The Doctor Gamble: How Vicki Avoided Amputation

By Kirstin Rizk

For four years, Vicki Sievers dealt with so much pain in her legs that she could hardly walk. Aside from the pain, her legs were heavy and numb. She recalled, “I felt like I was walking on two stumps.” This kept her from grocery shopping, doing chores, and going out with her kids or grandkids. Then, an ulcer on her big toe lead to osteomyelitis: extremely painful swelling in the bone from an infection.

But Vicki did not sit idly by while peripheral artery disease kept her from living. For a year, her specialists disagreed on how to treat her. Her podiatrist insisted that the toe needed to be amputated to keep the infection from spreading. At the same time, her cardiovascular surgeon insisted that her foot didn’t have enough blood supply to heal after a toe amputation, meaning she’d likely end up needing a more major amputation of part of her foot, below the ankle, or below the knee. Instead, he wanted to try to clear out the arteries to get blood flowing once again.

The cardiovascular specialist tried 5 or 6 endovascular procedures, but could not get through the hardened plaque in Vicki’s arteries. She also underwent 50 hyperbaric oxygen chamber treatments. Nothing eased her symptoms.

Still, the pain in her feet, and especially her infected toe, kept her up at night. With both a non-healing ulcer and rest pain, this indicated that Vicki’s PAD had progressed to chronic limb-threatening ischemia.

Between her impaired mobility and the number of failed attempts at fixing the issue, she began to feel hopeless.

Finally, her wound care specialist recommended a new podiatrist, and this podiatrist had a new idea. He did not want to amputate the toe. Instead, he wanted her to try a new, highly specialized vascular specialist: Modern Vascular. The clinic was not nearby, but Vicki was ready to sit through the drive for a new chance at hope.

Dr. Wande Pratt at Modern Vascular in St. Louis, Missouri, started with Vicki’s right leg. Due to the extent and hardening of the plaque in this leg, the procedure had to be done in two sittings. After the second procedure on the leg, Vicki was astonished. She states, “And I loved the fact that I could move it and I could walk. But I still was kind of debilitated a little bit because my left leg was really hurting still… So I looked at him and I said, ‘now can we do my left leg?’”

After the procedure on her left leg, Vicki was pain-free and walking. She listed off all the things she was able to do again: walk, dust, go out with her kids and grandkids. She recounts, “that really had me depressed for a very long time. And boy, not now. It’s like everything is just opened up to me.”

Vicki is thankful that she saw a new podiatrist who wanted to pursue other options before amputation. Dr. Pratt always supports this move. He says, “I believe that when patients are told they need to have an amputation, they should undoubtedly seek a second opinion. An amputation is final, and once it occurs there is no turning back.”

In a field where each doctor and each clinic vary in terms of training, experience, skill, technology, and resources, relying on a single doctor is akin to taking a gamble. Because she sought a second opinion, Vicki avoided an amputation with the potential to lead to more major amputations. She adds, “It’s been a miracle. It’s been a godsend. I can’t thank Dr. Pratt enough.”

To learn more about the non-invasive vascular solutions that Modern Vascular offers or to find answers to your PAD-related problems, you can call (888) 853-1278 or use the online form at ModernVascular.com to request a consultation with a Modern Vascular Patient Advocate.

5 Symptoms That You Should Refer Your Patient to a PAD Specialist

The technological advances in Peripheral Artery Disease treatment that save limbs and lives every day are truly a culmination of science and art where highly trained vascular specialists apply knowledge, a caring heart, and skillful hands. Unfortunately, PAD is still very much so a silent killer making Modern Vascular’s endeavors to drive awareness, education, and tailored treatment options that much more important. Early detection is integral for intervention and amputation prevention.

How to know when to refer?

As clinicians, the focus is on our responsibility to heal our patients, through observation, analysis, and care plans. Knowing when it is time to refer a patient to other providers who specialize in PAD treatment can be a judgment call. Many patients have high-risk factors but there are no showing symptoms. Risk factors include diabetes, hypertension, age, and early detection is vital for treatment. It is customary for patients with diabetes to get their feet checked every time they see their doctor, but more patients should be checked for discoloration on the foot, and also take a pulse of the foot. By carefully examining the foot, PCPs, Podiatrists, Endocrinologists and others can more definitely know which patients would benefit from consulting with a PAD specialist.

Here are 5 Symptoms that should be referred immediately:

PAD with Neuropathic Pain

Neuropathy, otherwise known as peripheral neuropathy, is a result of damage to the peripheral nerves located outside of the brain and spinal cord. This damage causes weakness, numbness and pain, usually in the hands and feet, also affecting other areas and body functions including digestion, urination and circulation.

Both Neuropathy and PAD affect the lower extremities, which sometimes results in mistaking one for the other. They can both be present at the time there are a few outlying symptoms that set them apart; they include¹:

Cramps in the thigh, calf, ankle, buttocks, or foot

Difficulty climbing stairs
Fatigue in the legs or achiness
Slow or non-healing wounds on the leg, angle, or foot
Temperature of one leg is cooler than the other
Leg hair loss or poor toenail growth
Numbness or weakness in the legs
Pain that stops at rest
Paleness or blueness in one or both legs

Neuropathy can occur when there are vascular disorders, in other words, when blood flow to the arms and legs is decreased or slowed by inflammation, blood clots, or other blood vessel disorders. Decreased blood flow deprives the nerve cells of oxygen, causing nerve damage or nerve cell death. Vascular problems can be caused by vasculitis, smoking and diabetes.

PAD with Claudication

Claudication is pain in the thigh, calf, or buttocks that happens when you walk may be a symptom of peripheral artery disease (PAD).²

At first, claudication pain occurs when you walk a certain distance and goes away when you rest. But as PAD gets worse, the pain can occur when you walk shorter distances. Over time, you may no longer be able to walk because the pain is so severe.

Claudication is linked to health conditions that also increase your risk for heart attack or stroke, PAD with claudication should be checked for and then treated for by a vascular specialist who can address the artery disease in other parts of the body.

