Peripheral Disease

MUSIC My name is Thomas Reifsnyder, and I’m a vascular surgeon at Johns Hopkins. MUSIC 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. MUSIC 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 re, or the necessary surgery to save that limb is known as, it, is easily done and something that can absolutely change the patient’s life. Its much better than to do 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 an, a prosthesis and you’ll be able to walk again. And you don’t have to undergo multiple procedures to try to save that limb. Most patients can actually undergo one or two sophisticated operations and save a limb, which will absolutely change their life. Peripheral Arterial Disease which, which used to be called Peripheral Vascular Disease basically is blockage of the arteries going to an extremity.

Avoiding Leg Amputations Due to Peripheral Arterial Disease QA

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 whatsoever. In other words, they go to their doctor, and the doctor cannot feel their pulses. There are millions of people in America who have decreased circulation in their lower extremities, but because they’re getting older, they’re not as mobile, they don’t have any symptoms whatsoever. 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 life 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. MUSIC The, 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. MUSIC Peripheral Arterial Disease is manifested most commonly as. No symptoms what so ever. the. The patients 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’s 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 arterial 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 get is they get pain in their calves or thighs after a certain distance of, of walking. The nice thing about peripheral arterial disease is that it’s 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 consis, consistently every day. MUSIC The patients that are the toughest patients to treat are those who present with poor circulation to their lower extremities and severe peripheral arterial disease. These patients can present with a lot of pain in the foot clearly they won’t be able to walk too far. And sometimes they’ll 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, 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 lower extremity. These patients can be treated with angioplasty and stinting, 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 effect the lower extremity arteries, but also extra 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 this, 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 a ulcer. And in the worst cases, that ulcer then gets infected and can threaten the whole foot. Diabetics sometimes will have normal circulation to their foot and sometimes they will have poor circulation to the foot. So treatment of a diabetic ulcer of the foot 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, toe, or toes of the foot. And or it might involve restoring normal circulation depending upon the situation. MUSIC In the last couple of decades the treatment of peripheral arterial disease is really undergone a revolution. There have been a large number of minimally invasive techniques that have they’ve really become quite common, and are quite widely available across the United States. And what I’m talking about is angioplasty and stinting.

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. And nowadays, the techniques are available where we can actually take totally blocked up blood vessels and be able to reopen them. Generally, this, this also involves putting in a stent, which is sort of a metal scaffolding that sorta looks like a Chinese finger trap, and that helps keep open the artery over a longer period of time.

In the worse cases the patient would need a lower extremity operation or a lower extremity bypass operation to be able to restore the blood flow. MUSIC The concept is really very straight forward and very simple, they 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 ha been reduced, so the idea is very straightforward. The actual surgical part can be a little tricky at times and most of the time what we do is, is we create a new blood vessel out of the patient’s own vein.

So you are 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. 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 stinting, or reopening blood vessels with a balloon or a, a little metal stint or scaffolding to keep the blood vessel open. The real advantage to these procedures are that they’re minimally invasive and therefore are low impact on the patient.

Most of these procedures are done as outpatients they can be done under local anaesthesia with just a tiny bit of sedation. And generally take one to two hours to perform, and the patients then are, 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 and basically can re, resume normal or more activity than previously within a day or two.

MUSIC. 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 that, 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 Johns Hopkins Hospital will, 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.

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