Transcription:
Let’s Talk about Peripheral Artery Disease (PAD)

Scott Webb: Welcome to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We put knowledge and care within reach, so you have everything you need to live your life to the fullest. This podcast is sponsored by UM Capital Region Health. I'm Scott Webb, and joining me today to discuss peripheral artery disease also known as PAD are doctors Charles Fox and Nathanael Dayes. Both of whom are vascular surgeons at UM Capital Region Health.

So doctors, thanks so much for your time today. We're discussing peripheral artery disease, much easier to say and express as PAD. So we'll do that as we move on here. And Dr. Fox, I'll start with you. The most basic question, foundational question here is what is peripheral artery disease?

Dr. Charles Fox: It's a degenerative disease of the arteries, and it can manifest itself in a variety of forms depending on what arteries are affected. You can have aneurysmal disease, which is a dilation of the artery, or you can have blockages due to atherosclerotic debris, deposits in the artery from high cholesterol and we are experts in managing those. We don't deal with coronary artery disease. We deal with the periphery artery disease, which affects the extremities, the GI track and the central torso.

Scott Webb: Yeah. And as you say, it's not really like a one-size-fits-all. There's a range of symptoms and so forth, and we're going to go through all of this today. So, switching to you, Dr. Dayes, what are the most common causes of PAD?

Dr. Nathanael Dayes: Well, there are several, but the classic risk factors are tobacco use or history of smoking, high blood pressure or hypertension, cholesterol abnormalities like hyperlipidemia and diabetes.

Scott Webb: Yeah. And those of course are some pretty serious risk factors, as you say. And, you know, when you list those things, it sounds like a lot of people I know, perhaps even I have a couple of those, so great to do a podcast on this and learn more about PAD. And Dr. Fox, are there certain steps an individual can take to prevent the onset of PAD other than, you know, quit smoking and so on?

Dr. Charles Fox: Yeah, well, certainly that's the big one. That's the one thing that we have within our control is avoiding tobacco use. But certainly, managing cholesterol and taking the proper medical therapies as patients are diagnosed is very important. So we do various screening tests to look for PAD. Particularly in men over the age of 65 with a history of smoking, they undergo screening of the carotid arteries for future stroke prevention. screening They undergo screening of the abdominal aorta to look for degenerative aortic aneurysms. And, in the meantime, the individual steps that we take are to counsel patients on proper blood pressure management. So compliance with their antihypertensive blood pressure medicines is very important in order to decrease the high pressures that are exerted against the walls of the artery and cause eventual breakdown.

Scott Webb: Yeah. And just sticking with you, Dr. Fox, are these all things that we do to ourselves? Is this all just behavioral lifestyle choices that we make, or is there any sort of genetic or family history component?

Dr. Charles Fox: I think that's a really great question. African-American populations are particularly at risk and vulnerable to high blood pressure. And it's important that we treat our young males with screening tests and making sure that they take their blood pressure medications. As mentioned, the onset of chronic kidney disease is a particular risk factor for PAD because the arteries become very calcified. And a risk factor for chronic kidney disease is uncontrolled essential hypertension.

Scott Webb: Yeah, and Dr. Dayes, there's never a time when I speak with an expert like yourself, where they say that, you know, later diagnosis of something is always better. You know, early diagnosis is so key with so many things and especially with PAD. So I'd like to have you talk about why early diagnosis is so key specifically about PAD?

Dr. Nathanael Dayes: Well, Scott, think you're hitting on a important point here. It is key. For most vascular patients, atherosclerotic changes, they're not just confined to the peripheral vascular circulation. In fact, many doctors use PAD as a marker for other cardiovascular complications, such as stroke or heart attack and even death. Therefore, it's important to, screen these patients as soon as possible using the guidelines that Dr. Fox nicely outlined earlier, so we can initiate medical management or different things that can reduce their overall risk.

The cornerstone of treating PVD, and I know we'll get to that later, , regardless of whether or not I see a patient and plan an intervention, the cornerstone really is risk factor modification and, like you highlighted earlier, counseling for a healthier lifestyle.

Scott Webb: Dr. Fox, what are some of the most common misconceptions about PAD?

Dr. Charles Fox: My patients are often fearful when they hear the diagnosis of PAD that it means amputation. And in fact, the majority of patients with intermittent claudication, which is the condition where your calf starts cramping with any kind of extreme walking or walking up an incline or climbing a hill or walking through a city street usually can be managed medically, risk factor modification, stopping smoking, taking aspirin, reducing cholesterol, and actually continuing to exercise despite the fact that they have these cramps. But many people stop exercising because they feel that they might be doing damage. And so I think that's a very common misconception that, when you are having those kinds of crampy pains, to go through the screening test, take the medical therapies, but continue exercising and recognizing that limb loss usually only affects those with very advanced PAD and those patients that are extreme risk are those with poorly controlled diabetes and chronic kidney disease. But there are many people with PAD, just simply it's nicotine-related or maybe genetic-related and they don't lose limbs.

Scott Webb: Yeah, and that's really interesting because, of course, I think the natural instinct in most of us, when we feel a cramp or something, would be to stop working out, to stop walking. But as you're saying, you got to push on through, right?

Dr. Charles Fox: I think another common misconception, Scott, is the fact that patients don't have to have surgery. Some people are fearful that when they have the diagnosis of PAD, that it means getting a bypass, but there are many other minimally invasive therapies that we can offer and there are many medical therapies. And normally, when I meet a patient with PAD on the first encounter, I don't usually proceed with surgical options. I counsel the patient on the risk factors, encourage them to exercise and usually establish some kind of followup visit in the very near future, so that we can assess what's happened once the patient starts to induce some of those changes.

