Dr. Elizabeth Blazick (Guest): Peripheral arterial disease is when there’s a deposit of fatty plaques which is also called “atherosclerosis” which develops in the arterial vessel walls. It can happen, really, in any artery throughout the body whether it’s in the heart or arteries in the brain, and, oftentimes, arteries in the legs.
Melanie: So, who is at risk for this type of disease?
Dr. Blazick: The major risk factors in people to develop PAD is high blood pressure, high cholesterol, and, probably one of the most important and the most controllable, is smoking. The other group of people that we see that it’s very commonly in is patients who have diabetes. These are also the same risk factors that can often affect people who have cardiac disease or who have had stroke.
Melanie: Does it affect women more than men?
Dr. Blazick: Well, it is a bit more common in men than women but, really, both genders are at risk.
Melanie: So, how would somebody know that they’ve got this? Would there be certain things they feel? People always say, “Oh, I’m looking for a blood clot,” and they put their hand on their leg looking for that warm spot. How would they know?
Dr. Blazick: Well, oftentimes, peripheral artery disease can be asymptomatic and, again, as I mentioned, it can affect multiple different arteries throughout the body, be it the heart or the arteries in the neck that go to the brain, the carotid arteries. So, if they were to affect those areas of the body, that would be something that could lead to heart disease or heart attack or a stroke or symptoms of a mini-stroke called a “TIA”. One of the other more common symptoms that we see is something called “claudication”, which is pain in the lower extremities when you’re walking. This is really a result of too little blood flow usually during exercise. So, when people walk, they will notice that they’ll develop some cramping, most commonly in the calves but sometimes in the thighs or even in the buttock area.
Melanie: So, this is what’s confusing to some people, Dr. Blazick, because sometimes it can be an overuse; it can be a sore tendon; it can be, you know, a number of musculoskeletal things that you feel in the calf sometimes.
Dr. Blazick: Correct.
Melanie: When you feel that pain and you’re on your treadmill or you’re exercising, do you run off to the doctor to get checked?
Dr. Blazick: Not necessarily. I think, that one of the things that patients should consider is whether or not they have one of those risk factors that we talked about. Peripheral artery disease is more common in older patients and, again, in those patients who have other risk factors like high blood pressure, hypertension and particularly cigarette smokers and diabetics. It’s not to say that somebody can develop these symptoms even in the absence of all of those other conditions but, generally, the thing that separates this from things like muscle sprains or difficulties with the muscles or the bones is that it’s a pretty reproducible pain within the muscles themselves. If patients say, “Every time I walk down two aisles at the grocery store, this pain comes on, and then when I stop and rest, it goes away. But then, if I walk two more aisles, the pain comes on again, and it’s pretty reliable and pretty reproducible.” That’s generally the classic type of symptoms that we see associated with claudication and peripheral cardiovascular disease.
Melanie: And how it is diagnosed?
Dr. Blazick: Well, the first thing that we do is we do a really thorough physical exam and a history on the patient. We try to assess their risk factors and then what we’ll do is we’ll check the legs and we’ll check the pulses of the legs. If people don’t have pulses that we can feel with our fingers, then we can use other tests such as a Doppler, which is like an ultrasound, or we can do what’s called an “arterial brachial index” which is a non-invasive study that basically helps us to qualify what the blood flow is to the legs. Oftentimes, this can help us to make a preliminary determination if there’s a narrowing or a blockage that’s resulting in decreased blood flow to the legs and whereabouts in blood vessels that area of disease might be.
Melanie: If you’ve determined that somebody does have peripheral arterial disease, what can be done for them?
Dr. Blazick: First and foremost is getting control of those things that we can change. So, if someone is smoking, they need to stop smoking immediately. Smoking is the biggest risk factor for this claudication and these relatively minor symptoms developing along into major symptoms when people think about things like pain in their feet that doesn’t go away or even losing toes or amputation. Smoking is the number one thing that we can control. So, we really, really are very aggressive with smoking cessation in these patients. The other thing to do, too, is to get a handle on cholesterol levels. We really start most of our patients on one of the statin medications like simvastatin or atorvastatin. Even in patients who have normal cholesterol levels, these medications have been shown to extend benefit to patients in terms of disease progression who have peripheral artery disease. So, while we’ll check the cholesterol level, we will oftentimes start patients on a statin medication even if those numbers are okay. The other thing to do, too, is to be very aggressive in trying to get people’s blood glucose under control if they’re a diabetic. So, we will really work with the primary care providers or the endocrinologist in terms of trying to get a better handle on that. And then, in terms of the patients, the one thing that we really have them do is to focus on an exercise program. The one thing that they can do starting now to really help their symptoms is to help build up the collateral network, which is basically the way that the body compensates for narrowing or for blockages in blood vessels. So, we will tell patients to start walking and really try to get on a scheduled program, at least three days a week, either on a treadmill or if they have the ability to walk outside. But, some place where they can consistently and reliably increase their walking levels. Over about two months or so, patients will really start to notice the difference.
