Scott Webb (Host): Peripheral artery disease or PAD and venous disease are diseases that affect our arteries and veins respectively. And if left untreated, can lead to poor quality of life and in extreme cases, amputations. And joining me today to tell us more about PAD and venous disease is Dr. Jamil Matthews. He's a Vascular Surgeon with Salinas Valley Health. 

This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb.

Doctor, it's nice to have you here today. We're going to talk about PAD, peripheral artery disease and venous disease. And I know you're a former college athlete and a medical professional, and so you're a good person to have on to talk about these things. So let's start there. What is PAD and what is venous disease?

Jamil Matthews, MD: PAD, Peripheral Artery Disease and Venous Disease describe a symptomatic spectrum of disease in the arteries and the veins. So before we go into it, it's important to know the differences between those two blood vessels. When you think of blood vessels or the vasculature, you have to think of that as an umbrella term.

And underneath that you have the arteries and the veins. They do similar things, but different things at the same time. And I'll explain. The arteries take oxygenated nutrient rich blood from the heart, and deliver it out to the tissues so the tissues can use it for metabolic processes. Once that's used up, that deoxygenated blood that has now been extracted of its nutrients, then circulates back to the heart to undergo the whole cycle again. Peripheral artery disease is disease on the arterial side of the vasculature, and what it is, is it's a buildup of atherosclerotic plaque or calcium that subsequently reduces the blood flow to the tissues that it supplies.

This can result in a wide spectrum of presentations. You can have pain with walking, which we call claudication, pain at rest in really severe circumstances where the tissue is so choked of blood because of the disease, that even without any activity, you start to feel pain. And in the worst situations you can develop wounds, which can often lead to amputation.

Now, on the venous side, the part where the blood is now returning back to the heart; venous insufficiency describes the malfunctioning of the valves inside the veins. So what happens is, as the blood is trying to return back to the heart, going against the force of gravity, this is particularly when I'm speaking about the veins in the lower legs, right?

Because everything in the universe follows the laws of physics. Blood, like anything else, wants to settle to the bottom and wants to go with gravity. But the body has, or mother nature, has really taken advantage of the fact that if we use our calf muscles with walking, with moving, it squeezes the column of blood up back towards the heart and the valves secondarily serve as one, one-way valves to ensure that the blood goes up but doesn't come back down.

However, in situations of venous insufficiency, that blood then refluxes, or it goes back down to the legs. That results in leg swelling. It can result in varicose veins and spider veins. In more severe situations, results in severe edema, which can cause skin discoloration and often ulcers. And in very, very severe situations, patients can actually undergo amputations as well.

Host: All right Doctor so you give us a sense there, at least for us laypeople. You had asked me earlier who listens to these, and it's generally laypeople like me and other listeners, and give us a sense of how PAD affects people, how venous disease affects patients and people and ultimately how it affects circulation.

So let's talk about the risk factors. Who's at the highest risk for developing PAD and chronic venous insufficiency?

Jamil Matthews, MD: For PAD in particular, one of the highest risk factors is smoking. Smoking actually is, in large part, what keeps vascular surgeons in business. What smoking does is when, when you smoke, you're taking in not only the nicotine, but the particulate matter of the cigarette smoke in and of itself, that stimulates an inflammatory process within the blood vessels.

Because remember, when you're inhaling these particulates, they then get absorbed through the lungs, into the bloodstream. And after years and years of doing that, that inflammatory process can cause atherosclerotic plaque deposition, which can result in the diminishing or the reduction of blood flow to the surrounding tissues.

Other causes can be cholesterol for the reasons I just described. You can form cholesterol plaques that build up and narrow the vessels, hypertension, end stage renal disease and I'm going to package end stage renal disease with diabetes as well. Because these two both cause a very unique process in the blood vessels and it causes calcification of the blood vessels where the vessels become very stiff and that affects blood flow, also narrows the blood flow and affects blood delivery to the surrounding tissues.

 Age is also a risk factor, as are genetics. Often my patients will come in either with PAD or venous insufficiency and will tell me that they have family members who have undergone the, have the similar symptoms or have undergone treatments that I'm recommending to these patients.

