NEWSLETTER SEPTEMBER 2014 SEPTEMBER IS P.A.D. AWARENESS MONTH STEVEN PRINGLE, BSN, RN Peripheral Artery Disease, or P.A.D., is a condition that affects the arteries that carry blood to your legs and other parts of the body. Plaque (cholesterol) buildup may block the flow of blood and may cause pain in your legs when you walk (a condition called claudication). In severe cases, P.A.D. can lead to gangrene and loss of the limb. P.A.D. is a common, underdiagnosed, and undertreated condition. It is estimated that there are 8-12 million people in the United States with peripheral artery disease. This condition deserves more attention because of the associated high morbidity and mortality. A recently published paper that surveyed people in the U.S. showed that the public has a relatively low knowledge of P.A.D. compared to rare diseases such as Lou Gehrig s Disease or multiple sclerosis. P.A.D. is worth knowing about because it is quite common but can be preventable through awareness and lifestyle changes. At least half of the population with P.A.D. do not have any obvious symptoms. Therefore, it is important to know if you are at risk and ask your doctor to be tested. You may be at risk if you have any of the following risk factors: P.A.D. is more common in aging populations (over age 65) and African Americans. Diabetes or smoking may double your chances of having P.A.D. Other risk factors include: high blood pressure, obesity, family history, sedentary lifestyle. If you have any of the risk factors listed above, contact our vascular team or talk to your doctor about simple testing that can diagnose the disease early. DID YOU KNOW? Patients with PAD have a lower survival rate than those with breast cancer or Hodgkin s disease 50% of those with PAD do not have symptoms Diabetics are at 3 times greater risk of having PAD Aggressive PAD screening decreases amputations by 47% Patients with PAD face a 10 year drop in life expectancy 1
View from the Bottom Up: Perspectives from a Foot Doctor STEVEN BLANKEN, DPM, FASPS, FAPWCA, DABFAS, DABPM P.A.D. is a chronic progressive disease, which means it gets worse over time. Early detection and treatment can significantly reduce the impact of long term health consequences and help prevent limb loss. Plaque buildup in the legs does not always cause symptoms, so many people can have P.A.D. and not know it. People who do experience symptoms, such as pain or cramping in the legs, often do not report them, believing they are a natural part of aging or due to another cause. If they are present, the typical signs and symptoms of the disease include: Claudication (leg pain or muscle cramping that occurs during exercise, especially walking and is relieved with rest) Pain in the legs and/or feet at rest or pain that disturbs sleep. Sores or wounds on toes, feet, or legs that heal slowly, poorly, or not at all. Color changes in the skin of the feet, including paleness or blueness. A lower temperature in one leg compared to the other leg. Poor nail growth and decreased hair growth on toes and legs. Steven Blanken, DPM, FASPS, FAPWCA, DABFAS, DABPM Board Certified in Foot Surgery Board Certified in Podiatric Medicine Blanken Podiatry Group, Silver Spring, MD Treatment Includes Closely managing conditions such as diabetes, high blood pressure, high cholesterol Stopping smoking Heart healthy diet Medications to help control blood pressure & cholesterol, and prevent blood clots Regular exercise (for patients with mild to moderate disease) In severe cases, vascular interventions may be needed to open blocked arteries 2 People with symptoms or risk factors should consider being tested with a simple non-invasive test that can be performed in your doctor s office.
