot of people with diabetes are on dialysis, unfortunately. And what also happens is with diabetes, there's a softening of some of the tendons in the foot that keep things basically appropriate, your arch appropriate. And there's an effect on the nerves of the feet that, unfortunately, leads to something called peripheral neuropathy.

So, all in all, with diabetes, you have a situation where you don't have enough blood flow. You have a funny distribution of pressure on your foot because you've lost your arch, and you have neurological issues because the teeny tiny nerves now in the foot are also affected because of this peripheral neuropathy.

Now, if you can't feel anything, you're going to step on a piece of glass, maybe bump your toe, and maybe not realize because you can't feel it, so pain is an important part of a human being because it protects us. When we feel pain, we move our feet away from a particular area. In diabetics sometimes, what happens is if they have peripheral neuropathy, they can't feel that pain, so they can't protect their feet. And then, what ends up happening is they get a wound in that particular location, and the wound will not heal because they don't have enough blood flow. That wound may get infected and not cause severe pain in the foot of a diabetic, which ultimately can progress and lead to something as bad as amputation.

Scott Webb: It's really interesting, isn't it? Normally, for most of us, we think, "Well, we don't want pain. Pain is bad." But in the case of diabetics and foot pain, being able to feel when they've injured their feet actually would be preferred, right?

Dr. Anahita Dua: Exactly. It depends on the type of pain, and that's really kind of an important nuanced discussion because the pain that I would feel if I, you know, dropped a soup can on my foot is a pain where I would pull my foot away from that area, and I would not allow it to get injured again. And that's a good thing. That's again, your body trying to protect you. And in a diabetic, if you have peripheral neuropathy where the little itty-bitty nerves are no longer firing appropriately, you may not feel that pain and that's a bad thing.

But then, there's the other side of the coin, which is ischemic pain, and that's a different type of pain. That is pain because you don't have enough blood supply getting down to your foot. That's essentially the equivalent of if someone is choking your toes, you're not getting enough blood flow, and what your body at that point is doing is screaming and telling you, "Hey, I need more blood flow." And sometimes it can get so bad that our poor patients have to wake up at night because of the pain; they have to dangle their foot over the side of the bed to try to get gravity to pull as much blood to that toe as possible because it's so very painful. And that type of pain, really nobody who's not experienced ischemic pain can understand, and it's this deep-seated, throbbing, continuous pain. And the only way to make that better is to get an increased blood flow to a particular area.

So, these two types of pain are very different. Obviously, pain again is a good thing in either situation, because it's giving you a warning shot, telling you, "Hey, you need more blood flow" or "You need to watch your feet. Don't get hurt." But obviously, we don't want to live in pain. And if it's possible to increase that blood flow by doing procedures that I, as a vascular surgeon can perform, that's absolutely the way to go, especially in our diabetic patients. Because ultimately what's going to happen is that tissue that's screaming out in pain because it doesn't have enough blood flow will not have enough blood flow to even be alive. And now, you'll start to develop a little wound, just a tiny little ulcer right on the toe, but it just doesn't heal. Months pass, and nothing allows it to heal. And the reason is because you don't have enough blood flow. And that little ulcer can turn into something much more sinister and lead to amputation as we discussed earlier, unless somebody comes and increases that blood flow for you, you heal up that ulcer and, you know, hopefully have no more issues.

Scott Webb: Yeah. You're so right that there's good pain and bad pain. In some cases, any pain would be good because it is, as you say, a warning shot. But let's talk about, you mentioned there about the blood flow and improving and increasing the blood flow when things are screaming out, "I need more blood," right? So, let's talk about PAD, the symptoms, who's at risk, and so on.