PAD with Rest Pain

More serious than Claudication is a symptom of PAD known as rest pain. When the arterial blockages are so severe that muscles aren’t getting enough oxygen while at rest. Foot pain is the most common signal. At first, it’s most troublesome when the leg is elevated, particularly in bed at night.

The earliest and most common symptom is called intermittent claudication followed by Rest Pain. Patients usually experience it as a cramp-like muscular discomfort, but PAD can also produce numbness, tingling, weakness, or fatigue.³

People with mild blockages can walk substantial distances before the symptoms set in, but patients with severe PAD may experience distress in just a few yards. Whether mild or severe it is recommended to refer to a vascular specialist to for a guided walking program or a endovascular intervention.

PAD with Gangrene

Gangrene happens when blood supply to certain tissues is stopped. This can happen due to⁴:

Infection
Injury (burns, infected dog bite, or combat wound)
Frostbite

Diabetes, PAD, or other chronic diseases that harm the circulatory system such as Raynaud disease, can lead to gangrene if they are severe and not under control.

If the patient’s gangrene is caused by poor blood flow, it may time to recommend your patient for vascular surgery to improve circulation. For instance, when gangrene is a result of a blocked artery, the patient may have bypass surgery or an angioplasty to address the condition.

Wounds that Won’t Heal

Chronic or nonhealing wounds and ulcers are caused by blockages in the arteries (arterial ulcers) and the result of a loss of sensation, often seen in patients with diabetes (neuropathic foot ulcers). Patients with underlying PAD and chronic wounds are at a higher rate of amputation. Referring to a PAD Specialist will help prevent serious complications in the early stages, helping to identify and treat both the PAD as well as other factors which may be impacting wound healing. Patients with underlying PAD are at increased risk of developing non-healing wounds and ulcers and have a higher rate of amputation. Therefore, it is important for people that have PAD to seek out wound care. Here are some common wounds that occur in patients with Peripheral Artery Disease.

Modern Vascular is not only diligent in early detection and treatment of PAD, but focused on amputation prevention. Consider referring your patients to us for minimally invasive vascular solutions.

We return your patients ready to heal.

To learn more about Modern Vascular to answer your PAD-related problems, or to find a clinic near you to refer to a refer a patient you can call (888) 853-1278 or use the online form at modernvascular.com/referring-doctors to request a consultation with a Patient Advocate.

Sources:

Is it peripheral neuropathy or pad? Is it Peripheral Neuropathy or PAD?: Vein and Vascular Solutions NYC: Board Certified Vascular and Interventional Radiologists. (n.d.). Retrieved April 19, 2022, from https://www.vascularsolutionsnyc.com/blog/is-it-peripheral-neuropathy-or-pad

Mayo Foundation for Medical Education and Research. (2022, March 2). Claudication. Mayo Clinic. Retrieved March 24, 2022, from https://www.mayoclinic.org/diseases-conditions/claudication/symptoms-causes/syc-20370952

Rest pain. Coastal Vascular Center. (2022, January 31). Retrieved March 24, 2022, from https://coastalvascular.net/peripheral-arterial-disease-pad/rest-pain/

Gangrene is a symptom of pad – stand against amputation. Take a Stand Against Amputation. (2021, December 30). Retrieved April 19, 2022, from https://standagainstamputation.com/symptoms-of-pad/gangrene/

Pad awareness month: Take off your socks at your next doctor’s appointment! PAD Awareness Month: Take Off Your Socks at Your Next Doctor’s Appointment! | Iredell Health System – Statesville, NC. (2021, September 27). Retrieved March 24, 2022, from https://www.iredellhealth.org/news/releases/pad-awareness-month-take-off-your-socks-at-your-next-doctor-s-appointment/

Treatment strategies for patients with peripheral artery disease (PAD). Treatment Strategies for Patients With Peripheral Artery Disease (PAD) | Effective Health Care (EHC) Program. (n.d.). Retrieved April 15, 2022, from https://effectivehealthcare.ahrq.gov/products/peripheral-artery-disease-treatment/research-protocol

What Do Vascular Surgeons Do?

Vascular surgeons are highly-trained medical professionals who manage the blood vessels throughout the body, except for the brain and heart. They treat different conditions that affect the circulatory system and determine the best course of treatment for the patient. It is their job to make sure that the vascular systems of their patients are healthy. Vascular surgeons are also experts in human physiology, particularly in the cardiovascular system, and can perform intricate procedures to improve vascular health.

Why would you need to see a vascular surgeon?

The most likely scenario for a patient to see a vascular surgeon is by referral from their primary care physician. However, it is also common for a specialist to refer a patient to a vascular surgeon. If your physician notices an issue with the health of your blood vessels they may send you for an evaluation. For example, a podiatrist may notice ulcers on the feet of a patient that is not properly healing, which can be a sign of peripheral artery disease. They can refer that patient to a vascular surgeon to be evaluated for peripheral artery disease to determine if the patient has it and how severe it is.

If you are referred to a vascular surgeon it isn’t a guarantee that you will undergo surgery. Their clinics have diagnostic tools and trained staff to look for blockages in the blood vessels. Some of the tools and techniques used to diagnose vascular disease are X-rays, ultrasounds, tomography, and angiography. You may be considered for a procedure if the provider decides that it’s the best treatment for the state of your condition.

What are some of the conditions that vascular surgeons deal with?

Different conditions affect the circulatory system. A vascular surgeon has the necessary tools, knowledge, and skills to deal with the conditions. They include;

Varicose veins – They are twisted and enlarged veins that may cause pain to your legs.
Peripheral artery disease – It is the narrowing of arteries in the legs due to fatty plaque build.
Spider veins – It is a variation of the varicose veins where you may have webs of veins under your skin.
Aneurysm – It is a bulge in your blood vessel. The swelling appears on the blood vessel’s weak spots, for example, where it branches.
Carotid artery disease – It happens when fatty deposits restrict blood flow to your brain.
Injury – induced blood vessel damage
Deep-vein thrombosis – It happens when a blood clot is formed in a deep vein. Usually, such clots develop in the thigh, pelvis, arm, or lower leg.