Testing involves performing an Ankle Brachial Index (ABI) using a series of blood pressure cuffs to evaluate the blood flow in your legs. Managing risk factors and making lifestyle changes are the key part of a treatment plan. Interventions to open blocked arteries should be used as a last option if conservative treatment fails or if disease is advanced. Many podiatrists see patients for at risk foot care several times a year. We screen the patients on these visits for such items as P.A.D. and/or neuropathy. We can act as a gate keeper when it relates to referring patients to vascular specialists for problems we encounter during our exams. Many times the podiatrist is the first to find a problem, such as pre-gangrenous changes that needs, in my opinion, immediate care. Podiatrists, endocrinologists, orthopedist, primary care doctors, and other medical workers need to be able to rely, depend on, and have close working relationship with a vascular resource such as Advanced Vascular Resources. AVR & Heart Health Facts * WE HAD A 98.8% P.A.D. INTERVENTION SUCCESS RATE OVER THE LAST 3400+ ABI TESTS THAT HAVE BEEN PERFORMED IN OUR NETWORK, 73% OF PATIENTS WERE FOUND TO HAVE SOME LEVEL OF DISEASE AVR CURRENTLY HAS 6 EXISTING CENTERS NATIONALLY WITH ANTICIPATED GROWTH TO OVER 20 BY THE END OF 2015 AVR HAS GROWN FROM 15 EMPLOYEES IN JUNE OF 2013 TO OVER 70 IN AUGUST OF 2014 *From April through August 2014, Across AVR s 3 busiest centers (DC, Atlanta, and Johnstown) 3
What are the treatment options for PAD? BABAR ALI, MD, FACC, INTERVENTIONAL CARDIOLOGIST, ADVANCED VASCULAR RESOURCES We recently spoke with Dr. Babar Ali at Advanced Vascular Resources to discuss the types of treatment options available for blocked arteries in the legs. Here is what he had to say: Historically, physicians have used open surgical methods to restore blocked arteries. This method typically involves a bypass surgery which redirects the blood through either a healthy blood vessel that has been transplanted or a man-made graft material. The vessel or graft is sewn above and below the diseased artery so that blood flows through the new vessel or graft. The hospital stay for a bypass surgery is 2 to 4 days and recovery can take 2 to 3 months. We may recommend a bypass surgery to a patient if it is necessary but often times a much less invasive method called an endovascular procedure can be just as effective with potentially fewer complications. An endovascular procedure can be performed in an outpatient vascular lab. The patient will go home the same day and normal recovery is about a week or less. This type of treatment involves the introduction of a catheter into an artery, typically the femoral artery near the groin. A contrast material is injected through the catheter to enable the physician to view the vessels under x-ray and detect blockages. The catheter can then be directed to the site of the blockage where a variety of methods are then considered to open or repair the blocked artery. Dr. Ali then went on to describe some of the most frequently used methods to restore blood flow during an endovascular procedure. The treatment varies based on a number of factors like the location and length of the blockage, as well as how long the blockage has been present and the symptoms the patient is experiencing. Some of the common treatments include angioplasty, stenting, and atherectomy. Angioplasty involves using a balloon to expand the opening and push the plaque away. Stents are a small mesh tube that are used to stabilize the vessel and hold it open. Stent placement may be necessary if the vessel shows elastic recoil following angioplasty or if the vessel is just too weak to stay open by itself. Atherectomy is a method of plaque removal. This can be done with devices that cut the plaque away or laser it to sort of dissolve it. 4
All of these treatments are performed through a catheter that is navigated to the site of the blockage and they all have the same objective. This is to open the blocked artery and restore blood flow. PAD is a common disease with the potential to cause considerable impairment in one s quality of life. Blockage of an artery above the left knee There is no cure for PAD (it is a chronic illness); the goal of treatment is to manage the disease, prevent cardiovascular complications, and improve quality of life by helping people live productive and satisfying lives. Blood flow has been restored after an endovascular procedure Blockages may develop again in 12-24 months, so follow up is essential. We work very closely with podiatrists who will play a key role in monitoring these patients for the rest of their lives. The patient will also be asked to return to their vascular specialist periodically and to have ultrasound studies which determine if the artery is staying open and whether new blockages are developing. We strive to carefully weigh the risks and benefits of treatment and tailor our approach by recommending the safest and most beneficial treatment. Some people may benefit from proper medical management and lifestyle changes. Others may need a more aggressive approach. Minimally invasive endovascular treatments may be recommended if claudication (leg fatigue, cramps) interferes with an individual s work or lifestyle. With proper patient selection, many patients will have significant relief of their symptoms immediately following their procedure. For those who suffer with non- healing wounds we often find that delayed wound healing may also be caused by a lack of blood flow. In this case, restoring blood flow, along with proper care and follow up, can improve circulation and facilitate faster wound healing. The important thing to remember is that none of these treatments are a cure for Peripheral Artery Disease. The goal of treatment is to restore blood flow, relieve symptoms, and prevent amputation. Patients then need to discuss with their doctor the reasons they developed blockages in the first place and develop a plan for lifestyle changes to prevent or slow the progression of the disease. 5