Dr. Anahita Dua: I am actually the co-director of our PAD center down at Mass General as well. And so, PAD is sort of my life, so I'm your girl to talk to about this. The issue with PAD is that PAD, or peripheral artery disease, is a disease process where the blood vessels of the legs, most commonly, have things deposited within them that stop the flow of blood. So, I want you to think of a road where a big boulder has fallen down in the middle of the road. What's going to happen? The cars are going to back up because they're going to be unable to get past this boulder. Or a four-lane highway is going to be turned into a one-lane highway, and only one car can pass at a time. And that's kind of what's happening in PAD. A big boulder, a big piece of calcium, kind of deposits itself in one of your blood vessels over time because of your genetics, because of smoking status, because of high blood pressure. And that boulder stops blood flow from being able to get down to your toes where it belongs.

So what ends up happening is if you could have blood flow pumping fully every minute, you would have no symptoms. But as the boulder gets bigger and bigger and bigger, less and less blood flow makes it through until the boulder may get so big that it blocks all blood flow to the leg, and that's, of course, a surgical emergency.

So, there are two types of categories with PAD. The first type is patients that, unfortunately, when they start walking, they're only able to walk a small distance. Some of them can only make it to the mailbox. Some of them can do a block of walking. But then, they get severe crampy pain in their calves on both sides. That is called intermittent claudication, which is just a Latin way of saying intermittent, so randomly happening. Claudication means cramping, and what's happening there is kind of the same thing that happens when you work out. If you take a weight and you are using it to do a bunch of bicep curls, after you do ten curls, you might start to get that crampy kind of achy feeling in your arm. That's the same thing that's going on. And the solution to that, unfortunately, is to walk more, because the more you walk, the more you're going to create itty bitty detours around that boulder that are going to get blood where it needs to be, and you get to avoid a surgery.

The other type of PAD, the other category, is much more sinister. That is critical limb ischemia. And that is when you have a critical situation where not enough blood flow is getting where it needs to go. And in that situation, those patients, unfortunately, will have severe pain, as we discussed, in the toes, maybe a constant burning, a constant aching, this idea of being unable to sleep because they're waking up with pain and ulcerations on the feet that are not healing despite their best efforts. Sometimes, they can end up with gangrene, which is when you have a black toe or a black area. And ultimately, that can lead to amputation if something is not done aggressively to get blood flow down to the toes. So, they are two different things that fall under the umbrella of PAD with very different management approaches, which is why a vascular surgeon is so important because you have to come in and get diagnosed correctly and then get the right treatment quickly.

Scott Webb: So, let's assume we've done that, right? We've taken your advice, right? So, we've been diagnosed, and you know which type of PAD it is. What are the next steps? Let's talk about how a surgeon like yourself, treats PAD, you know, the two different varieties. As you say, the most important thing is to be diagnosed, right? So, don't live with this; speak to your primary, see a specialist, and so on. So, you get diagnosed, you've got PAD, this is the type of PAD you have, so now here's the expert in the room, the surgeon in the room. What do you do to help folks?

Dr. Anahita Dua: There are multiple things that we can do. And it really depends on the patient. So, we are all about the patient. We don't treat the symptoms, we treat the person, and that's extremely important because, as I mentioned, you know, there are different types of PAD, and they manifest differently. So, let's take, for example, a person whose job is to be a postman, right? He or she is walking from house to house, depositing mail. In somebody like that, if they're unable to walk because of that crampy pain, that intermittent claudication, we would offer that patient potentially an angiogram, which is basically a procedure where we put a little needle into your artery. And we put a wire inside the artery trying to get past that boulder. Once we push the wire past the boulder, we can then take a balloon or a stent, and we can shove that boulder to the side of the road, so to speak, shove it over to the side of the blood vessel, allowing amazing brisk blood flow down to your feet.

Now, if that's a postman, obviously being unable to walk can affect their job. But if you are a grandma, let's say, and the issue is really, "Hey I'm having difficulty making it a block while I walk my dog, I would say to somebody like that, "Well, let's get you on a walking program. Let's stop that smoking. Let's get these medications in place. A little bit of blood thinner, a little bit of cholesterol-lowering medication, and get you on an exercise walking program where I'm monitoring it in order to generate these new collateral blood vessels so that we can get more flow down to the foot."

