5 minute read
CRUEL IRONY
The Cruel Irony
By Patti Muck
Dr. Kevin Lisman
This is a typical scenario for interventional cardiologist Dr. Kevin Lisman: A 54-year-old male diabetic smoker with high cholesterol, hypertension and a family history of heart disease comes to his offi ce with shortness of breath and diffi culty walking. Physicians diagnose him with triple vessel coronary heart disease.
Bypass surgery eases his symptoms, he begins to eat better and exercise. But within months, he’s back to Lisman complaining of severe calf pain with every step.
“We did an angiogram of his legs and found he had severe vascular disease on both sides in the superfi cial femoral arteries,” Lisman recalls. “We fi xed both legs with stents, he’s lost 50 pounds, stopped smoking and he’s now fi ve years out and hasn’t had any problems.”
Dr. Eric Peden Because he was under a cardiologist’s care, the man got help in time and likely added many years to his life.
Like nearly 70 percent of coronary bypass surgery patients, he suffers from advanced peripheral arterial disease or PAD, which is sometimes referred to interchangeably as peripheral vascular disease or PVD. The American Heart Association distinguishes between the two, describing PVD as a disease of blood vessels outside the heart and brain, and PAD as a form of PVD caused by structural changes in blood vessels.
Physicians don’t always distinguish between the two terms, although the majority of physicians interviewed for this story believe PAD is the more accurate description.
It is a disease intrinsically linked to atherosclerosis, a problem of fatty buildup — plaque — in the arteries throughout the body. Lifestyle changes, medical therapy, surgery and combinations of all three can keep atherosclerosis in remission, even lead to regression of the disease. But it is lifelong and incurable.
“If they need cardiac bypass surgery, it means they have atherosclerosis in their heart,” vascular surgeon Dr. Eric Peden explains. “If they have it in their heart, they almost certainly have it in other areas of the body. One of the most common places for people to get atherosclerosis in changes related to the plaques is in the legs.”
Plaque buildup restricts blood fl ow, causing legs to hurt and cramp when exercising. For patients who thought the bypass surgery fi xed them for good, PAD can seem a cruel irony. They experience claudication, or leg pain, from vascular insuffi ciency. “Now their heart is fi xed, their engine is working better, and they can walk all day from a cardiac standpoint. Then they get claudication,” Lisman says. “They get really frustrated.”
But it’s not something they have to live with. Simple screenings like the ankle brachial index are good indicators for patients at risk. This simple test compares pressure in the ankle to that in the arm. If the ratio is greater than 1, it’s
normal. If it’s less than 1, the patient has increased risk for heart attack and stroke related to atherosclerosis and plaque.
Patients with any of the fi ve risk factors — diabetes, smoking, family history, high blood pressure and cholesterol — should be screened and see a cardiologist. Patients with overwhelming health problems like diabetes or kidney disease requiring dialysis may overlook foot sores or ulcers that signal PAD and may lead to gangrene and limb loss. Peden currently heads a team visiting the 100-plus kidney dialysis centers around Houston to screen 400 dialysis patients for PAD, then report its fi ndings.
“The hope is then we can fully establish a screening program on a larger scale and preserve more limbs and prevent heart attacks and stroke,” Peden says.
At the Methodist DeBakey Heart & Vascular Center, physicians in several specialties join forces to fi nd solutions for individual patients. Medical therapy has become more important than physicians ever imagined. For example, the relatively new drug Pletal often helps with walking problems. The heart center is involved in a number of clinical trials testing new medications, including one that fi ghts claudication by opening up vessels and allowing more blood fl ow. Lifestyle changes, including nutrition education and exercise, always go hand-inhand with medical therapy for PAD.
Another ongoing trial blends Eastern and Western medicine in exploring whether acupuncture can help improve walking and circulation in PAD patients. When medical therapy isn’t enough, physicians look at endovascular treatments such as angioplasty and stenting. Traditional stents frequently fail because scar tissue and new plaque grow through them. A relatively new fabric-covered stent shows potential for holding the artery open longer and providing more durable symptom relief. Peden says another new graft on the market is bonded with a blood thinner to prevent clotting.
Methodist is also among the selected centers enrolling patients with severe arterial disease — those who are not candidates for angioplasty, stents or bypass surgery — in a stem cell therapy trial. Here, surgeons harvest stem cells from the patient’s hip, process them in the operating room and inject them into the leg tissues around blocked vessels. Early results have shown the stimulation of new blood vessels and dramatic improvement of previously unhealed wounds.
When medical therapy, lifestyle improvements and endovascular fi xes aren’t enough for a patient with PAD, minimally invasive bypass surgery is a growing specialty that Methodist’s surgeons teach to other physicians around the world. Methodist’s Dr. Mahesh Ramchandani’s course in minimally invasive coronary surgery is booked months in advance. Another course in minimally invasive aortic and mitral valve surgery is in the planning stages. !
