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Interactive Learning : HealthCast Transcripts

Episode 4 : More about PAD Diagnosis and Treatment, and Critical Leg Ischemia and Its Treatment

Release Date: November 3, 2006

Dr. David Meyerson: Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins, national spokesperson for the American Heart Association and your host for this edition of Vascular Disease Foundation's HealthCast. We're very excited to be able to bring excellent, easy to understand science to you on all topics relating to heart and blood vessel diseases as a public service. As a public education forum, the Vascular Disease Foundation is made up of representatives of the premiere medical and scientific advisory groups in the country that relate to vascular diseases. These are groups that use peer-reviewed science to verify that the information you are getting is nationally recognized as the very best and most reliable data available. Prior episodes of this series have dealt with exactly who the parent organizations of the Vascular Disease Foundation are, the spectrum of vascular diseases and how noninvasive laboratories, those labs that perform testing without needles, catheters, discomfort can be used to screen for such problems as carotid artery disease, that's the narrowing of the arteries in the neck that nourish the brain which can cause stroke, threatened strokes called TIA's or transient ischemic attacks also coronary artery disease, narrowings of the arteries that nourish the heart muscle that can cause angina, the chest pain you get when too little blood supply and oxygen gets to your heart muscle or heart attacks. Abdominal aortic aneurysms, the bulging and weakening of the major blood vessel of the abdomen which can cause life threatening blood loss and finally peripheral arterial disease, narrowings or the blockages in the arteries that nourish the legs which can limit your ability to walk, cause pain and ulcers of the leg, and in extreme situations, can even cause one to risk of amputations. These are largely preventable diseases. Once developed they are very treatable diseases and the early recognition and treatments can prevent your disability, promote your physical well being, help you maintain the healthiest and most active lifestyle you possibly can.

My special guest today is Dr. Alain Drooz. He is an interventional radiologist at the Fairfax Inova Health Center in Fairfax, Virginia and the current President of the Vascular Disease Foundation. It's really a privilege to bring Dr. Drooz to our HealthCast microphones today. Dr. Drooz, how are you today?

Dr. Alain Drooz: Well, thank you very much for having me on the program today, Dr. Meyerson. I'm happy to be here.

Dr. David Meyerson: Well, it's our privilege. I feel like we play some presidential background music for you. And insofar as you President of the Vascular Disease Foundation, do you want to spend a couple of minutes giving us your overview and vision for the organization and what its current work is.

Dr. Alain Drooz: The foundation has been in existence for about eight or nine years and we are a group of dedication professional from various medical societies as well from the lay public and from the business community. We get together, sit down, review the science behind the various vascular diseases and our mission is to go out and educate the public as well as healthcare professionals about the various vascular diseases. We really want people to achieve the maximum health they car in their life and to limit the effects of these horrible diseases should someone have them.

Dr. David Meyerson: And so today, I'd like to begin to talk a little bit about problems relating to the legs, the intermittent claudication and critical limb ischemia which I'll get back to in a moment. But Dr. Drooz, I'd like to readdress an analogy that we used previously on this program and that is if you had a sixty or a seventy-year-old house and a plumber came over and told you that there was a problem with the plumbing in the bathroom on the second floor and he showed you or she showed you corroded pipes in that area of the house -- with the house being the same age all over, it wouldn't surprise you for a moment that there would be vascular disease in other areas so that not only is it important for us to recognize peripheral vascular disease, but it becomes a marker for those people who develop it to ask their doctors, am I at risk for heart attack, am I at risk for stroke? What am I doing to minimize my overall risks because this peripheral vascular disease is a marker for disease elsewhere. So Dr. Drooz, you mentioned P.A.D. and just in case our listeners are unfamiliar with the term, what exactly is peripheral arterial disease?

Dr. Alain Drooz: P.A.D. is the build-up or plaque or narrowings in the arteries in the abdomen and leg and this build up of plaque causes the legs to receive less blood flow than they would normally. It typically affects older patients and typically affects most patients when they exercise or when they require more blood flow to the legs to get around. It can cause at that point, a cramping or soreness or fatigue in the leg that we call intermittent claudication or IC.

Dr. David Meyerson: And then that is different from something called critical limb ischemia. Is that right?

