Carl Maronich (Host): Welcome to The Pulse at Tallahassee Memorial Healthcare. I'm Carl Maronich, and with me is Dr. Andreas Vargas. Dr. Vargas is an interventional cardiologist from Tallahassee Memorial Healthcare. Doctor, welcome to the podcast.

Andres Vargas, MD: Thank you, Carl. Thank you for having me.

Host: Sure. And today, we're going to be talking about limb preservation and new advances that are making a big difference in that area. The doctor is an interventional cardiologist. Maybe we could start with getting a little bit of your background and how you got into limb preservation.

Andres Vargas, MD: I'm an interventional cardiologist, but I always think of myself as an internist first, and then a cardiologist, and then an interventional cardiologist. And among those things I do in Interventional Cardiology is limb preservation. I trained in Iowa. I completed my Cardiology and Interventional Cardiology training. That was back in 2017.

And I went to Arkansas for a good three years. So, I was in northwest Arkansas. And during my time there, I was taking care of patients with coronary artery disease and all cardiovascular conditions. And many of the risk factors that lead to peripheral arterial disease are the same ones that can cause coronary artery disease, hypertension, high cholesterol, diabetes, smoking. So, there's this overlap. And many of my patients will end up developing symptoms of peripheral arterial disease. And eventually, some of them will develop a more advanced form of peripheral arterial disease, which is critical limb ischemia.

So, I saw many of them struggling with that. And I didn't have the training at the time to give them options, myself to revascularize them. Where we were, it was kind of limited access to having a vascular specialist. They had to travel to Little Rock, they had to travel to Oklahoma City. So, this was a good three and a half, four hours, for them to be able to see a vascular specialist where this was a vascular surgeon or an interventional radiologist or an interventional cardiologist trained in these more advanced revascularizations, whether it's surgery or percutaneous procedures. And some of them did not get the help, the right help at the right time. And when I'll see them back, I will see them with an amputation and unable to walk, and it was just devastating. So, that prompted me to take action in my own hands and seek advanced training.

So for this, I went to a place called Houma, Louisiana at the Cardiovascular Institute of the South. They have a well-developed limb preservation program. Dr. Craig Walker is the physician I worked with for a whole year as one of his fellows, and it was a fantastic year. High volume days with very complex disease. I learned so much from the entire team, not only on technical aspects, but on clinical management, on multidisciplinary team, vascular ultrasound, diagnostic modalities.

And with those skills, I was recruited by Dr. Bill Dixon, one of my partners. He goes to one of the meetings that is called the NCVH meeting. And through that, we met and here I've been now for four years.

Host: So, the connection is about blood flow. Is that right? I mean, cardiologists know about the heart blood flow. And when we're talking about limb preservation, that blood flow and getting blood is essential in that process. So, there's a connection there, I'm guessing.

Andres Vargas, MD: Yes. And you see this overlap. So, the disease happens because of atherosclerotic plaque that forms in the blood vessels from all these risk factors, diabetes, smoking, high cholesterol, hypertension, and that eventually will plug the vessels and you don't get enough circulation to the end organ where it's the heart, the brain, in the case of carotid artery disease. And in the case of peripheral artery disease, you don't get enough circulation and blood flow to the legs. So, you can have progression of this disease, and there's an overlap of about 20-30% in these different vascular territories. So, a patient who has had a heart attack or has non-coronary artery disease has a good 20-30% chance of also having peripheral arterial disease and having carotid arterial disease. So, we should always be on the look and screening for this.

Host: So, let's talk about amputation preservation and why it's such a critical issue in medicine today.

Andres Vargas, MD: Absolutely. You know, for me, this is personal. Every amputation that I prevent is not just a limb that I've saved. It's a person that keeps walking, a person who keeps driving, maintains their independence. It's a grandparent who keeps playing with their grandkids. And amputation just carries such a high, high mortality rate out of all the procedures in medicine. And yet so, many of these are actually preventable. I've seen patients that they saw someone and they were told that there's nothing else to do. But with the right tools, there was something else to do. But the truth is, when you deal with a patient who has a wound and they have diabetes, you truly are dealing with a circulatory emergency. This is not just a blister in the foot. This is actually somebody who is in an emergency situation that needs prompt and quick restoration of flow, controlling the infection, if there's any. And by salvaging the leg, then you can save that life. Keep their independence, allowing them to have a normal life and eventually reduce this risk of immobility, of having a complete change in what they do and they enjoy doing their normal life. So, the mission is to lower the amputation statistics in our region, and we have an entire team of people at TMH that are working really hard to do this.

