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What are some of the benefits of the endovascular less invasive approach?

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Transcript:

Host: So give me some of the benefits of the endovascular less invasive approach

Doctor: Well first of all, the word explains it. It is less invasive, meaning through a small perforation in your groin. Not bigger than two to three milliliters in diameter. You can basically utilize any tool to either open a vessel or excise the plaque, the atheroma from inside the vessel and clean it up or optimize the results through metal cages called stents or even cleaning up cloths. So there’s everything we can potentially do to fix the stream of blood, we can usually do it from percutaneous. So as you make a smaller incision in the skin, then your infection is less, your infection rate after the surgery is less. So you minimize the infection complication rate. Number two, the complications related to general anesthesia in big long surgeries is minimized because also your operate times usually are little bit shorter when you do this and people can be wide awake and with only small local anesthetic in the skin level so they don’t have any pain when we puncture it. So there is a fairly good advantage of this and another thing is that people can basically walk out of the procedure in hour or two later after it. They can stand up, if you use specific closure devices, and they can even walk home if that’s maybe the case.

Host: Versus an open traditional surgery, what’s recovery time there typically?

Doctor: So usually people stay in the hospital, different lengths depending on what surgery is. It can be up to from one day, sometimes they might have to be in the hospital for five to seven days recovering from a big surgery. So the bedding is very, is a wide array of surgery so it is hard to pinpoint one day, but I can tell you certainly the recovery period is usually slower and to get back to their functional state it takes more time.

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Is there anything that a diabetic can do to try to control that or ameliorate PAD?

Transcript:

Host: So diabetes is a strong risk factor for PAD. Is there anything that a diabetic can do to try to control that or ameliorate that?

Doctor: Absolutely, diabetes I would say in our communities, especially in southern part of the U.S. where we have a very big Hispanic community understanding that the prevalence in Hispanic of diabetes is fairly high. About 60 years of age you’ll get up to 30 percent of people having diabetes and being that, of course it’s crucial that you have some control over that diabetes. The way to prevent complications that come from long term diabetes is sugar control. So if you can get your blood sugars under control with adequate therapy and on top of that you modulate your life style, remaining you get out of that couch, you do some exercise, you drop that cigarette, you stop smoking, all of those things will impact and minimize the complications long term. So if you can minimize your neuropathy which certainly comes from long period of badly control sugar levels in your blood then certainly you’ll prevent the issues that might come from neuropathy like we were talking about.

It seems kind of a double bind like you talk before about the golfer that could not continue because of the pain and so their tendency would be to rest or to avoid activity, but it’s activity you need.

Absolutely, and some of these people don’t even need an intervention, surgically speaking. Some people just need some advice. There are a great amount of people that if you just exercise them in inadequate fashion, you explain to them how they have to walk, what they have to do with a treadmill in a daily basis, most of their symptoms can go away. So it is very important to pick them up early enough in the game and advise them so they can prevent a future operation.

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If you have pain in your legs, what kind of specialist should you look for?

Transcript:

Host: So as a patient, if you suspect that you have pain in the legs what kind of specialist should you look for to be recommended for the next step?

Doctor: So there’s many specialist right know who deal with PAD, vascular surgeons, cardiologist, and even interventional radiologist, now they deal with PAD. But I absolutely think that you have to try to reach your PCP first. He is the person that could order the initial batch of quote on quote vascular labs that are a way of us, as physicians, identifying with objective data if a patient has or doesn’t have PAD. Now, it is very important and that’s where it gets a little bit tricky that the PCP is where were of some of the secrets involved in identifying this disease. Because well it’s not a secret that most people with PAD are either going to be ex-smokers or active smokers, they are going to be people of a certain age, the older population, we are going to have people with hypertension and diabetes. So as you go to this small subgroup of people that have all of these other things going on, what we call comorbidities the you tend to blame other things like for example your lower back pain, or you might say you had some knee surgery and your knee hurts and it might be that you are actually having pain when you are walking from inclusive disease, which means you are not getting enough oxygen and we have that in a fair amount of people that for months, and months, have or tried to find medical attention and they always for some reason focus on some muscular issue or some joint issue and at the end, the patient was having peripheral artery disease. People will say I’ll start walking, without any problem whatsoever and at some certain distance, 50, 100 feet, their thighs or their back parts of their legs will start cramping up in pain, which basically prompts them to stop because they can’t move a step forward. With a little bit of rest, couple minutes go by the pain subsides and then they can actually go on and walk again. So when somebody has this recurrent intermittent period of pain that comes basically from some exertion or some exercise and they have to stop because the pain is unbearable, but immediately as they rest the pain goes away that’s when you have to think I might have PAD, I need to find somebody that can work it up for me.

