Cardiologists have a message for frontline caregivers: peripheral artery disease (PAD) is a serious condition that, when caught early, can be treated with new technologies that offer improved results.
The key, they say, is screening for the disease and finding it in the early stages.
“There’s a little bit of a mindset shift that needs to happen with physicians, to take this as a legitimate and serious condition,” said Mike Ennen, MD, vice president of marketing for Foxhollow Technologies. “All the interventions that we’ve been doing on the coronary arteries have mostly been symptom relief.
Angina is really uncomfortable for people and they don’t like having angina, so they go in and have a balloon angioplasty and they get a stent in the heart. It’s the same thing (with PAD). If we’re going to do interventions to relieve people’s symptoms from having coronary pain, what would be any different in the leg? Why would it be okay to have your legs hurt every time you walk down the street? Getting that mindset shift to happen at the level of primary care physicians or nurse practitioners or podiatrists or any of those frontline folks is critically important.”
“We tend to overlook the presence of PAD and just kind of ignore leg pain as you are getting older,” agreed Robert Foster, MD, of Birmingham Heart Clinic. “It is a very early sign of severe vascular disease, and in fact, once you detect that you have abnormal circulation in your legs, your prognosis is worse than breast cancer for survival. It may be the only symptom someone has to make you aware that they have a severe problem. A lot of times we don’t ask … we don’t feel their pulses or we don’t check their circulation in their legs. We just assume that it’s arthritis.”
Or something else. Darry Martin, DDM, suffered with leg pain for four years before Foster treated him for PAD. A competitive dancer, Martin first adjusted his routines to compensate for the pain, but eventually he had to stop dancing altogether. Thinking the problem was in his back, he had seen a neurosurgeon, a neurologist and an orthopedist, and he had tried deep muscle massage, but the pain persisted. Once Foster diagnosed the PAD and treated him, Martin was on the way back to a full life. “On the second day after surgery, I went into the office and did my regular scheduled surgery load,” he said. “That was a Friday, and on Monday, I was back at work full time.” Two weeks later he started dancing again, and soon thereafter called a competition he had planned to visit as a spectator. He wanted to compete, not just watch.
He walked away with first place in both the events he competed in.
“Before the procedure, I couldn’t dance more than a minute without pain,” he said. “Last Monday, I danced six hours!”
Not everyone with PAD has this kind of success story, but Foster believes that early intervention and new technologies can offer more patients that kind of opportunity. “It’s very, very simple to ask,” he said. “They need to really ask specific questions, trying to tease out symptomatic behavior. And also, particularly in diabetics, asymptomatic PAD, because they get neuropathy, so they don’t feel their legs or their feet.”
The first question to ask patients is whether they have leg pain during exercise that goes away when the exercise stops. “It’s a supply and demand problem,” Foster explains. “When your body is demanding it and you have lack of supply, you are going to get symptoms. When you stop doing that, your body doesn’t demand as much and your supply is okay and it gets better. It’s a tightness, a squeezing thing. It’s not a sharp pain.”
Next, doctors need to look at the feet for non-healing ulcers or reddish-black discoloration of the toes.
If the questions indicate PAD, the next step is to check the blood pressure in two places. “With PAD we have a very simple test, and that’s just testing the pressures in the legs and ankles and comparing that with the arm. They should be exactly the same. If they’re not the same, then you have PAD,” said Foster.
Not everyone has the ability to test an ankle brachial index (ABI), however.
“What we typically say is if you palpate and you have diminished pulses, if you have ulcers, then you need to send (the patient) for screening,” Foster said.
Martin has a similar suggestion from the perspective of a patient who suffered pain for four years. “I feel that this could have been resolved early on by doing one thing: touching me. I was diagnosed simply through talking and putting me in a machine. As a vet, my most sensitive diagnostic tools are my fingertips. Had I been touched, I think it would have been diagnosed that I did not have a femoral pulse.”
Once the diagnosis is made, there are choices of treatment options. In addition to balloons and stents, two new technologies are improving recovery chances: laser and atherectomy.
Laser is currently offered by only a couple of practices in the Birmingham area, and Foster is researching the possibility of performing it in his practice. He made a recent trip to Atlanta to see the procedure.
“The first cases I’ve seen here this morning are people who had stents, which had since renarrowed with scar tissue, and ballooning and restenting really doesn’t work very well. The laser just cleans it out. I’ve watched it this morning and it’s absolutely beautiful. They clean all that plaque out of the stent. And the longer the stent, the more likely you are to have a renarrowing of some portion of it. We’re putting in long stents and treating long blockages now. This is a great technology to have,” he said.
Another new option is atherectomy, using the SilverHawk Plaque Excision System by Foxhollow Technologies. The SilverHawk system uses a tiny rotating blade to shave away plaque from inside the artery.
Foster has found the system to be a good option. “The advantage of the SilverHawk system is that it actually goes in and removes the plaque. As you cut it out, it captures it in a nose cone and you are able to remove it. It debulks by removing, and most of the time it is a standalone procedure; once you do that, you don’t have to do anything else. You don’t have to balloon after that; you don’t have to stent after that. Whereas with some of these other technologies, including laser, many times you have to balloon after. This is one of the few that is truly standalone. You debulk and you’re done. We’ve been doing it over a year now, and we’ve had one patient come back. It’s a very good technology.”
“It also preserves all treatment options,” Ennen added. “To date, PAD remains a progressive disease. People’s background, diabetes, and their smoking and all the other things that contribute to their vascular disease largely don’t go away after a procedure. So being able to preserve treatment options is a key difference for our technology.”
The results from the new technologies are impressive. “The renarrowing rates of the older technologies are much higher,” said Foster. “For just a standard balloon, the renarrowing rate is about 60 percent. If you stent it, your renarrowing rate is in the order of 40 percent. We’re finding with the newer technologies we’re actually debulking and don’t put any metal in it and don’t tear the vessels with balloons, then your renarrowing rates are getting below 20 percent. And we’re able to open up vessels that are completely blocked and debulk them by getting all that crud out of there rather than pushing it to the side.”
Foster hopes the treatments will continue to improve. “It’s brand new, because all this stuff is really within the last year to year and a half. There’s still so much more that we’re learning. We’ll just continue to get better at it.”
In the meantime, his message to frontline physicians is clear: it’s also time to get better at screening for the disease and catching it early.
August 2007
