THE APEX TEAM HAS ACHIEVED…
“My goal is to eradicate unnecessary amputations, especially in low-income communities of New Jersey.”
“I dedicate much of my practice to shedding light on a disease with a worse prognosis and mortality rate than cancer but with 50 times less awareness in the community.”
OUR VASCULAR DISEASE WARRIORS
PVD affects nearly 12 million Americans, and about half of them are undiagnosed. Additionally, an estimated 180,000 of them – disproportionately from minority communities – suffer avoidable amputations every year. By increasing PVD awareness nationally, Apex Heart and Vascular Care Vein Clinic hopes to improve access to PVD screening and treatments, which have been shown to improve quality of life, reduce care costs, and prevent limb loss. No patients should fall through the cracks. We encourage members of the vascular care community to use the tools mentioned above to spread the word about PVD Awareness Month among their colleagues, patients, friends, and communities. Together, we can increase understanding of PVD for all.
DEBUNKING PAD MYTHS IN 2023
Myth #1: PVD has consistent, defined symptoms.
Many people who have PVD exhibit pain in their legs with physical activity, such as cramping in the calves when walking, which gets better at rest. However, peripheral vascular disease symptoms can vary widely—such as changes in the appearance of extremities (color, loss of hair, shiny skin), cold legs and feet, open sores that don’t heal, erectile dysfunction, or no pulse or weak pulse in legs and feet.
Myth #2: PVD is limited to your legs.
While it is true that peripheral vascular disease is more common in the legs, PVD can happen in any blood vessel. Fat deposits also build up in arteries that supply blood to your heart and brain, which causes poor blood circulation to the kidneys, intestines, arms, legs, and feet and can increase your risk for heart conditions.
Myth #3: PVD isn’t life-threatening.
While PVD is treatable, and many people who have it can go on to lead long, healthy, and active lives, it is absolutely a life-threatening condition if ignored, misdiagnosed, or left unchecked. It’s dangerous because any significant blockages that restrict blood flow to your limbs and organs can cause irreparable damage over the long term, including gangrene that leads to amputation. Unfortunately, it is very clear from what the statistics tell us that this disease is claiming the lives of many Americans every year. A disease that is flying completely under the radar of our healthcare system but depleting it of its resources. 60,000 people are losing their lives due to PVD every single year – minorities being the most affected. We must concentrate much of our efforts on reducing these numbers, saving limbs, and saving lives.
Myth #4: PVD is a man’s disease.
This is yet another example of peripheral vascular disease myths that simply aren’t true. In fact, one study showed that women have equal to, if not higher, rates of PVD compared to men despite fewer cardiovascular disease risk factors. In addition, women with peripheral artery disease experience faster functional decline compared to men.
Because women have a longer life expectancy, they will be even more disproportionately affected by PVD as the population ages.
Myth #5: Treatment for PVD is invasive surgery.
In reality, PVD can be successfully treated with simple lifestyle changes and medication when caught early. This includes everything from quitting smoking to maintaining a healthy weight, diet, and exercise. If necessary, your doctor may suggest minimally invasive treatments such as:
– Angioplasty — A balloon system that uses a catheter to open up narrowed or blocked arteries.
– Atherectomy — Advanced laser technology that clears away built-up plaque on large blood vessels.
– Stenting — This involves a small mesh tube to keep closed-off blood vessels open for the long term.
WHAT IS PERIPHERAL VASCULAR DISEASE (PVD)
- Peripheral Vascular Disease (PVD) is a significant but often overlooked medical condition: it affects approximately 20 million Americans. The primary risk factors for PVD include smoking, diabetes, age, and family history, among others.
- Early detection and treatment are crucial for managing PVD effectively and avoidinga severe complications like gangrene and limb amputation. Diagnostics may include physical examinations, imaging tests, and minimally invasive procedures, while treatment options range from lifestyle changes and medications to surgery.
- For those affected by PVD, it’s vital to seek ongoing care from healthcare professionals specializing in vascular issues. This care will include a comprehensive, individualized approach that aims to manage cardiovascular risk factors, improve limb symptoms and functionality, and periodically reassess the patient’s condition for optimal management.
WHAT CAUSES IT >
POOR BLOOD CIRCULATION
(PVD), or PAD is a disease of the leg, arteries, and veins. PVD happens when there is a narrowing of the blood vessels outside of your heart. The cause of PVD is atherosclerosis. This happens when plaque builds up on the walls of the arteries that supply blood to the arms and legs. Plaque is a substance made up of fat and cholesterol. It causes the arteries to narrow or become blocked. This can reduce or stop blood flow, usually to the legs. If severe enough, blocked blood flow can cause tissue death and can sometimes lead to amputation of the foot or leg. The main risk factors for PVD are smoking and diabetes. Other risk factors include older age and diseases like high blood cholesterol, high blood pressure, obesity, sleep apnea, heart disease, stroke, and due to family history. Venous disease can be due to prior pregnancies, blood clots, family history, or jobs with prolonged standing. PVD can increase your risk of heart attack, stroke, and transient ischemic attack.