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Are there any disadvantages?

Transcript:

Host: We’ve seen and heard a lot of the advantages of endovascular and less invasive approaches compared to the open and traditional ways. Are there any disadvantages, is there any downsize?

Doctor: Absolutely, nothing is perfect. As operators we have to have that and we have to have the knowledge to say when something might not be appropriate. We’ve seen that the more extensive, defuse complex disease tends to have, in the short term poor patency rates what we call. How long does the procedure actually stay open and so that is something that we are certainty looking forward to optimizing as newer devices and medications and drugs allows us to maintain a procedure open for a longer amount of times. Now in the other hand you do have to know also that vessels are transparent under the ex-ray machine. You can’t see them like you see a bone. So in other to see the inside the vessels you use a special fluid called contrast and that helps us identify where the disease is. Now the problem with contrast is that it is nephrotoxic meaning it is bad for your kidneys. And so people who have issues with their kidneys, especially people that have some kidney baseline problem then there will be a subset of people that are at a higher risk of having renal complications from a procedure.

Host: What if somebody is in dialysis?

Doctor: That’s a great question. There are many of our patients out there that actually informed themselves and come basically in tears saying the problem is that i’m in dialysis, I understand I can’t get any contrast and actually that is to some extent not true because if somebody is already in a renal substitution system meaning they have hemodialysis over a catheter over their neck or their shoulders or they have peritoneal dialysis meaning they have a catheter in their belly that basically substitutes their renal function and the majority of people that are already in dialysis have no problem because they quote on quote have no kidneys we have to protect. It’s actually the subgroup of people that are close to getting to dialysis that if you expose them to contrast you’ll certainly are going to push them over the limit. So that’s the subgroup of people.

Host: And one of the big risk factors for PAD is age. Is there any absolute barrier of age in which a patient should no seek some sort of PAD surgical intervention?

Doctor: Not at all. It’s all about if the preoperative risk of the patient undergoing x procedure is adequate or the risk benefit balance is adequate for the patient. Age is no way a restriction.

 

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What is the future for treatment of PAD and related diseases?

Transcript:

Host: So what do you see as the future for treatment of PAD and related diseases?

Doctor: It is very exciting. Every few months we learn of a new technology that inside the box or outside the box change the way of thinking and I think that the most immediate future is the application of drugs or immunosuppressant slash chemotherapy drugs to the therapy of PAD. Pretty much the drugs you use to treat cancer are applied to the stents and balloons that we use to open arteries and the idea is this drugs are immunosuppressant meaning that it diminishes the ability of your body to react to something and to diminish inflammation. So now in days when we apply a stent in the most part of the stent is not covered with any medication. Is a dead structure, so to speak. To apply chemotherapy drugs in the inside and outside of the stent so that will actually bathe the inside of the artery and prevent the inflammation from happening. There’s this small catheter that infiltrate steroids, pretty much as you develop pain in the bottom of your foot and a doctor gives you a steroid shot to diminish inflammation. Is the same, we can go inside the vessel and inject this steroid into the wall of the artery to diminish inflammation that is not is not hard core science proven but its promising based on the evidence little evidence or enough evidence that we have, that they do work. This work has been applied to the coronary arteries in your heart whe they put stent in your heart and now it’s a rule that those stents have those drugs. That technology ahs been applied in the legs in the last few years and the initial results were not promising, but now there is better platform for delivery of the drugs so the drugs will stay in the artery and not go somewhere else that are making us hopeful that these technology is going to change dramatically the ability of the stent and our intervention to remain open for a long time. Right now I can tell you 99 out of 100 arteries we can open, but it doesn’t mean that artery will remain open ten years from now. That artery will be open one or two, and sometimes your heartbeat will result. But the key is to prolonged the longevity of out procedures and I think the answer in my opinion anyway recites from the application of drugs and delivery to arteries.

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What is the future of the techniques and procedures?

Transcript:

Host: Looking ahead what is the future of the techniques and procedures?