AVR Patient Testimonial Irish Legs are Walking Dale & Karen Thatcher were simply trying to enjoy a family trip to Ireland when it happened I was out seeing the sites, said Dale, enjoying my vacation when my left leg suddenly became very painful and my foot went numb. The pain was so severe I thought there was something very wrong. My leg felt dead. I noticed that I was trying to keep up, but could only drag my leg around behind me. The last thing I wanted to do on vacation was deal with doctors and hospitals. I told Karen that I didn t have a choice. I went to the emergency room where I spent the day having a series of tests. The doctors thought I may have a blood clot from sitting so long on the flight, but eventually they were able to determine that was not the case. I was prescribed anti-inflammatory medicines that did help a little, but the pain never went away. I then recalled I had hurt my leg while doing yard work a few days before travelling. I decided this must be the cause of my pain. I pushed through the discomfort to finish my vacation. The pain continued for the next week. When we got home I went to my family doctor for more tests. I was told that I had a condition called venous insufficiency and that I may need to have vein stripping surgery performed. I was also asked to have a Podiatrist look at my bunion to determine if this could be the cause of my pain. I wasn t thrilled about seeing another doctor and having more tests done, but the pain was still severe and I needed to find answers. I was referred to Podiatrist Dr. Betsy Rosenthal. She looked at my bunion and told me this was not the source of my pain. She suspected the circulation in my legs was bad. She performed a simple test right in the office, called an ABI, to know for sure. They put several blood pressure cuffs on my legs and measured the pressure in different areas. 6
The test was quick and painless and confirmed her suspicion. I had a circulation issue caused by blocked arteries. She explained that my leg muscles were starving for blood and this was likely the cause of my pain. Things happened very quickly from there. That same day I had an ultrasound to get a better look at my circulation, followed by an appointment with Dr. Ali at Advanced Vascular Resources. Dr. Ali confirmed my condition was severe and recommended a procedure to clear the blockages. His partner, Dr. Choudry, had an opening the following week, so I made an appointment with him to perform this procedure. When I arrived, I wasn t quite sure what to expect. The friendly and knowledgeable staff put me at ease and explained my procedure would be performed through a small needle puncture in my upper thigh. I would go home the same day. I was relieved to hear this wasn t going to involve a major surgery. Several hours later, I was walking out and immediately noticed the difference. My pain was gone and my leg felt great. Looking back in time, I realize I had been getting cramps in my legs that would wake me up at night. My wife also says I was walking differently, as if my legs weren t comfortable. I guess I had ignored these things until I felt the severe pain while just trying to enjoy my vacation. Because my blockages were so severe, I needed a second procedure to open up some of the smaller arteries in my lower leg and foot. That procedure went even smoother than the first. I was on my way home by lunch time. It s hard to believe how much better my leg feels and how quickly the pain went away. I look forward to another family vacation someday, and this time, instead of dragging me along, I m going to be the tour leader. They can all try to keep up with me. My wife Karen and I are grateful for Dr. Rosenthal s ability to recognize I had blockages in my legs and for sending me to the experts at Advanced Vascular Resources. The tests to detect this disease were very quick and simple and performed right in her office. We were also impressed with how quickly the Advanced Vascular Resources staff was able to diagnose and treat me. I recently quit smoking. I was told this may have contributed to my blocked arteries. The staff explained how not smoking should help reduce my risk in the future, as will eating better, exercising regularly, and keeping an eye on my blood pressure. 7
8 Advanced Vascular Resources is the premier provider of vascular services that works in partnership with leading vascular surgeons, cardiologists, and interventional radiologists across the country to develop and manage specialty office based centers dedicated to improving the delivery of vascular care in the U.S. Our proven approach to success in providing turn key management, operations, marketing and compliance allows Physicians to focus on patient care while AVR builds the practice. Clinical Services Our Team of highly skilled board-certified physicians, nurses and other health care professionals are dedicated to the treatment of vascular disease, prevention of amputations and the most current and innovative technologies to save limbs in patients with critical arterial and/or venous disease. AVR offers diagnostic and treatment for the following: Peripheral Arterial Disease (P.A.D.) Carotid Artery Disease Ulcerations and Gangrene of the Erectile Dysfunction Diagnosis Lower extremities and Treatment Abdominal and Renal Vascular Arterial and Venous Disease Diagnostic Ultrasound Venous Disease (Venous Ulcers, Dialysis Access Varicose Veins) Non-Healing Wounds CURRENT AVR CENTERS AVR ATLANTA 1938 PEACHTREE ROAD NW SUITE L-5 ATLANTA, GA 30309 PHONE: 678-831-2722 FAX: 678-999-5055 AVR HAGERSTOWN 11110 MEDICAL CAMPUS ROAD SUITE 101/103 HAGERSTOWN, MD 21742 PHONE: 240-329-0999 FAX: 240-329-2755 AVR JACKSONVILLE 4253 SALISBURY ROAD JACKSONVILLE, FL 32216 PHONE: 904-416-1540 FAX: 904-425-2137 AVR JOHNSTOWN 1027 BROAD STREET JOHNSTOWN, PA 15906 PHONE: 814-619-0945 FAX: 814-619-0325 AVR TRENTON 1450 PARKSIDE AVENUE SUITE D-18 TRENTON, NJ 08638 PHONE: 609-498-7038 FAX: 609-240-0513 COMING SOON AVR WASHINGTON 7610 CARROLL AVENUE SUITE 100 TAKOMA PARK, MD 20912 PHONE: 301-891-2500 FAX: 301-891-1704 Multiple sites in Arizona, Florida, Georgia, Nevada and Northeast US