Host: Yeah, that's great. I mean, quality of life is so important. And this really can preserve that if you're able to preserve the limb. Doctor, maybe we could talk about some of the common causes of limb-threatening conditions that you see in your practice.

Andres Vargas, MD: So in my practice, the number one cause is peripheral arterial disease. As we're talking, Carl, this is the same plaque blocking the arteries that can cause coronary artery disease and heart attacks or carotid disease. And strokes and diabetes is just the gasoline on that fire. And if you add to that smoking, you add to that chronic kidney disease, hypertension, and then you get these damaged vessels, and particularly in patients with diabetes, they get not only what we call macrovascular disease, which are the big arteries being blocked with plaque, but also microcirculatory problems. So, the circulation to the nerve essentially gets significantly impaired of those nerve don't work anymore. The patient cannot feel their feet, they have peripheral neuropathy, they can step in something sharp, get a wound, and then an infection sets on, and it's very hard to treat. You know, the minute that happens, then the clock starts ticking.

So, many times by the time the patient gets to us, it's because somebody has recognized that there's a wound that is not healing, it's been over a couple weeks. So, the goal is to see them before it gets to that point, before it gets that far. So, when we do, we still have the chance to restore the flow. And even when they come with really advanced disease, we still have the chance to control an infection if there's such, and restore the flow, whether this is with surgery or with endovascular techniques.

Host: In so many of these podcasts, no matter the topic, we always talk about common sense, be healthy, make sure you're getting regular checkups, a healthy lifestyle, diet, exercise, those kinds of things, and no different here. But if we want to try to get an early diagnosis to a condition that could prevent an amputation, what should individuals be thinking about?

Andres Vargas, MD: Yeah. So, you know, I always tell my patients and my colleagues, that it if a wound, particularly when you have diabetes or you're a smoker, if this has not healed and swing over two weeks, this is a vascular emergency. We got to restore flow. Make sure there's no infection; if there is, treat it. Offload the patient and get the patient routed through the system to see all the multiple players in the multispecialty team that we have.

So for patients, you know, I tell them, watch for changes in your activity tolerance, how far you can walk. "I used to walk a block. Now, I can barely make a third of that." So, that's intermittent claudication. "I have pain in my muscles that forces me to stop, rest, and then the pain goes away so I can keep walking." then, as you progress to this more advanced peripheral arterial disease, critical limb ischemia, then you get rest pain, you can see dusky changes in the color of your skin, your toes might feel cold, they can feel numb or you can start seeing wounds in the tips of your toes or wounds in the heels. So, that's something to recognize as a patient.

For our colleagues, we should always think about risk factors. The ones mentioned, people with coronary disease, carotid disease, there's this 30% chance of having peripheral arterial disease. Those with diabetes, smoking, chronic kidney disease, think about obtaining an ankle brachial index. So, this is a screening test for peripheral arterial disease. It's essentially putting a blood pressure cuff in the arms and the legs at the ankle level and get a baseline on how's the circulation to both feet.

The problem with this test sometimes is people with chronic kidney disease and diabetes, the test is not very sensitive. So, you can only take about 30% of that. So, we have to keep that in mind. There are different diagnostic modalities toe brachial indices, ultrasound studies, a perfusion test for the skin to see if there's enough oxygenation getting through the circulation to the tissue. So, we always have to keep this in mind.

And we rather see extra patients, who have this question where this is just a blister or a callus, and find out that this is truly nothing limb-threatening or life-threatening than have this patient come too late when there's truly nothing else to do. There's infection to the bone and they're going to end up with an amputation that we could have saved.