Doctor: Most of the money that is being directed to biomedical research has to do with two main areas and potential three. The first of which is genetic analysis as our ability to identify patients with a certain gene, the degree of expression of that gene become even more important. Once were are able to identify who’s at risk from a genetic standpoint and subsequently identify those patients not just possessing the gene because that would be many many more patients that actually have a problem from it . The degree from expression can be block by certain medications and although many of those are present in the laboratory right now and were testing them in animal models, they are not available yet but they are coming soon. So soon we will hopefully be able to have a pill that will not just suppresses inflammation, but suppresses many of the proteins that are involved in the initial plaque formation so identification is certainly and it also provides a treatment option for patients in a medical standpoint. So ultimately way down the road we will not be doing any surgical procedure or minimally invasive procedures in any one. We will be able to identify people at a young age, treat them medically and then they never progress to actually having any of the conditions we described. From a technical standpoint, in the more immediate future, the size of the catheters, wires, stents, and delivery systems that we put into someone are becoming smaller and smaller and smaller and although size is not everything its certainly very important because most of the complications we see have to do with bleeding from the vessel to where we puncture so smaller catheters and sheets and delivery systems become very important in lessen the incidents of those most common complications. A third thing that should be mentioned is a lot of research is being spend or a lot of research is been looking recently in bile absorbable materials meaning in regards to medical implantation of device. Currently most of the things that we place in the patient s are metallic or not absorbable, drug coding have improved the results we these metallic implantable devices. but ultimately most of us in the profession feel that bio absorbable matrices and bio absorbable wire forms or structural support systems combine with medicines that impregnated into them and allow a person’s native artery to remodel in a way that is not normal but near normal, thereby affecting actual plaque regression along with proper opening an inclusion we feel it represents the most encouraging or the most exciting development next.

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Is PAD similar or the same disease as cardiovascular disease?

Transcript:

Host: Is PAD similar or the same disease as cardiovascular disease?

Doctor: It’s the exact similar process that results in both. Meaning that patients that who have cardiovascular disease or arterial inclusion in the coronary arteries very frequently have them in the periphery, in the neck, in the legs, in the abdomen, and to our organs. So they are very commonly associated. Many patients that is evaluated and found to have any one of these diseases and spectrum should be fully evaluated for inclusions in other areas.

Host: If a patient would have had both cardiovascular disease and PAD, which one would typically show up first.

Doctor: Very typically we find, even a small wound or small lesion or a blister on the foot is often is the first manifestation of these diffuse process in many patients. Certainty in the diabetic population this is particularly confounding because they will often have no signs or symptoms of cardiac disease what so ever and yet have very profound arterial exclusive processes that affect both their legs and their heart any one of each can go unrecognized, so certainly the lower extremities of the more common location in the initial presentation, the relationship is not absolute, however. So it certainly indicates a spectrum of disease but they are related intimately.

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What type of people get PAD?

Transcript:

Host: So what type of people get PAD, what kind of risk factors do they present with?

Doctor: Unfortunately aging, nobody escapes aging and aging happens to be one of the most contributors to plaque built up. Your arteries as we age become harder and more prone to develop Atherosclerosis or plaque buildup. Now that does not mean we all have to follow that path, there’s some issues that we can control and some of them we can’t control. Something that we can control that is very important is tobacco. Tobacco usage is a huge huge risk factor for Atherosclerosis. I can tell you that somebody comes to my practice being a nonsmoker, I immediately think of something else that is affecting that patient for the symptoms and not PAD such as strong relationship. Diabetes is rapid in Arizona where we practice and everywhere in the world really. So diabetes is actually an important risk factor. Age, tobacco, diabetes, high cholesterol, high lipids in your blood, exposures you to having these kind of problems and other rare genetic disorder will also expose you to that problems. Obesity, high blood pressure, renal diseases , are less important contributor, but nevertheless are contributors to this problem.

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What are the treatment options?

Transcript:

Host: So once the patient has been diagnosed with PAD what are the treatment options?

Doctor: There is really a wide array and I don’t think that you can say one single thing is a treatment for it and I believe as physicians dealing with this we have to be tailors. Tailor the therapy to the patients’ needs and it is great to be unbiased when I say that because as a surgeon I feel very comfortable saying, you need an extremely complex big operation or you need an extremely simple non-invasive technique to deal with this. Or you don’t need anything we are going to do a great exercise program, you need to stop smoking, you need to get out of your couch, and you are going to start doing some exercise. So there is very different stages now, is there an ideal. Well I think for the supsent that needed therapy, I would definitely encourage minimally invasive therapy cause as time progresses we are reaching results fairly equal to surgery depending on specific and that you can have a great deal of discussion about, but certainly from getting to A to Z, now in days in treating these patients there is pretty much the same results if you do endovascular therapy as if you do open surgery. and understanding as we have spoken about today, these are a subgroup of people that are fairly sick and so subjecting them to a big vascular open surgery, sometimes is not the smartest thing. So if you can get away with an endovascular minimally invasive technique to repairing this it’s usually the better option

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How to we distinguish between PAD and PVD?

Transcript:

Host: We’re also here besides PAD, PVD or peripheral vascular disease. Are there similarities, differences, how to we distinguish those?

