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Join us on the podcast as we delve into the hidden epidemic affecting Black and brown communities: peripheral artery disease (PAD). Our guest, Anahita Dua, a vascular surgeon, sheds light on the alarming prevalence of PAD and its devastating consequences. From discussing the primary risk factors to exploring the importance of early detection and treatment, we uncover the critical steps needed to address this public health crisis.

Anahita Dua is a vascular surgeon.

She discusses the KevinMD article, “Preventing amputations and saving lives starts with bringing PAD into the 21st century.”

Mentioned in the episode: Get a Pulse on PAD (https://padpulse.org/)

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. Today we welcome Anahita Dua. She’s a vascular surgeon. Today’s KevinMD article is “Preventing amputations and saving lives starts with bringing peripheral artery disease into the 21st century.” Anahita, welcome to the show.

Anahita Dua: Thank you so much for having me.

Kevin Pho: All right. So let’s start by briefly sharing your story and journey.

Anahita Dua: So I’m a vascular surgeon at Mass General Hospital in Boston, and an associate professor of surgery at Harvard Medical School. Prior to that, I decided that my passion for vascular surgery was something that would drive me towards this particular location, because I could do academics and I could do actual things that would save my patients’ legs.

In order to do that, I had to first go to medical school in Scotland, then come and do general surgery residency at the Medical College of Wisconsin, and then went to Stanford for my vascular fellowship. But in the middle of that I did two years of post-doctoral research training specifically in blood thinning and clotting. That is associated, of course, with amputation, and we’ll hopefully talk about that in a little bit. I now live in Newton with my husband, a dog, and a 7-year-old daughter and 4-year-old son.

Kevin Pho: All right, welcome. And I think we were just talking offline, you’re in my backyard here in Nashua, New Hampshire.

Anahita Dua: Yes, I also do 10 days a month up in Southern New Hampshire Medical Center, because patients aren’t willing to drive that huge drive to come into Boston anymore. So I’m happy to come to them.

Kevin Pho: Perfect. So let’s talk about peripheral artery disease. Your KevinMD article is “Preventing amputations and saving lives starts with bringing PAD, peripheral artery disease, into the 21st century.” So for those who didn’t get a chance to read your article, tell us what it’s about.

Anahita Dua: So peripheral artery disease is basically the third of the three musketeers that are killing Americans across the country. And I don’t mean to sound dramatic, but it’s true. Essentially, stroke, heart disease, specifically heart attacks, and PAD, peripheral artery disease, are the three musketeers that are basically vascular disease in three different beds of the body that are causing serious problems.

Now, everybody knows what a stroke is, everybody knows what a heart attack is, and that’s because if that happens to you, you’re dialing 911 and you’re rushing into the hospital. It’s very dramatic. But PAD, shockingly, up to 70 percent of Americans don’t even know what that is.

And what it is, peripheral artery disease, is simply plaque that is being stuck in the vessels of the leg and preventing blood flow from getting to the toes. That may sound fairly innocuous, but actually what ends up happening is, you don’t have enough blood flow to get down to the foot, that ultimately results in amputation, and 50 percent of those patients end up going on to die.

So what the article is really about is bringing this to the forefront, saying that we have an epidemic, especially because patients have diabetes now, and that’s on the rise across the globe. And with diabetes, high blood pressure, and smoking specifically, these common risk factors, PAD really has exploded onto the scene. So it’s really important to know your enemy. You have to know what you’re fighting against in order to be able to do the right things to prevent people from dying of the disease.

Kevin Pho: What are typical symptoms that patients would feel when they have PAD?

Anahita Dua: So PAD is a little bit like saying the word cancer. If you have cancer, you could have brain cancer, you could have pancreatic cancer, you could have skin cancer, and you’d have slightly different symptoms.

Similarly with PAD, there’s really two groups of patients. You have what we call intermittent claudication, which is just Latin for, it hurts when I walk. And quite literally, when they start walking, especially if it’s on an incline or stairs, they’re going to get that burning pain in their calf muscles, and then they’re going to have to stop, and then the pain will go away, and they’ll start walking again. That’s one set of patients.