Host: To that point, and something you said earlier was if you've been able to walk a block or two and now you can only do half of that, that could be an indication of something. I think oftentimes, particularly as we age, we kind of chalk it up to, "Well, I'm just getting old and I can't do what I used to." But there really should be a red flag to some of that. That is something that should be checked out. And if people, patients are going for regular checkups, that's likely is going to be caught. So again, it comes back to kind of making sure you're getting regular checkups and just monitoring your own health in a good way correct?

Andres Vargas, MD: You're absolutely right, Carl. This also applies for cardiovascular disease in general. I've seen so many patients that it's very helpful when they come with a loved one, they come with their wife or their husband. And they're the ones saying, "Hey, I've noticed that for the past six months or past year, they have slowed down. We used to go walk the dogs or we used to play with their grandkids and now they can barely make it because they're short of breath or they're starting to have some chest discomfort." So, that'll be how coronary artery disease, heart failure can manifest. Same with the legs. You start having these pains and aches and you feel like maybe it's just age or maybe my joints are causing me trouble. So, I always look for pain in your muscles that is limiting you, and it's causing you aches. Some patients say, "It feels like a dog bites me on the leg every time I'm trying to walk," or it just feels like a burning sensation.

So, these are the red flags that, as a patient, you know, you can be looking for. It's not just aging. You should be able to be active as you want, of course, with orthopedic issues and things that can happen as we age. But if there's a significant change, and this doesn't happen always that acutely, you know, it can take weeks or month, but always be on the lookout for why am I not able to do the things I was able to do before. And having also that loved one who can identify, "Okay, something's changed," and raise a flag and raise the questions, that is kind of the way to prompt a consultation with a specialist to look into this problem.

Host: Great advice, Doctor, in the area of limb preservation, what innovations are you seeing, new therapies, technologies that are really helping patients?

Andres Vargas, MD: This is a very exciting time in vascular medicine in general, not only from an interventional standpoint, but also from a medical standpoint. We have, of course, aspirin and anti-platelets, like clopidogrel that has been out for many, many years. But now, over the past few years, we have also different anticoagulants that were used for, say, atrial fibrillation. In some lower doses, it can be used particularly for those patients who have revascularization procedures to prevent them from having acute loss of the blood flow to their legs, if they got a stent or a balloon treatment to the arteries in the legs or if they got bypass. There are advances in the management of diabetes. There are advances in the management of weight control and cholesterol control. We have injectables for cholesterol control. We have injectables for diabetes. We have some medicines called the sodium-glucose cotransporter-2 inhibitors. They can significantly lower the chances of kidney failure, which can lead also to peripheral arterial disease and also help in peripheral arterial disease.

So also, the medical aspect of the management of this condition has improved significantly. And then, from an interventional standpoint, as an endovascular specialist, it's very exciting. Now, we can reach arteries that before, say five years ago, we were not able to get to. Industry has always kept up with trying to find solutions to the products that we bring up to them as physicians. And they're stepping up to the challenge of creating wires that can cross very hard, difficult-to-cross blockages, that can reach to treat blockages, say below the knee, going from the artery in the wrist. This is a two-millimeter artery. And there are now sheaths that are long enough and resistant enough, or you can advance all this equipment from the arm or even if it's from the groin. We have a specialty wires, we have a specialty catheters to cross now through very difficult blockages that before, you know, if the patient didn't have an option for bypass, which is a fantastic treatment and should always be considered, if there is no surgical option, then we can try to do this endovascularly. And before we'll get stuck, we just didn't have the equipment and the tools to get through this blockages. There are things like intravascular lithotripsy, which is, you know, what the urologists use to blast kidney stones. Now, we can put balloons in the arteries that send these ultrasonic booms and waves that can crack the calcium and soften the plaque so you can then treat it with a stent or a drug-coated balloon to prevent the artery from re-narrowing.

