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Avoiding Leg Amputations Due to Peripheral Arterial Disease (PAD) [Transcript]
Featuring Thomas Reifsnyder, M.D., Assistant Professor of Surgery; Chief, Division of Vascular Surgery, Johns Hopkins Bayview Medical Center
Describe what you do.
My name is Thomas Reifsnyder and I'm a vascular surgeon at Johns Hopkins.
Why see a vascular surgeon for PAD?
My job as a vascular surgeon basically is one of education. Every patient that we see, we try to educate not only about their disease, but about what the treatment options are. And I try to guide them to what would be the best treatment modality for their disease.
What advice would you give to a patient who is in danger of losing a limb to PAD?
One of the things that absolutely amazes me is that people will undergo an amputation of their lower extremity and not get a second opinion before their leg is removed.
Peripheral arterial disease requires a lot of expertise and a lot of experience to be able to treat in the best fashion. I frequently get phone calls from physicians and family members of patients telling me that their loved one is going to require an amputation. And when I see those patients as a second opinion, frequently the repair or the necessary surgery to save that limb is not as...is easily done, and something that can absolutely change the patient's life.
It's much better to undergo a fairly significant operation and save a limb than it is to undergo an amputation. Many surgeons and many physicians out there believe that an amputation solves the problem. You can get a prosthesis and be able to walk again, and you don't have to undergo multiple procedures to be able to save that limb.
Most patients can actually under one or two sophisticated operations and save a limb, which will absolutely change their life.
What is PAD and how does it present?
Peripheral arterial disease, which used to be called peripheral vascular disease, basically is blockage of the arteries going to an extremity. Technically it could involve blockage of arteries going to the arm or hand, but that's uncommon. The most common is blockage to the lower extremities. Millions of Americans have peripheral arterial disease.
The most common presentation is no symptoms what-so-ever. In other words, they go to their doctor, and their doctor cannot feel their pulses. There are millions of people in America who have decreased circulation in their lower extremities, but because they are getting older, they're not as mobile; they don't have any symptoms what-so-ever. Those patients we don't typically see as a vascular surgeon.
The more common presentation for a patient with peripheral arterial disease is someone who develops pain in their calves or legs when walking. That is called lower extremity claudication. In the past, we didn't treat that very aggressively, because it's not a threat to the patient's leg or limb. However, in this day and age where we have a variety of minimally invasive techniques, particularly in the younger patients who have this problem, we may aggressively treat it with angioplasty and stenting.
What are the risk factors for PAD?
The risk factors for peripheral arterial disease include smoking, diabetes, high cholesterol, and one that we don't really think about, but just aging. As people get older, their blood vessels tend to wear out.
How is PAD diagnosed?
Peripheral arterial disease is manifested most commonly as no symptoms what-so-ever. The patient gets a routine physical examination and the doctor can't feel pulses. Unfortunately, a lot of Americans don't exercise enough. And if you don't exercise or don't walk very much, then there is not a large requirement for blood flow to the legs, and so you could have peripheral arterial disease and not know it. The most common symptom for peripheral artery disease is what we call lower extremity claudication. And the term claudication actually means "to limp." Patients don't actually limp with this, but what they do is get pain in their calves or thighs after a certain distance of walking. The nice thing about peripheral arterial disease is that it is very easy to diagnose. People with lower extremity claudication have that symptom every day, whenever they walk that distance. It's not like one day they can walk a block and the next day they can walk a mile. It's - at one block, their calves start hurting, or a calf starts hurting, consistently every day.
Which patients are the most challenging to treat?
The patients that are the toughest patients to treat are those who present with poor circulation to the lower extremities and severe peripheral arterial disease. These patients can present with a lot of pain in their foot. Clearly they won't be able to walk too far, and sometimes they will actually present with ulceration or gangrene of the foot. These people clearly are...clearly need to be treated and...or otherwise they could end up losing the function or actually losing their leg.
Depending upon the location of the disease - whether it's in the arteries near the aorta versus the arteries in the lower extremity - these patients can be treated with angioplasty and stenting or they can be treated with lower extremity bypass procedures.
A totally different group of patients are the diabetic patients. Diabetes tends to not only affect the lower extremity arteries, but also...it also affects the lower extremity nerves. And the root cause of almost all diabetic foot problems is the fact that diabetics don't have normal sensation to their foot. This doesn't allow feedback from their foot, so that if they develop a blister, they continue to traumatize that blister until it turns into an ulcer. And in the worst cases, that ulcer then gets infected and can then threaten the whole foot.
Diabetics sometimes will have normal circulation to their foot and sometimes will have poor circulation to their foot, so treatment of the diabetic ulcer really depends upon whether or not it's infected and then whether or not the patient has poor circulation. The treatment of the diabetic foot problem can involve just local wound care, it can involve partial reconstruction of the foot or partial amputation of toes or toe of the foot, or it might involve restoring normal circulation, depending upon the situation.
Describe when an open surgery or minimally invasive procedure might be recommended.
In the last couple of decades, the treatment of peripheral arterial disease. has really undergone a revolution. There have been a large number of minimally invasive techniques that have really become quite common are quite widely available across the United States. And what I'm talking about is angioplasty and stenting.
Angioplasty is inserting a balloon into a blood vessel and opening up the balloon and therefore opening up the blood vessel. Years ago, you might do angioplasty on a blood vessel that is narrowed, but only narrowed over a short distance. Nowadays, the techniques are available where we can actually take totally blocked up blood vessels and be able to reopen them.
Generally this also involves putting in a stent, which is sort of a metal scaffolding that sort of looks like a Chinese finger-trap. And that helps keep open the artery over a long period of time. In the worst cases, the patient will need a lower extremity operation or a lower extremity bypass operation to be able to restore the blood flow.
Describe the surgery.
The concept is really very straightforward and very simple. You have a blockage and you need to bypass from above the blockage, where the circulation is still normal, to below the blockage where the circulation has been reduced. So the idea is very straightforward, the actual surgical part can be a little tricky at times.
Most of the time, what we do is we create a new blood vessel out of the patient's own vein. So you're taking a vein, which normally carries blood to the heart, and making it into an artery which now will be supplying blood to the extremity.
What can patients expect after surgery?
As with most procedures in American medicine nowadays, we've gone to more minimally invasive techniques. And in vascular surgery, minimally invasive techniques involve angioplasty and stenting. We're reopening blood vessels with a balloon or a little metal stent or scaffolding to keep the vessel open. The real advantage to these procedures are that they are minimally invasive and therefore are low impact on the patient. Most of these procedures are done as outpatients. They can be done under local anesthesia with just a tiny bit of sedation and generally take one to two hours to perform. The patients then are recovered for only an hour or two, sometimes three or four hours, and then can go home that same day.
Most patients really feel nothing other than maybe a little soreness at the site where the procedure is done, which will go away in a couple of days. They basically can resume normal, or more activity than previously, within a day or two.
Why should someone seek treatment at Johns Hopkins?
Johns Hopkins has a wealth of experience in treating lower extremity arterial disease or peripheral arterial disease. Over the last decade, Johns Hopkins has added two new endo-suites, which are operating rooms where you can not only perform angioplasty and stenting, but also operating rooms where you can do open operations. Or you can combine those two techniques. The [new facilities at] Johns Hopkins Hospital will be opening which has even more sophisticated facilities for the treatment of peripheral arterial disease.
I think the most important aspect of the treatment of peripheral arterial disease. is having an experienced surgeon taking care of you. It's not only the techniques involved, but it's the decision making that's most important. Aggressive treatment of lower extremity arterial disease will result in limb salvage and maintain the ambulatory status of the patient.