The second set of patients, much more dire, deadly, are critical limb ischemia patients. And these are patients that have minimal blood flow to the foot. So they end up getting wounds that don’t heal, or they’ll have severe pain in the foot even at rest, just sitting in bed.

And so those typical symptoms in the critical limb ischemia group, non-wound healing and pain at rest, versus pain when you walk which goes away when you sit down and take a break, are the standard symptoms that you see in PAD.

Kevin Pho: So I’m a primary care doctor, as everyone knows. So in the exam room, someone comes to me with symptoms that I may think is PAD or not. Tell me the type of questions I should ask them to really determine whether it’s a vascular cause or not.

Anahita Dua: That’s a fantastic question. So essentially when a patient comes in, the first thing that needs to be asked is whether or not they’re having pain all the time or just sometimes when they’re walking. And then you really want to elicit whether that pain when they’re walking happens all the time or only when they’re in particular positions.

So for example, patients that have back problems will also have pain when they walk. But a classic question to ask is, when you go shopping in the grocery store, if you lean over the grocery cart and it goes away so you can walk for miles, that is a patient that has back issues and not a patient that has leg issues. But if the patient says to you, man, I can go only 25 steps before it just burns and I can’t do anything with my kids, I can’t go out, those are the sorts of questions that should be asked.

Another thing that’s important to ask them is if they have any wounds on the foot. Unfortunately, PAD, as I said before, is not very dramatic. So a patient may get a little wound, maybe their grandchild dropped something on their foot, and they may not really be thinking about it, but it may be festering and festering. And so bringing it up in that 10-minute appointment with their primary care doctor is really important, but they won’t say it unless you say something.

And then, in conjunction with the questions, you always as a primary care doctor will want to say, take off your socks and shoes, just take them off. Let the doctor look at them, because it’s amazing what the foot can really tell you. If it’s really red, swollen, you might say, hey, what is this wound? And they might say, I’ve had that for the last, you know, 2 years. And you say, oh, you’re a diabetic, which you would know, of course, and suddenly you have a story of PAD.

The other big thing is, quite literally, putting those two fingers on the pulse to see whether or not you can feel it. And if you can’t, that’s another classic patient that probably has PAD and needs to be checked out.

Kevin Pho: So if my clinical suspicion is PAD, tell us about some of the diagnostic options that we have in a primary care setting.

Anahita Dua: So the best thing that you can do in a primary care setting is an ankle-brachial index. And that’s essentially where you do a blood pressure of the patient’s arm and a blood pressure of the patient’s ankle. And when you do that, you compare the blood pressure in the arm to the blood pressure in the ankle, and it should be the same.

If it is the same, then the number will be, let’s say you would take 120 from the arm, and it’s 120 in the leg, it’ll be 120 over 120, which would be one, or 100 percent of blood flow getting to the foot. However, if the blood pressure is lower in that ankle by a particular percentage, that’s a patient that may have PAD. Anything less than 90 percent you can categorize as PAD. And when they drop less than 30 percent, so an ABI of 0.3, that’s critical limb ischemia and needs to be seen right away.

Another easy test is to just take a pulse ox and stick it on the toe. If that pulse ox is lower than 100 percent in a patient that’s breathing at 100 percent on their finger, something’s not right, and they need to be seen.

One other thing to mention as a caveat is, in this day and age, a patient may have an OK ABI, like the blood flow to the ankles is all right, but their toe pressure may be zero. Because of diabetes, we’re getting microvascular disease of the foot, which is basically carpet bombing of all of the tiny blood vessels in the foot. And so you could get a patient that could fool you because their ABI is all right, but actually their toe pressure is zero. So sticking that pulse ox on there, real quick and easy thing to do.

And if your practice has a Doppler, that’s always wonderful, to have the nurse just check the Doppler signals, because if there’s signals, that gives you a sense of what type of blood flow is getting down there as well.

Kevin Pho: So we have a diagnosis of PAD. So I know that there are some medical options. So at what point do we consider a medical option versus sending someone to a vascular surgeon like yourself?

Anahita Dua: So if a patient has intermittent claudication, which is the whole, I’m walking and I’m getting pain, there are important lifestyle changes that need to be made in order for them to build what’s called collaterals, essentially new blood vessels that can sprout that can get them through their life without having to have a procedure.