The space below the knees is a very difficult space. These arteries are smaller. They're almost the size of a coronary artery of the heart, and we are starting to see new and new tools to treat these vessels. The challenge always with these arteries is you can balloon them open and then they will close, and that happens about 50% of the times. But when we go after this type of blockage below the knee, it's not for a cloudicant, it's not for that pain when I walk, it's more for limb salvage when I have a wound that is not healing. So, we know this is probably going to fail. The artery is going to close. It's going to fail in terms of patency, but we're going to succeed in terms of achieving wound healing. The time the artery stays open to allow that blood and oxygen and nutrients to get to the wound to allow it to heal is what we're looking for. And there are different tools nowadays with drug-coated devices, retrievable stents, resorbable stents that can keep that vessel open as long as it's needed to allow that wound healing to happen. And then, if it re-narrows, you know, the wound has healed and the patient is in this kind of remission phase.

And there is something else that I think I should mention. You know, when you deal with these more advanced forms of peripheral arterial disease, which is critical limb ischemia, truly, you are never cured from this condition. You live with this condition. And it's almost analog to what we see in patients with cancer. If you're a patient who has cancer, goes on remission after going through chemotherapy, immunotherapy, radiation therapy, or surgery, and you have the diagnosis and you're in remission, you're monitored to make sure that the cancer doesn't reactivate or you don't get metastasis somewhere else. You can think of critical limb ischemia almost as cancer of the legs. If you look at the mortality of things like lung cancer, colon cancer, prostate cancer, critical limb ischemia is up there. It's in the first places of things that really carry a poor prognosis for patients. So, we get them to remission. You get the wound to heal so they can keep their legs, they can keep their independence. And then, we start this program to monitor them, to make sure the wound doesn't reopen, to make sure they're offloaded, to make sure they don't get any trauma to their legs. There's good podiatric care, wound care, if there is still any, any recurrences of wounds. And then, all these risk factors that we talk about. Being on a good antiplatelet, being on good diabetes control, good cholesterol control, high blood pressure control.

Host: What you just talked about makes me think of a multidisciplinary approach. It's not one doctor dealing with this. It's a team, as you kind of mentioned earlier as well. So, talk a little bit about how that multidisciplinary approach really helps the success rate.

Andres Vargas, MD: Absolutely. You know, and this is the only way to do this kind of work, it's truly a team sport. At TMH, we have a multidisciplinary team with vascular surgeons, vascular medicine specialists, interventional cardiologists, podiatrists, Wound Care specialist, Plastic Surgery and Endocrinology, nephrologists, Physical Therapy, nutritionists, and a fantastic wound care center. And it takes a whole village to get this patient to remission, to wound healing, to preserve their limbs.

One of the advantages when you have many players is you're not just seeing the patient in a single focus. You're seeing this patient on many perspectives, and we all support each other to get the patient to succeed. Risk factors are difficult to control sometimes. Diabetes, so you need the help of an endocrinologist. You have a cardiologist who can help you control the hypertension. Same with the nephrologist. Control the cholesterol. You have the internist who is the director of the orchestra. So, it's a team sport that requires all these players to focus really on each single aspect that can lead to the wound to recur and end up with an amputation. I don't think there's any other way of doing this and doing it right for the patient, by the patient than doing it as a team with multiple specialties. It's not a one-man game for sure.

Host: Doctor, any success stories that you could point to or want to mention, patients you've had who have really done remarkably well?

Andres Vargas, MD: We do this procedure called deep vein arterialization. And this is a newer technology. It got approved back in 2023. We participate in some of the trials also in vascular and endovascular procedures at TMH. We were part of this trial, and the device had gotten approved out of trial. And I saw we're going to call Mr. Smith.

So, Mr. Smith came to me, referred by one of the podiatrists in town with a wound in his great toe, and he was very concerned that wound have been there now for a month. It happened after some trauma at his home. He's in his mid-60s and he has a longstanding history of diabetes and chronic kidney disease that progressed to end-stage renal disease. He was on dialysis, had been for a couple of years, and the usual coronary disease, prior stents, high cholesterol, high blood pressure. So when we met, I tell him, "Well, let's study you since you have critical ischemia." We talked about the ABIs not being very sensitive, and this is a circulatory emergency. So, we right away went on with a peripheral angiogram. We took him to the cath lab that same week. After obtaining the films, we discussed him in a multidisciplinary approach with my Vascular Surgery colleagues. We obtained x-rays of the foot and the arteries were so heavily calcified, which is what you see in patients with chronic kidney disease and diabetes. So, there was essentially little hair-like vessels from his lower third of his leg to his feet. There was no name artery, and essentially this is what we call a desert foot, or it used to be called a no-option critical limb ischemia patient. But now, they have become a yes-option critical limb ischemia patient thanks to these advancements in technology.