Dr. Alain Drooz: That's absolutely true. Critical limb ischemia occurs when there's so little blood flow going to the legs that there's not even enough blood to supply the resting needs of the legs and this is a very, very serious condition. It does occur in a minority of patients with P.A.D., but it can lead to amputation and it's very important to recognize this early.

Dr. David Meyerson: And that's why I wanted you to mention it early in the program. A little bit of a method to my madness here, is that usually if we begin a discussion with peripheral arterial disease, you and I could go on for ten or fifteen minutes and then we cross over into talking about critical limb ischemia, but I want you to be able to tell again our listeners why critical limb ischemia is so important. It's so important that they need to hear it again. It's a little bit like somebody who has heart disease having chest pain at rest or awakening them from sleep or with very trivial amounts of activity. If you're somebody who has coronary artery disease and you had angina, the chest pain that comes from too little blood supply getting to the heart muscle,. If you're having chest pain at rest, or waking you from sleep or with trivial amounts of activity, for example, walking from the kitchen to the bathroom, that's something that you must immediately tell your doctor about and you actually would be safer being in the emergency room because that means that the reserve of the heart muscle is so little that it's getting too little oxygen supply even sitting doing almost nothing. And then Dr. Drooz, that's the analogy that you're giving with critical limb ischemia, isn't that correct?

Dr. Alain Drooz: It sure is and in these patients, the muscles in the legs, the tissues, the nerves, don't even get enough blood flow to function normally at rest when a patient is sitting or lying down and that--

Dr. David Meyerson: So one of the risk if the person had heart disease was that it could go on to become a heart attack and everybody knows that they would like to prevent a heart attack and we should also, just to complete the circle, if you're having transient episodes where your mouth is drooping or you can't -- your speech is garbled or you can't use one side of your body and that lasts for a few seconds and goes away, that's nothing that you go to sleep with and then call the doctor tomorrow. That's something for which you get medical attention immediately. And so what would be the risks of ignoring the warnings of critical limb ischemia?

Dr. Alain Drooz: The major risk is amputation and unfortunately there still are many, many amputations performed in the United States each year and our goal is to help reach these patients before they get to the point where this may be in their future. Typically a patient with critical limb ischemia will get some warning signs. The pain that may occur is a aching pain or fatigue in the legs, but it occurs at rest and one of the places that it occurs is in bed at night. This keeps patients from sleeping. They typically will hang their leg over the edge of the bed to use gravity to get some blood flow down to the foot. Other patients may experience even trivial or small wounds in a nail bed or on a toe that just don't heal.

Dr. David Meyerson: And those can sometimes become quite large.

Dr. Alain Drooz: Absolutely. They enlarge over time, they tend to get infected and these types of wounds tend to occur most often in patients with P.A.D. who are diabetics or who are smokers --

Dr. David Meyerson: And why are diabetics so especially at risk?

Dr. Alain Drooz: Smokers and diabetics, also older patients, hypertension or elevated blood pressure or elevated cholesterol, blood fat, are also risk factors for P.A.D. and for critical limb ischemia.

Dr. David Meyerson: But you and I have both seen in our clinical practices, diabetics whose ulcers I once took care of, when I was in training, I once participated in the care of a forty-four-year-old gentleman who had a daughter who was playing jacks, you know those little multifaceted things that onesies, twosies and things like that and his daughter had left one of the jacks on the floor and he stepped on it and being a diabetic, one he didn't realize -- it wasn't that painful to him because he had neuropathy, he didn't feel the same sensation that you or I might feel and then within a few weeks, the infection was so nasty that his leg actually had to be amputated and I always remember that example for diabetics and you see this in your practice all the time, the diabetics, because they don't have the sensation, their wounds can get very large and there can be a lot of ischemia or lack of blood supply to the area and they wouldn't even know it.

Dr. Alain Drooz: About forty percent of our P.A.D. patients in my practice are diabetics and unfortunately these people, as you mentioned, don't have the protective mechanisms to know when they're damaging the tissues on their feet. I think an important message for anyone with diabetes and P.A.D. is that they need to get to a foot care specialist, such as a podiatrist, who specializes in treatment of the diabetic foot to help them add the protection that these patients may not normally have.

Dr. David Meyerson: And of course, once the diagnosis of peripheral arterial disease is made, they should be following up with their internal medicine and family practice provider and possibly even seeing a vascular specialist at that point, isn't that right?