So in that patient’s case, a primary care physician would basically ask the patient to walk at least 30 minutes a day. And the patient will balk at you. They’ll say, 30 minutes? I can’t do that, I can barely walk steps. But you tell them, no, no, it’s 30 minutes in total. What you tell them to do is walk as far as they can uninterrupted, and then once they get to a point where they can’t walk anymore, do another minute. They should have tears in their eyes. That’s what I tell my patients.

And in conjunction with that, ensure that their blood sugar is controlled, hypertension is controlled, they’re on a statin, and they’re on something like an aspirin or a Plavix. That’s what a primary care doctor can do in that type of situation, where there are no wounds and the patient has pain when they’re walking. Smoking cessation also, star, underline, mandatory.

But if the patient is critical limb ischemia, that’s actually an emergency, and they really should be seeing a vascular specialist essentially within a month of you diagnosing them with this. The sooner the better, because they might be a patient that, by the time I get my hands on them, might need an amputation.

Kevin Pho: All right. So let’s say I refer a patient to a vascular surgeon like yourself. Tell me what happens in your exam room, and some of the things that you look for to determine whether surgery is needed versus something that could be managed electively.

Anahita Dua: So the first thing I do as soon as I get that referral is I’ll send the patient to get formal ABIs, the ankle brachial index that I mentioned. All of us have vascular labs that are in our hospitals, and we have techs, in our vascular surgery practices we’ll have techs, that will be able to do these easy non-invasive procedures to tell us what the actual pressure is down to the foot.

After that, I see the patient in my clinic and I do a thorough examination, including a Doppler and of course capillary refill, to see what’s going on in conjunction with those ABIs.

If the patient doesn’t have femoral pulses, then I send them for a CT scan to take a look to see if they’re occluded in kind of the more abdominal segment, because it’s possible that the patient has an occlusion of their aorta or their iliac vessels, and that would need something potentially surgical, whether that is endovascular where I’m using wires and stents and catheters, or an actual cut on the belly and surgery. That’s determined by the patient’s anatomy, how old they are, what type of surgeries they’ve had, and other things that are surgical determinants.

But if the patient has an endovascular option, I personally will usually go for the endovascular option first, so that I can get them a little bit of time, especially if they’ve got critical limb ischemia. But a bypass for these patients is always on the table, and again is another surgical decision based on how sick they are and what they actually need.

The goal of doing any procedure is to get them great blood flow for an extended period of time. If I do a procedure on them, whether surgical or endovascular, and I get a beautiful result that day, who cares? I need 200 days of excellent blood flow to the wound in order for it to heal. So what I really need is something durable, and something that’s going to get them that flow for an extended period of time. So there’s a lot of conversation with the patient, involvement with the patient, to see what they can do, to offer them what surgical options are best.

Kevin Pho: So in general, when someone does a surgical procedure for PAD electively, and they do everything that you say in terms of lifestyle changes, blood pressure control, cholesterol control, stop smoking, what are the general outcomes for patients like these?

Anahita Dua: So it depends very much on what they started with, and when they entered my clinic, at what point in their journey.

If it’s a patient that’s caught early, and that’s why this article is so important, because the screening is so important and catching them early is so important, just like cancer. If you catch them early, then we can provide them with, as you pointed out, all those lifestyle modifications, appropriate therapy, and stop the progression of this disease, in conjunction with some endovascular or open options that get them better flow.

And if the patient adheres appropriately, and they are followed up with surveillance, and they take their antiplatelet medication, they have quite good outcomes. And by good, what I mean is, we can reverse the processes that are going to kill them. Specifically, the drugs and the therapies that go with PAD also reduce stroke rates, also reduce heart attacks. So overall you’re saving the patient’s life and, of course, saving their leg, which is very important.

But if I catch them late in the journey, just like again in cancer, if I caught you but you now have stage five, or stage four cancer, the outcomes are a little bit different.

But what we can do if they come to a proceduralist early is watch them, survey them, and be able to intervene quickly before whatever procedure I did for them clots off. And if I can intervene before the clotting happens, then I can get their leg to sort of putter on for the rest of their lives. And that’s really the goal.