Host: Yeah. Yeah, you used the word symptoms there and that's kind of where I want to go next. You know? Do folks know they have PAD or venous disease? You know, what can they be on the lookout for? What could they recognize or do they really just need to be diagnosed by a professional?

Jamil Matthews, MD: They need to be diagnosed by a professional. That's true. But I think most important is for patients to realize one thing, and this is what I live by as a practicing surgeon. You are your best doctor. And what I mean by that is you know your symptoms better than anybody else. So what's important is that we as providers do, is educate patients on what symptoms to recognize and know when it's time to be seen by a specialist. So in the case of peripheral artery disease, one of the most common symptoms that patients will present with is called claudication. Claudication is basically a description of pain in the muscles, particularly in the calves, but also can occur in the buttocks and thighs with walking.

And one of the key characteristics of this is when you walk, you develop the pain. Patients say that this develops after walking 10 feet. Some people say it occurs after walking several blocks. What makes claudication very distinct is that once you stop walking, the pain starts to go away.

And if you were going to walk again, you would reproduce those same symptoms. And what is happening is that as you're walking your body's metabolic need for oxygen increases because the muscles need that oxygen in order to function. Once you do that, unfortunately your blood vessels may not be healthy enough to keep up with the oxygen requirements of the muscle that's drawing that oxygen. And you don't feel it at rest because at rest, metabolic need is not that high. The muscles are fine, but once they want to extract more, it's the job of a healthy blood vessel to keep up. And when they're not healthy, they can't do that. So that's claudication.

As the severity of disease increases, then you can go to where you have rest pain.

That rest pain is basically numbness or pain at the toes, and this occurs at rest, and this demonstrates a more severe disease because even when the metabolic needs aren't high, when you're at rest; you're still getting such diminished flow to the toes, which is the most distant part of the blood supply.

It's the last stop on the subway train, right? It's the last spot where the blood's going to make it to, and that area is being choked of blood, even at rest. So the basic metabolic requirements that those toes need at rest cannot be fulfilled by what the blood vessels are able to provide at that time.

And then the most severe case of it is now not only are you feeling the pain, but now you can't even keep the tissue alive. So then you start to form ulcers and wounds and gangrene of the toes. And in those situations, amputation is the only answer at that point.

Host: Right.

Jamil Matthews, MD: So for venous disease, again, it occurs on a spectrum as well. In very mild situations of venous insufficiency, patients may have varicose veins that form on their legs, and we all know what the, what vari, the dreaded varicose veins are either from discomfort or just the cosmetics of having varicose veins in your legs. However, as the degree of reflux gets worse, patients can now develop edema. Okay? We have a classification system called the CEAP classification to describe these level of symptoms and anyone can look this up online, through Google or any other search engine obviously.

But you can develop swelling. This can cause fatigue, pain in more severe cases, itching and just overall discomfort to the patient. As the disease gets worse, you start to develop hyperpigmentation or discoloration on the legs, particularly in, in an area we call the gator region, which is a region of the leg just above the ankles.

And what happens is the, you get the hyperpigmentation because the blood is settling down in your legs for such a long period that the iron deposits in the blood start to leach out and they subsequently tattoo the surrounding skin. And what color is iron? Iron's like a darkish brownish color. So the skin ends up becoming that color as well.

And on the worst side, now the skin starts to break down from the prolonged edema and you can develop wounds in your legs. 

Host: Yeah. So you give us a sense there of what we might be experiencing, feeling. But in general, talk a little bit about diagnosis of these conditions, different tests that are involved.

Jamil Matthews, MD: Physical exam is paramount and it's important for you to be seen by a vascular specialist so that they can evaluate you not only for what they see on physical exam, but also to get your story. Do you develop your symptoms when you're walking? Does it get better when you stop, as I described with claudication?

What measures have you tried before to try to help improve your symptoms? Those things are always important, but we have a lot of imaging modalities or a lot of imaging techniques that are available for the diagnosis of both peripheral artery disease and venous disease. So, for example, one of the most basic ones is an ultrasound and a duplex ultrasound is very important. On the arterial side, it allows us to look at the blood vessels, see what blood vessels are narrowed or occluded, and will give us information as to how the blood is making its way down the leg so that we can plan surgically or non-surgically on how to treat it.