Dr. Alain Drooz: Absolutely. The primary care physician can assist in many of the functions in terms of risk reduction, recognizing the disease and knowing when to refer a patient to a vascular specialist for more involved testing or for possible treatments.

Dr. David Meyerson: So let's go back and list really quickly what somebody can do between today and tomorrow to lessen their risk of developing peripheral arterial disease and then I'm going to ask you a little bit about the diagnosis and treatment.

Dr. Alain Drooz: Well, let's set things up like this. First, stop smoking if you're a smoker. If you are a diabetic, control your diabetes and keep your blood sugars under good control. Exercise and keep yourself at a normal weight. Control your hypertension. There are guidelines for lowering lipids and cholesterol and as well, it's important to get daily exercise.

Dr. David Meyerson: Let's hit the smoking issue once again because it is just so critical. Smoking diminishes the amount of oxygen in the blood, it increases the carbon dioxide, it makes the cells and blood platelets more likely to coagulate and cause blood clots, it accelerates the hardening of the artery process all over the body and can even cause spasm of the arteries that nourish the lower extremities and can trigger critical limb ischemia, so I, for one and I'm sure that you'll join me in saying that if you are a smoker, you must, must, must stop. And one other thing when patients tell me, Dr. Drooz, they say, "Dr. Meyerson, I'm cutting down. I'm smoking much less." You know, I usually say that's wonderful that you're trying to do that, but please understand this. Cutting down is like saying I only drive a hundred and thirty- five miles an hour two days a week. So you're going to get into an accident on a Tuesday or a Saturday. Cutting down is laudable, but go the full distance. For those people who are smoking, we see -- you and I see people with lung cancer, we see people with vascular disease, we see people with strokes and heart attacks and amputations. You would totally agree with what I said about smoking.

Dr. Alain Drooz: One of the programs that I ran in the past was a vascular exercise or rehabilitation program and we were able to tell once patients got on the treadmill, which patients had had a cigarette in the parking lot before they came in to exercise on the treadmill. The effects of cigarettes are so significant that even one cigarette can make a difference in one's exercise performance. It's easily measurable. Imagine what it's doing to the arteries and the heart and the brain and the abdomen and the legs if it's having that quick of an effect on exercise ability.

Dr. David Meyerson: And all of the other prevention -- going back to the analogy of the seventy- year-old house, the prevention issues that you meant are also solid prevention issues for prevention of heart disease and stroke.

Dr. Alain Drooz: Yes they are and exercise is very important. If we can talk about that for just a moment. Walking exercise does help the circulatory system in general. It helps make our muscles more efficient. It does help lower our blood pressure and our weight and is something that after speaking with your physician, you can engage in an exercise program that not only will make you healthier inside, but will make you feel better outside.

Dr. David Meyerson: So that's a little tiny bit different from what we advise our heart patients to do. If they start to get chest pain with a little bit of activity to first stop what they're doing, tell their doctor immediately and don't trigger the chest pain until the doctor tells you, you know, how you can do it safely and with proper medications and work up. But in your situation when you counsel somebody with peripheral vascular disease, you're actually telling me, if I hear you correctly, that working through the pain sometimes is of value.

Dr. Alain Drooz: It is, but this should be done in conjunction with your physician, whether a primary care physician or a vascular specialist simply because if this patient, if this individual has heart disease as well, it could trigger some problems with the heart such as angina during exercise. So we always like to have the ability to evaluate a patient and make some recommendations about exercise, but after that is something that the individual can do at home on their own and is very beneficial, yes.

Dr. David Meyerson: Do you find that there are any medications are really clinically valuable in enhancing blood flow to the legs more than just what the drug companies would advertise, but what you feel is of clinical value?

Dr. Alain Drooz: There are and you have to consider the goals with these medications. For many patients with P.A.D. and intermittent claudication or IC, their ability to walk is so limited that they have difficult doing activities of daily living, going to the grocery store. In many cases even going to the mailbox and back or doing daily activities around the house, so for instance, for someone who can only walk a block without having to stop because of leg pain, a drug such as Cilostazol with a trade name pletal, which has been shown to help increase walking distances by about fifty percent or so, can also provide --

Dr. David Meyerson: That's substantial.

Dr. Alain Drooz: -- enough of a boost to assist a patient becoming a little bit more independent.