Doctor: There are subtle differences, but for arterial disease is a fixture of arteries alone where peripheral vascular disease is any vessel. So other vessels, in arteries include veins and lymphatic vessels. So PVD or peripheral vascular disease is a wider term that that encompasses peripheral disease as important part, but it is not the only one.

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How does the recovery time for the more invasive and less invasive procedures relate?

Transcript:

Host: What about recovery time for the more invasive and less invasive procedures. How do they relate?

Doctor: Recovery time is very widely and is typically determined by patients’ overall health conditions mostly, but I can tell you that most of the patients that undergo arteriography and some sort of minimally invasive vascular reconstruction is discharged home the same day. 20 years ago, tissue loss or ulceration or gangrene was a mandatory inpatient hospital stay. Patients stayed for weeks and today we send them home as outpatients. And that is the most frequently case. The larger surgical procedures the hospital stay has been shorten also however. And medical care overall has improved to the extent that really frequently patients will go home on the second day, sometimes even the first day after a large surgical bypass.

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How does smoking contribute to the constriction of the blood vessels?

Transcript:

Host: One of the risk factors we address briefly with smoking, exactly how does that contribute to the constriction of the blood vessels?

Doctor: Smoking does a number of things. It doesn’t just cause constriction. That’s part of what nicotine and binding to the nociceptors in the body does cause. And what you are referring to is vassal spasm, constriction of the very small blood vessels in the arterial system. Smoking, getting back to inflammation becomes extremely egregious in regards to the fact that it failed to initiate a diffuse body inflammatory process. So the body perceives it as an injury, that injury instigates the inflammatory cascade and that inflammatory cascade results in the development and progression of a atherosclerosis, hardening of the arteries or plaque buildup. So the vassal spasm is only part of that. The permanent damage that is caused to the arteries has to do with the oxydated process also and the way the body heals naturally to the response to injury and inflammation. So truly again getting back to the root of what we feel atherosclerosis is derived from is inflammation and smoking is one of those agents that we’ve known along with dietary issues to cause plaque buildup.

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What is the success rate?

Transcript:

Host: What’s the success rate today with the options they have? I know that is a hard one to answer?

Doctor: It depends on the location of the inclusion. So the results are very widely, but we do have a large body literature now that guides what we recommend patients. And to specifically say that in the upper part of the leg, or in the pelvis patency rates or success rates using stents are in the range of 85 percent in 5 years. In the thigh similar results have been recently reported, 80 to 85 percent one year patency rates with long segment inclusions in the upper thigh. Its when you get below the knee is where we find the most difficultly. And this is where treatment is tailor to a specific patient’s anatomy and where the unclusions are. Currently we can treat all the way down to the foot and we treat what they call foot disease using techniques and catheters and micro wires that are able to treat and reopen one millimeter and two milliliters blood blood vessels, so there been fairly profound advances in the past few years that have been expanded the armourterian of our tools to treat these patients.

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Why do we focus so much on low fat diets as opposed to anti-inflammatory diets?

Transcript:

Host: There appears to be more and more evidence that cardiovascular disease is caused in general by inflammation and yet and diet is a big risk factors that we’ve talked about. So why do we focus so much on low fat diets as opposed to anti-inflammatory diets?

Doctor: That’s a big topic and that has been dramatically changed in the last few years as you said by research. I happen to have a strong bias towards plant based diets meaning being a vegan myself. Not a lifelong vegan but a recently transformed vegan and based on the evidence the research was made by very respectable people that is now available to the general public now in books and dvds that you can purchase in any website store that indicate that animal protein as well as some enzymes found in milk and dairy products are absolutely detrimental to your blood vessels. Iron stores and iron deposit are huge inflammatory factors that you actually put in your mouth that damage your arteries. Why we focus on one or the other, I think that food is comfort. Food is comfort just like smoking and that is a very difficult part to attack. Believe I’ll be the happiest even if I lose my business to propose a plant based diet for everybody. I actually have some patients in my practice who I have argued against an intervention when they requested so when they are three or four hundred pounds of weight. They have to go and lose that weight because it doesn’t matter what I do to those legs the stress of that weight on the leg is there and that doesn’t change. So I agree with you, why so much focus on low fat diet well animal protein is more detrimental than fat in my opinion anyway and according to the recent research. So I think Americans in general and people in world general they have to rethink the role of diets.

Host: You alluded to animal protein as potential cause that we have been eating animal protein forever thousands of years, and yet the incidents has only risen in recent years dramatically. wondering if the process protein we get today might be what is causing it. Any research on that topic?