So, the deep vein arterization is what we offered him, this is essentially connecting one of the arteries from the proximal segment of the leg, right below the knee crossing from the artery into the vein. So, we get access in one of the arteries in the groin. We access one of the veins in the plantar aspect of the foot, and then we have a needle that crosses from the artery into the vein into a little basket. And then, you can thread and feed a wire from the artery into the vein. And you essentially have through and through wire from the groin exiting the foot. And you dilate that connection between the artery and the vein with a balloon. And then, you have to remove a valve to kind of get rid of that resistance. And then, you lay a stent graft, cover stents from the artery that taper into the bigger diameter vein, all the way to the ankle. And in that way, now you're giving arterialized pressurized blood from your arterial system, reversing the flow into the veins, using the vein as your conduit to give oxygen and blood to the foot. So, this is what he went through.

And I told him, you know, this is actually the first time I'm going to do this procedure here at TMH in Tallahassee. I've done them off the shelf during training using devices like cover stents and such. But this was the first time using the system and I told him, "Well, you'll be our first patient here and you have a whole team of people behind you and rooting for you." And he and his wife gave us some thought. I said, "All right. Let's go for it. We believe this can work." So, he went through a procedure. You know, we warned him he was going to experience some swelling in the foot. We're rerouting blood from the artery to the vein, and that happens and, you know, that can lead to some pain. So, he dealt with that for a couple of days and improved. And this takes time to heal. On average, the wounds take sometimes up to four months to heal. In his case, he ended up with a minor amputation of the great toe, but he kept his foot. This procedure sometimes requires a follow-up angiogram to make sure the flows and the stents are open. You still have flow, and sometimes you have to put coils in the veins to focalize the flow to the foot, diminish the drainage of the blood flow coming to the foot. But he eventually achieved wound healing.

And the best part of this story for me, as a physician and particularly taking care of these patients is this: he told me when I met him first, he said, "I'm really looking at getting my kidney transplant." And he had been seen at Tampa for kidney transplantation. And he was en route of completing his workup for this, a lot of tests to get his kidney transplant. And then, this wound happened. And had he had an amputation, he would have been excluded as a potential kidney transplant recipient. And he was very worried. This was going back to his independence of not being on dialysis three times a week for several hours. And he really wanted his save his legs so he could get his kidney.

Well, about a few weeks ago, I was able to write his pre-op clearance for him to go ahead and get his kidney transplant. And this was one of the happiest days for me in my career as a physician, as a critical limb ischemia specialist to be able to that for him and he will get his kidney transplant soon.

Host: Congratulations to you on that and seeing him through and being able to help him that way. And, Doctor, I think this whole conversation tells us that if a patient has heard the word amputation and that they're fearing that maybe in their future, there are a lot of options now available that can prevent that. And you and your team are focused on making that happen.

Andres Vargas, MD: Absolutely. We're here for the community. I want to say, if you as a provider has somebody who has a wound that hasn't healed for over two weeks, and this patient is diabetic, again, this is a circulatory emergency, please reach out to us. We're a team of three vascular surgeons and three endovascular cardiologists specialized in critical limb ischemia, and we have the whole support of endocrinologists, nephrologists, wound care specialists. The TMH Wound Healing Center does a fantastic job in getting these patients to healing. We have plastic surgeons. We have podiatrists in the community that can help us with offloading. But it takes a whole village, a whole group of people that are passionate and dedicated to saving limbs.

Host: Dr. Andres Vargas, internal cardiologist with Tallahassee Memorial Healthcare. Thanks for being a part of our podcast today, giving some great information on limb preservation. And for more information on critical limb ischemia and limb preservation, visit tmh.org/heart. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics that may be of interest. I'm Carl Maronich, and this has been The Pulse at Tallahassee Memorial Healthcare. Thanks for listening.