Dr. Nathanael Dayes: Yeah, i want to piggyback on what Dr. Fox just said, it's important when you first see these patients to have that discussion that he talked about, , risk factor modification. And often to dispel the misconceptions that they need an operations, especially operation right away. I can't tell you how many times patients come to the office and say, "What am I getting my stent?" not It's not always the best first-line treatment. And often like Dr. Fox said, these patients just get better with, lifestyle modification. And they don't have to be exposed to the risk of any endovascular open surgery.

Dr. Charles Fox: Another misconception is on the advanced side of the disease when providers are single-handedly managing things that are often misdiagnosed as gout or as a gouty arthritis or misdiagnosed as a nail fungus or misdiagnosed as a healing diabetic ulceration, when in fact they really do need a vascular assessment of the blood flow to the foot.

Scott Webb: Yeah, that's really interesting. I'm just taking all this in. So as you say, sort of misdiagnosis on each end of the spectrum, and always interesting to me when a couple of surgeons say, "You know, we'll do surgery if we have to, but that's really a last resort. That's not the first thing we talk about." We talk about behavior and lifestyle modification, risk factor modification, and we've touched on, Dr. Dayes, a few of the treatment options. Let's go through, generally speaking, what are the options available, stents and so on, for PAD?

Dr. Nathanael Dayes: For patients with PAD who meet criteria for an intervention, and we can start off with claudication. Usually, patients whose lifestyle has been significantly affected by the pain. First-line is usually an endovascular option and that, is minimally invasive. We are able to enter an artery with needles, balloons, and wires, and place a stent if needed. The other option is more traditional, an open operation, which would be an arterial bypass, where we connect, one healthy artery to another healthy artery using a conduit, most likely, their vein, patient's own vein. And, I think here at Cap Region, we're, well-versed versed in both of those therapies. And we try to select the best one for the patient on an individual basis.

Scott Webb: Yeah, Dr. Fox, what are your thoughts on treatment options?

Dr. Charles Fox: Well, the first thing I do is I basically complete the full assessment. But, Evaluating all of the pulses in both extremities and getting an assessment of the blood flow to the feet. And then, I bring the patient back in about a month or so and assess whether, they've been able to stop smoking, if not refer them to smoking cessation classes or someone who has expertise in counseling patients for that.

Once I feel like I've got the risk factors modified, then I proceed into supervised exercise program. Simultaneously, we're managing the medical aspects of their conditions. And then, after I'm satisfied that, we've done everything we can on the non-surgical side, then bring them back for endovascular management, which is minimally invasive therapies, usually a diagnostic angiogram, which involves injection of contrast into the arterial tree and seeing what the arteries actually look like or performing an ultrasound assessment or a treadmill assessment. We'll actually walk the patient on a treadmill and actually see what happens when the patient is active. And then bring them back subsequently to that and review those diagnostic studies to see which direction we're going to go. Now, obviously, if the patient's condition necessitates it, we might have to leap ahead of some of those steps and take the patient right to surgery if it's an extreme situation. But many times, these patients have a little bit of time between the clinical presentation of PAD and the actual therapy.

Scott Webb: Yeah, that's good to know. I think all of us as ,patients and doctors are patients, too, of course, the last thing we want is to sort of be rushed through a process. As you say, if you have to, if you have to jump ahead in the process, you will. But generally speaking, kind of goes at a pace that probably works for providers and hopefully patients. This has been really educational learning more about PAD and the different options that are available. I'm going to give a last word to each of you. Dr. Dayes, I'll start with you. What are your takeaways when it comes to PAD and how you can help folks?

Dr. Nathanael Dayes: In terms of treatment options, I also didn't mention that there's other medications that we sometimes give these patients early in the treatment of intermittent claudication. For example, there's a medication called cilostazol, which combined with an exercise program, helps many patients avoid the need for ever progressing to surgery. And I think that kind of piggybacks into my takeaway for our audience today is that, one, if you have any of these symptoms or any of these risk factors, , come to see your doctor or come to see us, as soon as possible. These are not things, , you want to wait too long on. And, once you come to see us, , having an open mind. Be ready to learn about it and ask questions.

Scott Webb: Yeah. Advocate for yourself. You know, knowledge is power, and that's why we do these to try to educate people, some free medical advice to get them, to talk to their doctors and to reach out to specialists and get referrals and so on. So good stuff. Dr. Fox, I'll finish up with you. What are your takeaways?

Dr. Charles Fox: Patients in the Prince George's region have about three to four times the PAD of the neighboring counties. And it's a real problem in this county. We have the most state-of-the-art advanced imaging available with a full team that's, capable, as a heart and vascular center, of offering a range of treatment options.

Scott Webb: Oh, that's great to know, great to hear. And guys have used a lot of the buzz words today, minimally invasive, state-of-the-art. And such a pleasure of my job that I get to speak with experts and surgeons and learn more in this case about PAD. So thank you both and you both stay well.

Dr. Charles Fox: Okay, thank you very much, Scott.

Dr. Nathanael Dayes: Thank you.

Scott Webb: This episode is sponsored by UM Capital Region Health, the largest healthcare provider in Prince George's county, dedicated to enhancing the health and wellness of the community by providing high-quality accessible patient care. UM Capital Region Health, changing up healthcare in Prince George's county.

And find more shows like this one at umms.org/podcast. And thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again.