Doctor: Absolutely, modern research let me give you my personal thoughts because people find vegan or vegetarian people as strange and unreasonable. And let me tell you why I have this personal conflict with these people who are carnivores who tell me that humans are hunters by nature. That basically we used to hunt elk and to support your family, but this is not certainly what you do in 2013. I mean you go to the supermarket where every piece of meat you get is seasoned and is exposed to pesticides and chemicals. So if you tell me that you live in an island, remote away from civilization and you actually piece fish for your diet and your families diet then go for it. I have no problem with that. But once you processes all the chemicals and unnatural synthetic additions to your food that’s where the problem comes. And so I believe that is the different between true carnivore diet, a true carnivore human being and the human beings we are now. We follow specs from McDonalds and that’s is certainly not what should be done.

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What indicates the need to have the amputation?

Transcript:

Host: To the most extreme of patients may be facing an amputation and in the minimal they are looking at a non-invasive procedure, what is the indicator that says sorry you have to have the amputation?

Doctor: If I would have to choose one topic that is the most difficult topic I faced daily in my career is that question you just asked me. When is an amputation indicated, I think any vascular partition find that question very intriguing and difficult to answer and let me tell you why. There is literally 70 to 80 different therapies that I can offer somebody to do to try to save their legs. And you can persuade and continue to try to save a leg until you eventually run out of options that the patient is tired of undergoing so many surgeries that an amputation is required. There are a lot of patient, physician communication in that you have to know an end point. There’s an endpoint where keep attempting salvage becomes nonsense and you have jump to an amputation. That being said that is rare. Now in days with technology in 2013 were have several options to treat somebodies diseases before getting to amputation. Let me give you an example of an amputation. It would be somebody that comes in what we call wet gangrene. Gangrene in basically dead tissues when the tissues of your foot die and that processes above the ankle and the whole foot is basically gangrene, there is no way to save that foot because it is such a massive amount of destruction that an amputation is indicated. Any disease below the ankle especially the forefoot I think we have techniques in this day of age where it allows us to save most of the feet if not all. But, once again, deciding when to amputate is actually is much more important difficult done than performing the operation itself for us.

 

Endovascular Leg Therapy Information

Dr. John Pacanowski, Dr. Luis Leon, and Dr. Miguel Montero-Baker utilize medical illustrations in The Latest Procedure: Endovascular Leg Therapies to show anatomy and surgical entry approaches. Those images, along with their explanations for each, are provided here as an additional resource. The caption information is from the television program.

Medical Illustrations: Mike Austin

Jim Cissell explains different procedures that are now available to treat PAD with the assistance of an animated video. Animated Video courtesy of Edwards Lifesciences

Atherosclerosis and PAD

A wondrous network of arteries carries oxygen rich blood from the heart to all areas of the human body.  

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When disease strikes within these arteries they begin accumulating plaque or atherosclerosis. These areas usually continue to narrow until they obstruct normal blood flow starving the downstream tissue of vital oxygen.

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PAD is any arterial disease that lies outside the heart. Common locations for PAD are the corroded arteries in the neck, arteries within the abdomen, and arteries that supply blood to the legs. It is in this area that many people experience their first symptoms of arterial disease like pain, fatigue and ulcers.

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Contralateral Retrograde and Antegrade Approaches

Most physicians use a contralateral retrograde approach where wires and catheters are pushed up into the aorta and back down the femoral artery on the other side. This is typically the easiest approach and provides the best option for management of the access site.  

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A second approach is called an antegrade approach where the femoral artery is accessed and the wires and catheters are pushed directly down into the leg. This approach can be cumbersome and more difficult to close postoperatively in certain cases.

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Pedal Access

A new approach is now being used called Pedal Access, which tries to enter directly through the foot just below the blocked anatomy.

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Plain Old Balloon Angioplasty

A balloon is maneuvered into an occlusion or an obstruction in order to modulate the inside of that artery by trying to stretch it open again.

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If plaque is present instead of removing it we are going to open it up by inflating the balloon, which fractures the plaques slightly.

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The balloon comes in different sizes, lengths and widths.

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Atherectomy

This tool is an atherectomy device that cuts into the plaque and debulks it. Physicians use debulking to shave the plague, attempt to grab pieces of the plaque, and then remove it from the body in order to create a better hole. There is adequate data out there that the results tend to be very good when you do an atherectomy.

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Stents

Stents are metal scaffolds that are placed inside arteries in order to allow them to open.

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Stents are made very flexible in order to be placed in different parts of the body. For example, you know that your leg is going to be flexing and so it allows the movement of the stent to basically conform to the artery.

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