In our Ask a Doc series, we sit down with physicians and other clinical experts across our Highmark health plan networks, including at Allegheny Health Network (AHN), for a chat on an important health topic. In this edition, we're talking about peripheral artery disease (PAD) with Dr. Rajiv Swamy.
It can be all too easy to dismiss the most common sign of peripheral artery disease (PAD), thinking it's a normal sign of aging or chalking it up to overdoing it on yard work or other physical activity. But cramping, pain or tiredness in your leg or hip muscles that starts while you're moving and subsides when you take a break shouldn't be ignored.
One in every 20 Americans over age 50 has PAD — a total between 8 and 12 million people — but it doesn't always trigger symptoms, so many don't know they have it.
Amanda Changuris (AC) Dr. Rajiv Swamy, as an Allegheny Health Network cardiovascular specialist, explain the connection between PAD and experiencing leg pain?
Dr. Rajiv Swamy (RS): Peripheral artery disease is a clinical condition where people have blockages in the blood vessels of their lower extremities. If it's allowed to progress, the reduced blood flow can lead to cramping and pain in the legs at rest or even ulcers on the feet or wounds on the legs that are very hard to heal.
AC: How does a lack of blood flow contribute to stubborn ulcers and wounds?
RS: When patients develop wounds for any reason, our blood supply is responsible for delivering white blood cells and infection-fighting blood cells as part of the natural immune response. Additionally, if you take antibiotics for a wound, you need an intact blood supply to the area. So if the patient comes in and has a wound on their leg and you're worried that it's infected, you give them antibiotics. You're making the presumption that the blood supply is intact so that the antibiotics are reaching the desired site. If we see a wound is not healing, it may be because the blood supply to that wound is compromised.
AC: So if a patient comes in with the classic leg pain symptoms or a wound that won't heal, how do you determine it's PAD and not another condition?
RS: The most common screening test for peripheral artery disease is something called an ankle — brachial index. An ankle — brachial index is a relatively straightforward and simple procedure that can be done at any doctor's office. You measure the blood pressure in the arm and the blood pressure in the leg and you take a ratio of the two and if it's below a critical level, then that's considered to be abnormal and it's probably PAD.
The diagnosis can be confirmed using an angiogram, a procedure where you inject X-ray dye through an IV that's placed into the leg and take pictures of the blood vessels in the legs. Then we look at the arterial tree and see where the problem is. Based on what the problem is and where the problem is, we can select the most appropriate form of treatment.
AC: Once you know you're dealing with PAD, what treatment options are available?
RS: The mainstay of the treatment of peripheral artery disease is an intense exercise program, if the patient is able to do it. That can be a catch 22 because the patient often has leg pain with movement and the treatment is to move more. They can start slow, but it's paramount for them to increase their activity tolerance.
We can also provide treatment to increase the blood supply in the lower extremities. That can be a balloon angioplasty, stenting the blood vessel, or if there's a very significant or severe blockage, we can consider bypass surgery.
AC: I know cardiovascular surgeons at Allegheny General Hospital recently became the first in the region to use some new technology in the treatment of PAD through the Highmark Health VITAL Program. What can you tell me about Avinger's Ocelot™ and Pantheris™ systems?
RS: The Avinger systems allow you to evaluate the blood vessel by going through the narrowing area with a camera in real time. Without that camera, it's like trying to find your way through a dark tunnel; with the camera, it's like you've been handed a flashlight.
It can be used during a procedure called an atherectomy that serves to de-bulk the vessel in terms of blockages. If you imagine a narrow pipe, you can try to open up the pipe but you may not be able to, so you may want to scrape down all of the narrowing areas and that's what atherectomy does.
AC: Generally speaking, does a procedure like this require a hospital stay?
RS: If you come to see me, almost all of the procedures we're talking about are outpatient procedures; you come in the morning and you go home the same day. Some doctors keep people overnight for these procedures, but by and large, it should be done most times as an outpatient procedure.
AC: What risk factors are associated with PAD?
RS: The biggest risk factors for PAD are high blood pressure, diabetes and smoking. There's also a genetic component. Right now, it's hard to quantify or measure, but we know that patients whose family members have the condition are more apt to get the condition, as well. We also know that African Americans are more than twice as likely to have PAD as their white counterparts.
AC: And what's the best way to try to prevent the development of PAD?
RS: The biggest thing for prevention is to increase exercise. The more active you are, the less likely you'll develop peripheral artery disease. Or if you do have PAD, increasing your ambulation can help in the development of what are called collateral vessels. They're part of the body's natural response of creating new blood flow in areas where blood flow is reduced. That's why exercise programs are necessary for prevention and as part of treatment.