Doctor Checking Varicose Veins — Vascular surgeon evaluated a patient with varicose veins.

The vascular surgeons at Modern Vascular are experts in the diagnosis and treatment of peripheral artery disease. Some also provide treatments for varicose veins, depending on the managing physician of the clinic. Visit our clinics page to learn about which services are available at the Modern Vascular clinic closest to you.

How do vascular surgeons treat patients?

Vascular surgeons do not prefer a specific type of procedure and will choose the best option for the patient. They are able to perform open surgery if necessary. At Modern Vascular, vascular surgeons prefer minimally-invasive procedures. Minimally-invasive procedures are less intrusive procedures that can have faster recovery times and fewer complications than open surgery.

Some of the minimally-invasive procedures a vascular surgeon may perform are:

Angiogram – The physician injects a dye into the arteries and uses an X-ray machine to study the flow of blood. They are able to establish whether there are any abnormalities in your circulatory system without making an incision.
Angioplasty – The vascular surgeon can unblock restricted arteries using a catheter. The surgeon guides the catheter through a blood vessel towards the blocked artery. After the catheter is placed a balloon can be inflated in order to expand the blood vessel and push the buildup against the artery walls.
Venoplasty – It is a procedure similar to angioplasty. However, this procedure is used on patients that have a blockage in their veins.

Other treatment options that don’t involve a procedure are prescribing medications or lifestyle changes, such as a structured walking plan. Surgery is only considered if these are not viable options for treating a patient.

What kind of training do vascular surgeons need?

In order to become a vascular surgeon, an individual needs to meet educational and training requirements. There are additional skills that can come in handy for those who wish to become a vascular surgeon, such as good communication skills, being well-coordinated, having composure under pressure, being a leader, and having empathy.

Education requirements

Vascular surgeons must first receive a bachelor’s degree, which is a required qualification to attend medical school. In medical school, there is learning in a classroom setting and also clinical education. The first two years of med school are pre-clinical and focused on learning in a classroom setting. The last two years are similar to an internship, because the student becomes part of a care team, providing support to residents and attending physicians to care for the patients.

Training

After completing medical school the student will complete an internship under the supervision of experienced surgeons. The experienced surgeons train them and help develop their skills.

After the one-year internship, the surgeon must complete a five- to seven-year residency program. Before the surgeon is considered fully qualified, the surgeon has to complete a fellowship program that takes about two to three years. The fellowship program trains the surgeon to specialize in cardiothoracic, cardiovascular thoracic, or cardiovascular surgery.

What can you expect if you see a vascular surgeon?

The vascular surgeon is mainly interested in your medical and family history on your first visit. Therefore, carry all your recent blood work, diagnostic tests, and magnetic resonance imaging (MRI) results. You may need to change into a gown, so wear comfortable clothing.

The surgeon then performs various tests to try and diagnose your problem. After the diagnosis, the surgeon comes up with an appropriate treatment plan. Depending on your condition, the treatment plan varies.

It may include lifestyle changes, more tests, medication, or even surgery. Sometimes the treatment may take a long time. You may have to see your surgeon for years before you heal. Therefore, you must choose the right surgeon for your circulatory system treatment.

Vascular Surgeon Video Interview — Dr. Wande Pratt Discussing Vascular Surgeon Training at PAD Conference

Choosing a vascular surgeon

Considering that a vascular surgeon deals with a sensitive part of the body, you need to emphasize your selection process. There are several factors you can consider;

Board certification – The surgeon you choose needs to meet all the training requirements of a vascular surgeon. A good surgeon needs to be certified by a notable organization, for example, the American Board of Surgery.
Experience – Surgeons need to be well versed with what they are treating. The more experienced the surgeon is, the better the care the surgeon can offer.
References – Ask your primary caregiver to refer you to an excellent vascular surgeon. Also, you can get suggestions from friends and family.
Communication skills – It would be best to have a surgeon who can communicate articulately and makes you comfortable. Also, look for one who has excellent and welcoming staff.

Bottom Line

Vascular surgeons are responsible for their patients’ vascular health. You will usually only see a vascular surgeon if you are referred by your primary care physician or a specialist. These medical professionals have years of training and education and have an extensive understanding of the cardiovascular system. They are able to perform open surgery but will opt for minimally-invasive methods whenever possible because of the advantages for the patient.

Can You Reverse Peripheral Artery Disease Naturally?

How to Slow the Progression of PAD Symptoms

Living with Peripheral Artery Disease (PAD) can be challenging, as this condition develops when plaque, made up of fats and other substances in your bloodstream build up in your arteries, making it harder for your arms, legs, head, and organs to get enough blood.¹ If blood can’t get to these areas, tissue damage and eventually tissue death can occur. Left untreated, there is a chance of stroke, heart attack, kidney disease, amputation, and can be life-threatening.

Many people ask our doctors how they can reverse PAD naturally. There isn’t a cure, but you can manage, and possibly even reverse, the symptoms. It is preferred to manage PAD with lifestyle modifications, but there are also minimally-invasive endovascular procedures available if it cannot be managed by those changes.

What Lifestyle Changes Can You Make to Treat PAD?

There is no cure for PAD, but you can manage your PAD symptoms and stop the progression of the disease through the following lifestyle changes:

Exercise

A key component to PAD symptom reversal is exercise. Studies show that patients who engage in regular physical activity may lead to fewer and less severe symptoms.¹ The distance a patient can walk without pain is often the indicator of a successful PAD treatment. Routine workouts can also aid in improving your mood, self-esteem, energy, and sleep. Exercise can also reduce your risk of other cardiovascular diseases such as heart disease, stroke, or heart attack.

Don’t know where to start? Well, walking is an excellent option. Your doctor might recommend supervised exercise therapy or a walking program to help manage your PAD. Regardless of the exercise regimen chosen, consistency is the key. The goal is to get some kind of activity as often as you can.