On the venous side, an ultrasound is very good because it will help us determine do you have underlying reflux disease? Do you have some form of compression of your vein by surrounding structures? What is it that's causing your symptoms? These imaging modalities can then be escalated to more complex, more invasive techniques, such as angiogram. It's important for me to state that one of the basic things that we do during a physical exam is obtained what's called an ankle brachial indices. And what it tells us is generally several things. Does this patient have peripheral artery disease? Is it significant? And is this something that requires further studies to figure out the best treatment?

Hmm. Yeah, and just want to have you in general, sort of broadly anyway, discuss the treatment options for PAD, Venous Disease, both surgical and non-surgical.

The treatment of peripheral artery disease and venous disease is an escalation of scale. You start first with the non-surgical techniques to minimally invasive techniques to surgical techniques.

Jamil Matthews, MD: And what you often find is that a large portion of patients improve significantly just off of the medical techniques, and that's why it's very important to be evaluated by a vascular specialist who not only understands how to do the procedures, but also understands the pathophysiology and the theories behind arterial and venous disease.

So for peripheral artery disease. Depends on the presentation, but typically you'll start with lifestyle modification. Well, what does that involve? Not smoking. Watching what you eat, making sure you're eating a healthy diet, low in saturated fats, low in sugars, you exercise daily. I always recommend to my patients to at least start with 25 minutes of cardiovascular activity daily. I mean, just going for a walk. Putting on your headphones, going for a walk around the block. But at least do 25 minutes of that per day.

Also optimization of your medicines. Are you on an aspirin? Are you on a statin? This is in particular for patients with peripheral artery disease. And if so, are you on the right dosages, and we start with that. We put you on a regimen of that and then follow up and see if your symptoms improve.

If your symptoms don't improve, then you escalate and you go to further treatments. And that includes possible angiogram with intervention, or we may have to escalate to an open surgical procedure.

For venous insufficiency,

it always starts with compression. Compression is vital for several reasons. The compression process will both help clear that fluid buildup that's in your legs, which will help with your overall symptoms, but it also helps in wounds healing. And that together is very important in the progression of the patients and making them feel better following treatment.

And what we have found, people way smarter than me is that if you put a patient on a physician monitored, and that's very important, physician monitored medically appropriate compression trial for three months, a large portion of those patients are not going to require any further treatment.

Host: Okay. Just want to give you a chance here at the end, maybe talk about some of the advancements in vascular surgery, the minimally invasive procedures that are really improving outcomes for patients.

Jamil Matthews, MD: The biggest advancement in vascular surgery is endovascular procedures. Is the the fact that a lot of these procedures that we would've typically 20, 25 years ago, maybe a little bit more, would've had a patient on operating table for six hours doing a bypass, we can now do in a cath lab.

And this is very important in patients who have an underlying, cardiac or respiratory disorder, where giving them general anesthesia and exposing them to surgical risk and volume shifts involved with open surgery, could be detrimental to them. Vascular surgery is unique along with a couple other specialties, but I'm speaking particularly of vascular surgery where we advance more proportionally with the advancements in technology.

For venous, there are also minimally invasive techniques such as radiofrequency ablation and glue, that have really revolutionized the treatment of venous disease. You come into the clinic, you don't have to go to the hospital. You can have the done at outpatient center. Your procedure's done within 30 minutes, and you're home that afternoon walking around the house or grocery shopping. I could go into the details of all the different devices that are out there, but I can assure you there's a large number of devices that come through FDA approval every year that allow us to do these minimally invasive procedures that would've otherwise been done in the operating room much more quickly and efficiently than was done before. I think it's important for patients to understand that they are their best physician and their best advocate. If you notice symptoms, especially the symptoms that I've described; make sure you see a vascular specialist immediately.

Host: Right. I love hearing how excited you get, you know, when you're talking about, all the advancements and the future of vascular surgery and minimally invasive procedures, and I know a lot of folks affected by PAD and or venous disease, so, great to have your time and expertise today. Thank you so much.

Jamil Matthews, MD: Thank you very much.

Host: To schedule an appointment with Dr. Jamil Matthews, call Salinas Valley Health, Cardiothoracic and Vascular Surgery at 831-759-3289.

And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.