Kevin Pho: One of your goals in writing on KevinMD and coming here, of course, would be to increase the awareness of peripheral artery disease. So tell us some of the efforts that you’re doing to bring awareness to this condition.

Anahita Dua: There are a few things that we’re doing. The first thing I really want to highlight is the PAD Pulse campaign.

So I have said, and if you probably noticed in this, I’ve not used the word vascular surgeon very often, I say vascular specialist. And the reason I say that is because vascular surgeons, interventional cardiologists, and interventional radiologists in the United States take care of these types of patients. And we’re done with the turf wars, because there’s so many patients that are losing their legs. We’re all coming together now to say, let’s do something about this.

And that’s what the PAD Pulse campaign is. The three societies that I just named off have come together to really get the message out there. Because we were sort of talking at a high level, talking about the different procedures, talking about the different technologies, when we should have been saying, hey, do you even know what PAD is? So we were sort of taking it incorrectly initially. Now we’re coming back to the drawing board and teaching our providers and our patients what this disease is, so they can be a part of the process and really understand when they need care. So there is a website that kind of details some of this.

The other thing that I’m doing personally is, last year I was honored to be selected as a Presidential Leadership Scholar by President Bush and President Clinton. They have a group basically that selects 60 people a year that are leaders in America that are doing different things. And I specifically focused down on decreasing amputation rates, and so got that message out. We had a New York Times article that was published that was titled “My patient didn’t have to die this way,” and it’s specifically about this.

And the final thing I’m doing is, I do have an organization called Healthcare for Action, which is a political PAC that specifically focuses on getting health care workers elected to congressional office and the Senate. And the reason we’re doing that is because having doctors in office is the way in which we can get some of these things not only funded, but also the attention that it needs.

And to that effect, there is an act called the ARC Act, which was written by Congressman Payne, who’s from New Jersey, and Bill Pascrell, who’s down in Florida. Bipartisan act that was meant to give primary care doctors Medicare coverage to do PAD screening.

Sadly, and shockingly, Congressman Payne just passed away this last month from complications of PAD. He died of a heart attack, unfortunately, but he was on dialysis, he had multiple amputations, and he had previously had a stroke. So literally the patient, and he was a 65-year-old Black man.

Which speaks to the fact that, as with PAD, it affects everybody, but there’s an absolute disproportionate effect on Black and brown populations. Even a sitting congressman, whose father was a congressman, dies at the age of 65 as a Black man. And there’s something to be said about that in this country, and we need to put a focus on that. So these are the things that we’re doing to really create awareness.

Kevin Pho: And how can people find out more about the PAD Alliance, and what kind of websites do you recommend people going to?

Anahita Dua: So the PADPulse.org website is an excellent one to give you a lot of information about the disease process. If you literally were to Google peripheral artery disease, there’ll be a significant amount of information.

And I urge our people that are listening to go and ask your doctor about it. Doctors want to talk about it. We want to have the conversation with you now in the office, not at 2:00 a.m. in the morning when I’m telling you I’m cutting your leg off. So please come and discuss it, because this is a complex thing, and it’s not as simple as, get on the internet and read, there’s all kinds of different things. So it’s important.

There is a health advocacy group also called Global PAD that’s run by a lady named Kym McNicholas. That is a patient advocacy group, has multiple people involved. That’s another place to look. And then, of course, your local hospital will undoubtedly have a website that specifically talks about peripheral artery disease.

Kevin Pho: We’re talking to Anahita Dua. She is a vascular surgeon. Today’s KevinMD article is “Preventing amputations and saving lives starts with bringing PAD into the 21st century.” We’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Anahita Dua: I urge the audience to really take control of their health. I know that that’s something that people say left and right, but in this particular case, in the state of United States health care, we all know that we have a problem. We know that there is an issue, and the issue is that the medical community is a bit fragmented.

So you as the patient have to take some ownership and ensure that the doctor’s answering your questions, you’re not being rushed out and replaced by the Epic computer that we’re all filling out, and that you really sit and take your time.

We are here to serve you. And so I want to leave with the audience the welcome message. Please come into all of our offices, ask your questions, let us quell your fears, and let us do our job, which is taking care of you.

Kevin Pho: Well, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Anahita Dua: Thank you.