Note: Before making any lifestyle changes to help with your symptoms it is important to discuss with your Primary Care Physician (PCP) or Vascular Specialist.

Quit Smoking

Tobacco use and smoking constricts and damage your arteries and is a significant risk factor for PAD. Smoking cessation reduces the risk of your symptoms developing further and lowers your odds of Cardiovascular Disease (CVD).

Studies show that people who keep smoking after their diagnosis have a higher risk of death from complications of heart disease than those who quit after their diagnosis.²

If you’re having trouble quitting on your own, ask your doctor about smoking cessation programs that might include the following, behavior modification programs, nicotine replacement therapy, and stop-smoking support group.

Healthy Diet & Weight

In living with PAD, a heart-healthy diet can help you control your blood pressure, cholesterol levels, and diabetes, which may lower your risk Many people with PAD also have underlying health issues that benefit from healthy ways of eating. In general, it is important to eat a diet low in sugar and avoid processed food, focusing on meals that highlight vegetables, fruits, and whole grains. Include low-fat dairy products, fish, poultry, legumes, nuts, seeds, and non-tropical vegetable oils like olive oil. Reduce salt, added sugars, and red meat. It is also important to maintain a healthy weight.

Avoid Certain Over-the-Counter Medications

Some over-the-counter cold medicines that contain pseudoephedrine including Advil Cold & Sinus, Aleve-D Sinus & Cold, and others, constrict your blood vessels and could make symptoms worse.¹

Stop or Reduce Alcohol Intake

Long-term, heavy drinking can lead to alcoholic cardiomyopathy³, a condition where consuming too much alcohol damages your heart. Ultimately, it can cause your heart to enlarge irreversibly. This weakens the heart muscle, keeping it from pumping as well as it should, which may increase your risk of worsening your PAD symptoms. Limiting alcohol intake may be able to keep it from getting worse.

Take Care of Your Feet

Careful foot care is especially important for people with PAD as they may also have diabetes, wounds, and/or injuries on the lower legs and feet that don’t heal. If wounds are not healing properly, it is due to poor blood flow, which puts you at a higher risk for infection. Taking care of your feet in the following manner will also improve your

Quick tips for Foot Care:

Wash feet daily and dry thoroughly.
Moisturize feet often.
Wear thick, dry socks.
Make sure shoes fit properly.
Treat any fungal infections immediately.
Be careful while cutting nails.
Look over your feet every day to see if you have any injuries.
Have a foot doctor treat bunions, corns, or calluses.
If you have a foot injury, see your doctor right away.

Final Thoughts

When you have PAD, your doctor will want to control your symptoms and stop further buildup of plaque in your arteries. Sometimes, lifestyle changes are enough to meet these goals. If not, your doctor might suggest medication or a procedure.

Sources:

Benisek, A. (n.d.). Can I reverse peripheral artery disease (pad)? WebMD. Retrieved March 8, 2022, from https://www.webmd.com/heart-disease/reverse-peripheral-artery-disease.
Mayo Foundation for Medical Education and Research. (2021, January 14). Peripheral artery disease (PAD). Mayo Clinic. Retrieved March 16, 2022, from https://www.mayoclinic.org/diseases-conditions/peripheral-artery-disease/diagnosis-treatment/drc-20350563.
Alcoholic cardiomyopathy: Causes, symptoms and treatment. Cleveland Clinic. (n.d.). Retrieved March 16, 2022, from https://my.clevelandclinic.org/health/diseases/21994-alcoholic-cardiomyopathy.
WebMD. (n.d.). Tips for living with peripheral artery disease of the legs (PAD). WebMD. Retrieved March 16, 2022, from https://www.webmd.com/heart-disease/tips-living-with-peripheral-artery-disease.

6 Things PAD Patients Should Consider Before Starting an Exercise Routine

Regular exercise improves heart function and is beneficial in preventing the progression of Peripheral Artery Disease (PAD). Here are some important considerations for getting started with a PAD exercise routine:

1. Exercise is Only Part of The Equation

One of the most important things that you can do to manage your PAD is to reduce or quit smoking. For lifetime smokers, the thought of quitting can be intimidating. A great way to start is through a smoking reduction program. Gradually decreasing the number of cigarettes you smoke each day can be one way that might help you get and stay on track.

Maintaining a healthy diet is also important when living with PAD and can address health conditions and risk factors that contribute to PAD, such as high blood pressure, high cholesterol, obesity, or diabetes. In general, it is important to eat a diet low in sugar and avoid processed food. A healthy diet also takes into consideration your other underlying health conditions such as diabetes or kidney issues.

2. Consider A Supervised Program

By partnering with a medical professional, you will ensure that your health program is customized to your current health and medical conditions. Your medical practitioner can work with you to develop a diet and exercise program that works for your current health and risk factors. Open, clear, and honest communication between you and your medical practitioner will ensure the best possible outcome.

3. Start Gradually

The ideal PAD exercise routine is designed to gradually increase the amount you are able to exercise without stopping. Starting slowly with only 5 – 10 minute short walks twice a day will make sure you are calibrated to your current health level. After a few days, ramping up to 15 – 20 minute walks should feel pretty good. It is important that you do not burn yourself out at the start of your routine so that you stay motivated and make progress.

4. Track Your Progress

If you keep track of everything you have done, when you look back at it you can get a good idea of the progress that you have made. Keep a notebook of your progress and celebrate your improvement with small but healthy rewards. If you miss a day, don’t worry about it, you can always start fresh the next day. It is important to realize that exercise is not about perfection – it is about progress. There are also apps available for tracking exercise and journaling if you would prefer that over a pen and paper.

5. Listen To Your Body

Always rest when necessary. PAD exercise routines are not designed to stress your body but to build up its strength. Mild discomfort while walking is normal but if you find you are unable to complete your routine due to weakness or discomfort, it is time to check in with a medical professional. If you start to experience chest pain, stop walking immediately and call 911.