The other thing that I would do is if you come in with critical limb ischemia, as in you don't have enough blood flow to your toes, then I'm all about trying to figure out how to get it there by any means necessary, so to speak. So, we can do it one of two ways. One is what I described earlier, where we put a needle into the artery and a wire into the patient's leg, take a look to see where the blockages are and go and remove those blockages. The other option is if the endovascular or minimally invasive procedure doesn't work because the calcium burden is so extreme, there are too many boulders, it's unsafe to kind of push past them, then we would offer a bypass, a surgical bypass, which would include basically creating a detour. So, if that boulder on the road could not be moved, the cops would come and do what? They would detour the cars right from the road where the cars are stopped to a piece of the road beyond the boulder, which is normal. That's exactly what we do as vascular surgeons. We take a piece of your vein sometimes from the same leg, sometimes from the opposite leg that you don't need, or we take doctor plastic, essentially, it's called PTFE. It's a type of material that allows us to make a bypass and we connect an area of good blood flow to another area of good blood flow beyond the boulder, thereby allowing blood flow to continue down to the feet.

We are surgeons. We love to operate. But the right thing to do for patients is if you don't need to operate, you shouldn't. And so, we do absolutely everything to provide that comprehensive vascular care, really understanding what that particular patient needs so that we can offer anything out of our toolbox to ensure that they get the optimal result. And that can include anything from the walking program and medical management all the way through to a major bypass. And I'm able to do all of that.

Scott Webb: Yeah. It's so great having you on. I feel like we could speak for hours. There's so many topics. We're just sort of scratching the surface here today, but it is so helpful and so educational. Doctor, as we wrap up here, as you say, you're very patient-centered, patient-focused. I'm sure patients are going to want to know if they have diabetes, what they can do, behavior, lifestyle, or otherwise to sort of reduce the complications of PAD.

Dr. Anahita Dua: The patient really is at kind of the helm of making sure things go well. The most important thing that can happen in diabetes is control of blood sugar. HbA1c is basically a way in which we determine how well the glycemic or sugar control is over a period of time. The most important thing to do is to keep that H HbA1c below 6. So ensure that you're taking the appropriate dietary requirements, you're taking the appropriate medications, including your insulin if you're on insulin, appropriately dosed or the hypoglycemic medications that are necessary to keep the blood sugar in check. And diet and exercise. And I know all doctors say, "You got to diet and exercise," and it's true. But in this case, it's really true.

And then, the other major thing that you can do, absolutely major, is if you smoke, stop smoking, because, again, all doctors say cigarette smoke is bad. But in the case of vascular surgery, cigarettes are exceptionally bad. And the reason is because every artery has three layers to it, like a layered cake. And the innermost layer is called the intima. And that's almost like think of an ice-skating rink. It's a nice, beautiful, flat surface through which blood rushes pass, ice skates pass and gets to where it needs to. When you smoke for whatever reason, the stuff that's in cigarettes causes little itty-bitty fractures or cracks in that inner lining of the blood vessel. So, think of like, if you put cream cheese on a bagel and you leave it out, how it starts to crack in different areas when it dries out, same concept. And what happens when that inner lining cracks, bits of blood slip into those cracks and whenever bits of blood fall and slip into the cracks, they clot. And they start to form these kinds of mountains of garbage that shouldn't be there, ultimately causing the boulders. So, there is a direct association between smoking and amputation. And so, it's really important if you do smoke, that really needs to get nipped right in the bud, because that is a major component and, on top of diabetes, that can result in very dire consequences if not under control.

Scott Webb: It definitely can. And doctor, if there were an award for the best analogies by an expert to help people like me understand what you're talking about. The cream cheese, absolutely. You leave it out. It starts to crack. I mean, you are so great with the analogy, so helpful. I'm sure listeners are nodding their heads, too. Doctor, thank you so much. You stay well.

Dr. Anahita Dua: Thank you very much. It's a pleasure to be here.

Scott Webb: And for more information, visit snhhealth.org/vascularsurgery. If you enjoyed this podcast, please be sure to tell a friend and share it on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.