Dr. David Meyerson: So there are medical treatment and there are preventive treatments, but occasionally we have to go a bit further and on another one of our programs, we talked about making the diagnosis of diminished blood flow to the legs with doppler studies, with noninvasive sound wave, radio wave tests if you will. But then once we find out that there are some very limiting issues, you as an interventional radiologist -- could you tell me a little bit about what you do in your laboratory and how you can benefit people as well?

Dr. Alain Drooz: Once we've spoke to a patient regarding their disability and gotten an idea of just how much this limited activity is affecting them, we will get some anatomical information from that ultrasound test or from specialized cat scan called a CTA or specialized MRI scan called an MRA.

Dr. David Meyerson: Let me be a devil's advocate here. What is anatomical information mean to our lay public?

Dr. Alain Drooz: We essentially want to create a roadmap of the circulation from the belly button if you will, from the aorta all the way down the legs and --

Dr. David Meyerson: So the plumber is – if you'll forgive me for calling you that for a moment, it's only meant in the most glowing terms, but at this point, you're defining where the pipes are corroded.

Dr. Alain Drooz: That's exactly true and in patients with P.A.D., there's going to be multiple areas of corrosion all along the pipes and the key is fitting those blockages to a patient's symptoms and developing a realistic and useful plan in terms of treatment. In other words, which blockages really need to get opened up and can we open them effectively?

Dr. David Meyerson: And some people can go into your laboratory one morning and the next afternoon, they could be home and able to walk longer distances?

Dr. Alain Drooz: Absolutely and --

Dr. David Meyerson: How do you do that?

Dr. Alain Drooz: Well, what we do is we first take that roadmap and then we'll actually take a tiny catheter tube into the arteries that supply the legs and update the roadmap with a little bit more detail and I'm essentially going to borrow a patient's blood vessels and take this tiny device and drive up to the blockage. The blockages will then be opened either by stretching the blocked artery open with a balloon or by putting in a small metal screen of scaffolding called a stent. The stent actually acts like the hoops on a barrel would to hold the vessel open and the stent becomes a part of the wall of the blood vessel, just holding it open. And those treatments are very effective for blockages in the legs, particularly for short or medium length blockages and they tend to work better in the larger arteries up in the pelvis or in the upper thigh, but they are effective treatments.

Dr. David Meyerson: So we have a whole scenario here where people can both prevent disease, they can get medical treatments for it, they can get interventional treatments for it, meaning that catheter based and non-surgical treatments and then of course, there would be people who you probably couldn't benefit that would still need a more traditional vascular surgery procedure, right Dr. Drooz?

Dr. Alain Drooz: Open surgery these days is reserved for patients with critical limb ischemia, those with pain at rest or those who have tissue loss or gangrene or at an extreme risk for amputation. And in many cases, those cases, those patients can actually be treated with endovascular means, the balloons or stents, but some of them have to be treated by traditional open surgery which still can save a patient from having to undergo an amputation.

Dr. David Meyerson: Now so much of this is tailored to getting somebody more active, but when they're back doing the activities that we want them to be able to do, then their entire cardiovascular health is improved, so that both of us I think, would work very hard to see that somebody with peripheral vascular disease gets the proper treatment and then also talks to their doctors about what their risks are for heart disease and for carotid artery disease and stroke because all of these are preventable diseases. Dr. Drooz, as the President of the Vascular Foundation, what closing comments would you like to leave our audience with?

Dr. Alain Drooz: Well, recognition and treatment of the blockages in the abdomen and legs goes hand in hand with recognition and treatment of the risk of stroke and heart attack. We do know that atherosclerosis is a systemic disease and this disease is largely preventable and treatable and we'd like to offer patients, offer the public the information that we've produced to help them lead healthier lives and more enjoyable lifestyles.

Dr. David Meyerson: Imagine if they're not afraid to seek help, they can actually be walking and at times running and not risking an amputation. I think that's enormously valuable information. You've been listening to Dr. Alain Drooz. He is an interventional radiologist at the Fairfax Inova Health Center in Fairfax, Virginia and he is the current President of the Vascular Disease Foundation. This has been a privilege to have him with us for VDF HealthCast, for the Vascular Disease Foundation, I'm Dr. David Meyerson, thank you so much for listening.

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