6. Have Fun With It

You will be much more successful if you find a way to enjoy your new routine. Consider finding a walking buddy – a regular routine with another person can help you stay on track and make your exercise routine more enjoyable. Listening to music is another great way to make your exercise plan more fun and relaxing.

If you are a PAD patient and would like to start a medically supervised PAD exercise program to manage your symptoms, please call us at (833) 4PADHELP, and one of our patient advocates can set you up for a consultation at one of our 16 Modern Vascular locations.

PAD Patients: Exercise Routine Considerations

5 Tips for Improved Circulation

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Wear Red Socks for PAD Awareness

The third Saturday in February (February 19, 2022) is designated as annual “Red Sock Day” recognizing Peripheral Artery Disease (PAD).

For everyone who has PAD, knows someone with PAD, or treats patients with PAD, this is big news. TheWaytoMyHeart.org, a national non-profit Peripheral Artery Disease (PAD) patient advocacy group out of California, announced that February 19, 2022, will be the first annual national “Red Sock Day” building awareness for Peripheral Artery Disease (PAD), its patients, and treatment.

Kym McNicholas, who heads TheWaytoMyHeart.org explains the importance of the day’s designation. “We are using this day as a way to build awareness of PAD and encourage patients to take their socks off when they visit the doctor. Just taking two fingers and two seconds to check the foot pulses of a patient over 50 can make a huge difference in the early diagnosis and treatment of PAD and related life-threatening diseases.”

Modern Vascular will be recognizing the day in a big way with over 300 employees wearing red socks in the clinic the Thursday before and creating a social media presence celebrating the day on the 19^th. Yury Gampel, CEO of Modern Vascular explains his passion for the project, “The secret is in the collaboration. On Red Sock Day every PAD treatment facility puts aside its own practice and focuses on awareness, diagnosis, and access to care for patients. Modern Vascular’s mission is to eliminate unnecessary amputations due to PAD, so definitely wanted to take a leading role in this initiative.”

On February 19, we are encouraging everyone to pull out their red socks in solidarity. Any red sock can be a show of support. Thewaytomyheart.org is asking folks to post photos online with the hashtag #nationalredsockday. For more details, visit the official National Red Sock Day webpage.

Treatment Options for Peripheral Artery Disease

Peripheral Artery Disease (PAD) is not curable, but is treatable, and often without major surgery. The best method of treatment depends on the patient and the severity of the disease. The following treatment options are the most common options for patients that are suffering from PAD.

Lifestyle Modifications

The lifestyle modifications are typically prescribed to all patients with Peripheral Artery Disease. In some cases, making these modifications are all a patient needs to see improvements to their condition. However, some patients may still require a procedure. After a procedure, the patient should also adjust their lifestyle to prevent a recurrence.

All patients with PAD are advised to:

Maintain a healthy, low-sodium diet
Take aspirin, as directed by your physician
Consistently take blood pressure, diabetes, or cholesterol medication(s) as prescribed
Stop smoking
Begin a structured walking program, if possible

Angiogram & Endovascular Intervention

If your symptoms cannot be managed with these lifestyle changes alone, the next step is to get an angiogram with endovascular interventions. An angiogram is performed by inserting a thin tube, called a catheter, into an artery in your leg. A contrast dye is then added through the catheter to take x-rays of the blood vessels. Then, the doctor will be able to see where the blood is flowing perfectly and where there are blockages disrupting the flow of blood.

What can vary during an angiogram is which minimally-invasive approach the doctor uses to treat blockages. Your provider will make this decision based on the location, size, and the number of blockages found while performing the angiogram. The types of treatments your doctor may perform during an angiogram are the following:

Atherectomy: Physician “debulks” or removes plaque from artery walls
Angioplasty: A tiny balloon is inflated in the blocked area, flattening the plaque, making space for blood to flow through again, and then the balloon is removed.
Stent placement: A small, expandable, mesh-like tube is expanded in the artery, where it remains to keep it open.

These minimally-invasive treatment options have been shown to be safer, yet equally as effective as the next, more invasive option, which is open surgery. ¹

Peripheral Artery Bypass

Occasionally, the minimally-invasive endovascular options described above must be repeated to keep the artery open for strong circulation. If for any reason these options are not providing long-lasting relief, an open surgery called “peripheral bypass surgery” may be performed. In this procedure, the surgeon will use either a man-made graft to act as a new blood vessel or take a healthy vein from your body to use.

Whereas the options above clear out existing arteries for blood to flow through, in this option, the new blood vessel is attached to direct blood around the blockage. The blocked artery stays in your body, but no longer helps with circulating blood.

Which Treatment Option is Best?

It’s best to leave that decision to the experts. Speak with your doctor to discuss your options. It is most beneficial to get peripheral artery disease diagnosed early to increase the likelihood that the treatment is less invasive. If the less invasive treatment options do not provide relief it may be beneficial to ask your doctor to refer you to a vascular specialist. Specialists have a deep understanding of specific conditions and have helped many people suffering from the same condition.

5 Tips for Improved Circulation

The circulatory system is the transportation highway of the body. Blood vessels carry and deliver oxygen, nutrients, and healing cells to all parts of the body. Poor circulation can result in poor wound healing, heart disease, stroke, and a myriad of other conditions. Symptoms of poor circulation may include muscle pain, swelling, and fatigue. Fortunately, there are many simple and manageable steps one can take to improve circulation.

Exercise Regularly

Regular exercise is a sustainable way to improve circulation. Exercise increases the heart’s pumping rate, which increases the flow and pressure of blood throughout the body. The controlled increased pressure of blood helps stretch blood vessels, making them more flexible with time. This stress is essentially like stretching for blood vessels because it helps retain flexibility. To start an exercise routine, it is recommended that one start slowly and build steadily to avoid overstressing the heart. Simple stretching, walking, and yoga and great exercises for beginners.