Melanie: So then, when does it resort to an intervention of some type or having to do angioplasty or something along those lines?
Dr. Blazick: So, I really try to make sure that I have done everything from a medical standpoint. I’m pretty insistent that patients really commit to getting all tobacco off. So, no more smoking, no more patches, no e-cigarettes. Those are great adjuncts to try to help somebody in their quitting process, but I ultimately want people to become free of tobacco and nicotine. So, if someone has stopped smoking, if their diabetes is under control, if they’re taking the statin medication, they’re taking all of their medications as prescribed but the still come and say, “You know, doctor, I can't do my job right now. I can't do things like I can't go shopping. I can’t take care of my home. I can't do those things because my legs are hurting so badly that I just can't take care of the things I need to take care of.” Or, in patients who have noticed their progression in their symptoms despite walking and doing those things and they start to notice either sores on their feet or pain in their feet even when they’re resting or sleeping. That’s the patients that I will move along towards doing something a little bit more invasive such as an angiogram.
Melanie: And, if you do that, then tell the listening what is it you’re really hoping to accomplish with those kinds of procedures.
Dr. Blazick: First and foremost, what that procedure will do is it will give me a good road map for how the blood flow is to the legs, essentially from the belly all the way down to the toes. That’s the first thing that I need to know is that where is there an area of disease or blockage. Sometimes if the area is a fairly short area or it’s affected or blocked, that’s something that we might be able to treat with a balloon or with a stent, which is very similar to what a lot of people have heard that happens for heart disease. It’s essentially the same sort of procedure that a cardiac catheterization or a cardiac stent is, except that we use bigger stents for the arteries in the leg. So, if we are able to go in there and to treat this with a stent or a balloon, then that will save a patient a much more invasive operation such as the bypass.
Melanie: What’s life like for with someone with claudication, with peripheral artery disease, if they do or don’t have the stent or the angioplasty, whatever they get done, is this something that can reduce over time and get those plaques off their artery walls? Are they’re going to be able to walk without pain? What's life like for them?
Dr. Blazick: If patients are very committed to making the lifestyle changes, we can see a really significant improvement in their quality of life. We have seen patients who have come in who have had claudication so bad that they weren’t able to do the things that they liked to do like play tennis or ski or any of the things that they used to be able to enjoy. But, if those patients really do commit to quitting smoking and to working on a regular exercise program, these patients can become pain-free. The important thing to remember, though, is that this isn’t something that you can just work towards, and then once you get improvement in your symptoms to stop exercising. It’s really important to commit to a lifelong healthy lifestyle with taking care of your medications, taking care of your other diseases like high blood pressure, high cholesterol, diabetes, and really staying active with a walking program. If somebody gets to the point where they will require a stent or a balloon, I think the important thing to remember there is that that is something that’s going to require long-term surveillance with your vascular surgeon. I don’t put a stent in somebody, and then say, “Good luck. Send you on your way. We’re not going to see you again.” I think it’s very important to continue to follow-up patients because these stents can narrow over time, the disease process can reoccur and the symptoms can return. So, I always bring my patients back on a fairly regular basis to check to see how they’re doing and if it looks like there’s something that’s going awry, we can try to get on top of it and intervene on it early.
Melanie: Tell the listeners your best advice and why they should come to Maine Medical Center for their care. Tell us about your team.
Dr. Blazick: I work with five other vascular endovascular surgeons who, really, we do the full array of vascular procedures from aortic aneurysms to interventions on carotid disease and lower extremity blockages as well as varicose veins and DVTs. We really have a broad spectrum of patients that we treat. And then, we also work within a larger institute called the “Cardiovascular Institute” which also encompasses our cardiology colleagues as well as some interventional radiologists who also perform some of the angiogram and angioplasty techniques. So, I think that the one thing that is so impressive of our group is that we have a very broad range of providers who are very committed to our patients and to patient care and we have each other’s expertise and abilities to work with each other and really provide patients with all-encompassing care.
Melanie: Thank you so much, Dr. Blazick, for being with us today. It’s such great information. You’re listening to MMC Radio. For more information, you can go to mmc.org. That's mmc.org. This is Melanie Cole. Thanks so much for listening.