Drink More Water

Drinking adequate water is another simple way to improve vascular health. Because blood is composed of 50% water, maintaining healthy hydration, in turn, maintains healthy blood viscosity and pressure. Water aids in digestion by increasing bowel regularity and flushing bacteria and waste from the bladder. This positive effect on digestion allows the body to break down nutrients effectively and also allows the circulatory system to efficiently deliver those nutrients throughout the body.

Eat a Healthy Diet

Small changes to diet can make a big difference for the circulatory system. Limit saturated fats in the diet and include more omega-3 fatty acids. Replacing red meat with fish can improve heart health. Some foods have a direct effect on the blood vessels. Capsaicin is a chemical that makes food spicy and stimulates the release of vasodilators, which are chemicals that can help expand the blood vessels. Cayenne pepper has been shown to increase circulation and reduce the amount of plaque that gets stuck on the artery walls. Other vasodilators, such as leafy green vegetables and turmeric, release nitric oxide to elicit their effect. Antioxidants, such as anthocyanin found in berries, prevent arteriosclerosis, or hardening of the vessel walls.

Reduce Stress

Taking steps to manage your stress can improve circulation and reduce the potential for vascular disease. Chronic anxiety can cause hyperventilation which can increase the amount of carbon dioxide in the bloodstream. Increased carbon dioxide levels lead to vasoconstriction, increasing damaging blood pressure while decreasing blood flow efficiency. To reduce stress, prioritize restorative sleep. Sleep improves concentration, regulates mood, improves decision-making abilities, and restores the body.

Identify triggers and work to eliminate them. Plan things ahead more often to eliminate surprises that can cause stress. Exercise, meditation, and massage can all increase stress-relieving hormones. Finally, a trained psychologist is the best resource for providing mental health care, including managing stress.

Quit Smoking

One more important step to take for circulatory health is smoking cessation. Smoking is known to contribute to hypertension (unhealthy high blood pressure) and cardiovascular disease. The nicotine in cigarettes and smokeless tobacco products cause vasoconstriction. As discussed earlier, this vasoconstriction decreases healthy blood flow throughout the body and increases blood pressure to a point that the internal vessel walls are damaged. Smoking increases carbon monoxide levels in the blood. Carbon monoxide binds the oxygen-carrying molecule, hemoglobin, thereby decreasing oxygen transport throughout the body.

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Final Thoughts

Improving circulation can be sustainable and doesn’t need to be difficult. A decreased risk of heart attack, peripheral artery disease, and hypertension can be as easy as incorporating the above tips into one’s daily routine. Of course, it is important to share your concerns and lifestyle with a physician. Small lifestyle changes can make a big impact on not only vascular health but overall wellbeing.

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What is an Angiogram?

Outpatient facilities like Modern Vascular provide patients with noninvasive treatment options that intervene in the effects of chronic diseases like Peripheral Artery Disease (PAD), that if left untreated may lead to amputation and even death. Early diagnosis and prompt treatment can lower a person’s risk of dying from untreated Peripheral Artery Disease.

In order to address moderate to severe blockages in patients with PAD additional diagnostic tools and interventions are necessary. A diagnostic test that doctors use to identify blocked or narrow blood vessels is called an angiogram, in other words, X-rays of the blood vessels. ¹ These X-rays provide images of the blood vessels in many different organs, and in patients with PAD, the focus is on the lower extremities, the legs, and the feet.

Physicians use angiogram results to diagnose a series of diseases ² including:

Aneurysms
Atherosclerosis
Pulmonary Embolisms/Blood Clots
Vascular Stenosis
Congenital Abnormalities (in the blood vessels or heart)

How are Angiograms performed?

Traditional angiograms are performed by doctors by inserting a long, narrow tube called a catheter into an artery located in the arm, upper thigh, or groin. Then they inject contrast dye into the catheter and take X-rays of the blood vessels. ³

The contrast dye improves the visibility of the blood vessels on X-ray images. A physician requests an angiogram when they need to understand what’s happening inside arteries of the lower extremities.

Contrast materials help distinguish or “contrast” selected areas of the body from surrounding tissue. This helps physicians diagnose the severity of medical conditions like Peripheral Artery Disease, by improving the visibility of specific organs, blood vessels, or tissues.

Not all angiograms involve X-ray machines, however. Doctors can also perform angiograms using CT scans and MRI scans. ³

Analyzing Results

Our physicians use angiograms to analyze the flow of blood in the lower extremities or legs down to the toe. An abnormal angiogram result may indicate that a person has one or more blocked arteries.

In these cases, the doctor may choose to treat the blockage during the angiogram to revascularize the pedal loop.

Intravascular Ultrasound

Intravascular ultrasound (IVUS) uses a transducer or probe to generate sound waves and produce images of blood vessels.⁴ When used to evaluate the arteries, IVUS can show the entire artery wall and provide important information about the amount and type of plaque buildup, which can help measure the degree of blockage. Ultrasound does not use ionizing radiation, has no known harmful effects, and can provide clear pictures of soft tissues that are not well seen on x-ray images.

This is typically used for patients in addition to the angiogram to evaluate the severity of PAD.

Risks

There is a very low risk associated with patients and angiograms in terms of developing major complications afterward. That being said, the more invasive the procedure, for instance utilizing a catheter in the heart, does have some risks.

Other risks can be associated with renal failure and allergies to contrast dyes. If you or a patient you’re advocating for has a sensitivity be sure to share this information with your vascular specialist in order to facilitate accommodations.

Sources:

Vancouver General Hospital Cardiac Cathlab. VGH Cardiac Cathlab Why do I need an angiogram Comments. (n.d.). Retrieved December 21, 2021, from http://cathlab.vch.ca/angiogram/why-do-i-need-an-angiogram/
Eske, J. & Martinez, K. (n.d.) What is an angiogram? Uses, procedure, and results. Medical News Today. Retrieved December 21, 2021
ACR, R. S. N. A. (2021, July 20). Contrast materials. Radiology.org. Retrieved December 23, 2021
Yammine H, Ballast JK, Arko FR. Intravascular ultrasound. In: Sidawy AN, Perler BA, eds. Rutherford’s Vascular Surgery and Endovascular Therapy. 9th ed. Philadelphia, PA: Elsevier; 2019:chap 30. Retrieved December 23, 2021

Revascularization or Amputation?

Technology has opened the door for innovation in medicine that has led to great advances in the treatment of many chronic diseases. Over the last 20 years, patients with Peripheral Artery Disease have benefited from life-saving revascularization treatments that are minimally invasive and focused on limb salvage. These changes although remarkable for those with success stories, don’t come without scrutiny and can result in tension within the vascular community.

The History of PAD Treatment

Historically, treatment for peripheral artery disease is based on risk-factor management or surgical interventions that were only done in a hospital setting.

Risk Factor Management

Roughly 30% of Modern Vascular patients receive a recommendation to move forward with a procedure at their initial consultation. Many more are recommended to control their risk factors through:

A walking program
Exercise
Aspirin Regimen
Healthy diet
Staying away from smoking
Controlling diabetes, high blood pressure, and high cholesterol

Interventions & Amputations

If risk factor management approaches are not successful, other treatment options include revascularization therapies to treat blockages. Revascularization techniques can be minimally-invasive using stents and balloons or can include open surgery such as bypass surgery.

Treatments for Severe PAD Include:

Balloon Angioplasty/Stenting
Bypass Grafting
Cryoplasty
Percutaneous or Laser Atherectomy

Patients with critical limb ischemia have an advanced form of peripheral arterial disease where patients are getting no blood flow in their foot and are in danger of losing a leg to amputation.

Amputation is a procedure used when tissue destruction, infection, or disease affects a body part so severely that it is impossible to repair or puts the person’s life in danger. For instance, in PAD patients, a foot or leg may be removed by surgical amputation if blood flow cannot be returned to the foot or leg.

Unfortunately, amputation can impact a patient’s life expectancy. According to a study in Vascular Health and Risk Management, the rate of death after major lower extremity amputation in the US is approximately 48% at year 1, and 71% at year 3.⁴

This is why it is so important to catch PAD early so that a doctor can intervene before the disease cuts off blood flow to a body part for an extended period of time, leaving the patient with limited options.

About 54% of all surgical amputations result from complications of vascular diseases and other conditions that affect blood flow, such as diabetes and PAD.²

Chronic vascular problems can lead to tissue death in the toes, feet, and legs. Of patients undergoing amputation for complications of these diseases, nearly half will die within five years of the amputation procedure.

Innovation & Tension in the Vascular Community

Over the last decade, there have been great advancements in the treatment or therapy used for Peripheral Artery Disease. PAD affects 8 to 10 million Americans, primarily those with diabetes, over the age of 65, and ethnic groups including Black, Latinx, and Indigenous communities. With technology, we have been able to detect PAD much earlier and treat it without the need for amputation or other invasive procedures.

The innovations have not come without a cost, as there is a bit of tension within the vascular community on the legitimacy and necessity of certain approaches.

With regard to the evolution of medical innovation, not everyone has been this forward-thinking. While some in the vascular community hesitate to deviate from the traditional methods, tension is increased further as many vascular surgeons who are not embracing endovascular treatment are losing patients to those who are. These revascularization procedures can be done more safely and earlier in the disease progression, in outpatient facilities like Modern Vascular with multiple clinics throughout the country.

Patient advocacy has played a huge part in emphasizing the importance of treatment options for patients because the patient’s best interest should ultimately be the focus of care. Patient advocate and Founder of The Way to My Heart, Kym McNicholas shares, “When it comes to treating patients with peripheral artery disease, every single vascular physician needs to respect the fact that different doctors have different tools, techniques, and approaches… Patients should be made aware of, whether one physician or another offers them so that they can make a well-informed decision on what it will take to give them a better quality of life.”

Sources:

Logar, C. M., Pappas, L. M., Ramkumar, N., & Beddhu, S. (2005, March 21). Surgical revascularization versus amputation for peripheral vascular disease in dialysis patients: A cohort study. BMC nephrology. Retrieved December 2, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1079864/.
Amputation | Society for Vascular Surgery. Retrieved December 8, 2021, from https://vascular.org/patients/vascular-treatments/amputation.
Torbjörnsson E;Ottosson C;Blomgren L;Boström L;Fagerdahl AM; (n.d.). The patient’s experience of amputation due to peripheral arterial disease. Journal of vascular nursing : official publication of the Society for Peripheral Vascular Nursing. Retrieved December 21, 2021, from https://pubmed.ncbi.nlm.nih.gov/28527728/
Swaminathan, A., Vemulapalli, S., Patel, M. R., & Jones, W. S. (2014, July 16). Lower extremity amputation in peripheral artery disease: Improving patient outcomes. Vascular health and risk management. Retrieved December 21, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4107174/
Innovations in pad therapy: Make sure you’re up-to-date on … (n.d.). Retrieved December 21, 2021, from https://journals.lww.com/nursing/Fulltext/2008/03001/Innovations_in_PAD_therapy__Make_sure_you_re.3.aspx

Native American Heritage Month

Written by Kirstin Rizk

November was Native American Heritage Month and we are recognizing and celebrating Modern Vascular’s work with this community in this month’s PAD Answers blog.

Through his work on reservations, Dr. Scott Brannan, Modern Vascular’s Chief of Endovascular Surgery, has learned the value placed on the connection to the earth. The Navajo people have variations of a prayer that begins with “Walk in Beauty,” or “In beauty I walk.” Each line is centered on experiencing the earth’s beauty and most end with “I walk.” As limb salvage experts, Dr. Brannan explains, “We, at Modern Vascular do all that we can to help our patients practice that faith to walk in beauty.”

Dr. Brannan and ultrasound technologist Denisse Martinez go onto reservations regularly to ensure patients have access to much needed health care. This can include late nights after a full day of procedures at their Modern Vascular clinic in Mesa, Arizona, and even weekends, as they travel to the nearby reservations to check in on patients. As many patients have advanced disease, these trips are especially important to prevent amputation and promote overall health. Most difficult to treat are patients that are not referred at all during the course of their disease and find their way to Modern Vascular as a last resort. According to Denisse, “Many Native American patients present to our clinic for a second opinion when they have been signed off to have a major amputation.”

Luckily, some patients are referred by doctors who know a multidisciplinary approach is necessary to save limbs. Denisse recalls one patient referred after having a surgery to remove part of the bone in her heel. The wound had made no progress toward healing after several weeks. After a significant surgery like this, blood flow is vital to the healing process and closing of the surgery site. With advanced PAD, however, arteries of the leg and/or foot are so clogged that blood is barely circulating through the foot. Denisse remembers, “I thought to myself, ‘I can literally see her bone, there is no way we will be able to turn this around and have her back on her feet.’ Well, I was wrong! Dr. Brannan was able to re-canalize the previously occluded and stenotic arteries which provided her with great run-off. Afterward, with good wound care management, this patient healed!” Between Dr. Brannan reestablishing blood flow to the foot and the wound care specialist treating the wound, the patient was able to keep her foot.

Graphic Image

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Graphic Image

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Graphic Image

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To Denisse and Dr. Brannan, this patient’s story reaffirmed many lessons they’ve become familiar with. First, this patient highlighted the need for preventative care and early intervention in communities that typically don’t receive treatment for PAD until it is too late to save the limb. Second, it showed the importance of coordinating care, as this patient’s level of disease required each of her specialists’ commitment to save her foot. Finally, it revitalized their commitment to spread awareness of the importance of trying all options to save the limb before amputation. Even at extremely advanced stages of disease where amputation seems inevitable, other options should be given a chance first.

The extended version of this story is available in the case study.

What to Expect at a PAD Evaluation

Patients who are referred to Modern Vascular often wonder exactly what will happen at their consultation. Although every patient is different, we will discuss what you can expect to happen in a standard Modern Vascular evaluation and consultation for Peripheral Artery Disease.

Referrals

Patients with PAD are referred to Modern Vascular in one of few different ways: Primary Care Physician, Podiatrist, Vein Specialists and Endocrinologists (to name a few), or self-referrals. In terms of self-referrals, patients will have a conversation with our Patient Advocates after taking our PAD Assessment, which incorporates recognized risk factors from the American Heart Association.

Vascular & Doppler Ultrasound

On the day of a PAD Evaluation at Modern Vascular patients fill out new paperwork which will include questions related to a list of medications, current medical conditions, and providers (physicians/specialists) that they currently see.

After the paperwork is filled out an ultrasound will be administered by an ultrasound tech.

A vascular ultrasound uses sound waves to evaluate the body’s circulatory system. Doppler ultrasound is a special ultrasound technique that can help detect areas of restricted blood flow through an artery. Ultimately, these ultrasounds are used as a diagnostic tool to garner a clear picture.

Generally, there is a scan of the hip, entire leg, foot, the tip of the toe, slowed blockages, which help identify blockages or narrowing in the arteries, decreased circulation, and disease.

After the ultrasound is complete you will meet the Advanced Practice Provider (Nurse Practitioner or Physician Assistant). They will go over your complete medical history and ultrasound results and do a comprehensive physical exam. Depending upon the findings, you will learn about the appropriate treatment.

Treatment Options

Treatment is unique for every patient and is dependent upon the severity of the blockage. Blockage can be categorized between minor, moderate, or severe. The provider will decipher the appropriate approach for the type of blockage.

Minor Blockage

Not every patient requires a procedure-based intervention. If a patient is found to have minor blockages, their treatment could involve a conservative approach involving changes to diet, temporary medication, and incorporating a Walking Program.

Moderate to Severe Blockage

Patients who have signs of moderate or severe blockage may require additional diagnostic tools and procedures to intervene.

To better visualize the patient’s condition an angiogram or arteriogram is used. An angiogram is an imaging test that uses x-rays and a special dye to see inside the peripheral arteries. This minimally invasive procedure is done in our Modern Vascular clinics in the procedure rooms.

Living with PAD

Peripheral Artery Disease is a chronic disease so early detection is vital and staying on top of it is integral in saving limbs and lives.

How to know when to refer?

Here are 5 Symptoms that should be referred immediately:

PAD with Neuropathic Pain

PAD with Claudication

PAD with Rest Pain

PAD with Gangrene

Wounds that Won’t Heal

Why would you need to see a vascular surgeon?

What are some of the conditions that vascular surgeons deal with?

How do vascular surgeons treat patients?

What kind of training do vascular surgeons need?

Education requirements

Training

What can you expect if you see a vascular surgeon?

Choosing a vascular surgeon

Bottom Line

How to Slow the Progression of PAD Symptoms

What Lifestyle Changes Can You Make to Treat PAD?

Exercise

Quit Smoking

Healthy Diet & Weight

Avoid Certain Over-the-Counter Medications

Stop or Reduce Alcohol Intake

Take Care of Your Feet

Quick tips for Foot Care:

Final Thoughts

1. Exercise is Only Part of The Equation

2. Consider A Supervised Program

3. Start Gradually

4. Track Your Progress

5. Listen To Your Body

6. Have Fun With It

Lifestyle Modifications

Angiogram & Endovascular Intervention

Peripheral Artery Bypass

Which Treatment Option is Best?

Exercise Regularly

Drink More Water

Eat a Healthy Diet

Reduce Stress

Quit Smoking

Final Thoughts

How are Angiograms performed?

Analyzing Results

Intravascular Ultrasound

Risks

The History of PAD Treatment

Risk Factor Management

Interventions & Amputations

Innovation & Tension in the Vascular Community

Referrals

Vascular & Doppler Ultrasound

Treatment Options

Minor Blockage

Moderate to Severe Blockage

Living with PAD

Learn more about Monica’s experience at Modern Vascular of Fort Worth.

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