Doctors diagnose PVD with a physical exam and heart and imaging tests. Treatments include lifestyle changes, medicines, and sometimes surgery. Lifestyle changes include dietary changes, exercise, and efforts to lower high cholesterol levels and high blood pressure. Left untreated, PVD can lead to gangrene and limb amputation.
WHAT IS IT >
HOW DO I KNOW IF MY PATIENT HAS PVD OR SOMETHING ELSE?
For a big portion of those affected by PVD, symptoms will not appear until the issue has significantly progressed and requires more extensive treatments. Patients who smoke, over the age of 50, have diabetes, restlessness, tingling sensations, or numbness should get a screening as soon as possible to reduce the risk and improve blood flow.
DIAGNOSIS AND LONG-TERM FOLLOW-UP FOR PATIENTS WITH PVD
Leg pain does not always indicate PVD, but older patients, especially those who are at risk, should see a physician. A simple, noninvasive ultrasound and leg BP examination can diagnose PVD and determine its severity. Patients with symptoms of PVD should be referred to a vascular surgeon. Vascular specialists can perform necessary treatments, including medication management, minimally invasive endovascular angioplasty, stent procedures, and bypass surgery if indicated. PVD is a lifelong medical condition, and our clinicians will develop a unique, comprehensive care plan for each patient. This follow-up plan includes regular clinical evaluations by one of our health care professionals with experience in treating PVD. Care for PVD will involve risk reduction with medical therapy and lifestyle changes, optimizing patient function with structured exercise, and revascularization when needed. Continued reevaluation is necessary to assess risk factors, limb symptoms, and functional status.
CLEANING BLOCKAGES FROM 20 YEARS IN 20 MINUTES
PREVENTING AMPUTATIONS ONE REVASCULARIZATION AT A TIME.
Revascularization mainly aims to improve claudication symptoms and quality of life rather than focus on limb salvage. It should be an option for PVD patients still facing functional limits despite comprehensive treatment, including medication and structured exercise. The choice between endovascular methods and surgery depends on symptom severity, prior treatment responses, patient goals, and the prospect of long-lasting relief.
TECHNIQUES TO TREAT VASCULAR BLOCKAGES AND CLAUDICATION INCLUDE ANGIOPLASTY, STENTS, AND ATHERECTOMY.
Restless nights and restless legs…
SAY GOODBYE TO TOSSING AND TURNING
Leg pain that disrupts sleep could mean dealing with both Restless Leg Syndrome and Peripheral Arterial Disease. These conditions can overlap, making symptoms more severe and complicating diagnosis and treatment. PAD can trigger or worsen RLS symptoms by causing muscle hypoxia, while RLS can exacerbate PAD symptoms by increasing muscle oxygen demand. Diagnosis typically involves Doppler ultrasound for PAD and neurological exams for RLS, and treatment for one may not be effective for the other. Accurate diagnosis and tailored treatment are crucial for effective relief.
Case 1: Retrograde access through Anterior tibial artery (ATA).
Case 1: Angiogram showing occluded right Anterior tibial artery and Tibioperoneal trunk
Case 1: Guidewire going through Anterior tibial artery (ATA).
Case 1: Final Angiographic Result.
The angiogram results were generally favorable for the major vessels, including the aorto-iliac and common femoral arteries. However, there was a notable 90% stenosis in the tibial peroneal trunk (TPT) and multiple 75% blockages in the posterior tibial artery (PTA). To address these, the team used a combination of antegrade and retrograde techniques. Advanced medical equipment was used to remove the blockages in the patient’s ATA, PTA, and TPT. After clearing the obstructions, the team performed balloon angioplasty with specific measurements: they used a 3.5-x 300-mm Ultraverse BD Bard balloon for the dorsalis pedis artery (DPA), ATA, and PTA, and a 4.0-x 60-mm Lutonix DCB for the TPT. The outcome was considered excellent based on extravascular ultrasound (EVUS) assessments. To ensure hemostasis and further minimize the risk of complications, manual pressure to close the access site securely. The patient responded very well to the treatment; he was able to walk an hour post-procedure and received additional treatments for his severe leg infection. This case highlights the effectiveness of using trans-radial access in patients with complex health conditions. The techniques used included specialized catheters ranging from 5 to 6 Fr and 6 to 7 Fr GSS sheaths. The outcome showcases the potential benefits of alternative access routes and specialized equipment in vascular interventions for high-risk patients.
Case 2: A 67-year-old male with a significant medical history, including hypertension, hyperlipidemia, and type 2 diabetes mellitus, presented with severe claudication in his left lower limb and a nonhealing wound on his left 2nd and 3rd toe. Physical examination revealed a pale left lower extremity with minimal hairs, indicative of reduced blood flow. Arterial Duplex demonstrated a 90% stenosis in the mid-left superficial femoral artery, coupled with monophasic waveforms throughout the left lower extremity below the knee. The ankle-brachial index/pressure-volume recording (ABI/PVR) ratios told a compelling story, with the left side registering an alarming 0.5, compared to a more reassuring 0.8 on the right. Arterial ultrasound findings further supported the diagnosis, affirming monophasic waveforms and the critical 90% stenosis in the mid-left superficial femoral artery. A confirming CT angiography sealed the diagnosis. Faced with these challenging findings, the patient underwent balloon angioplasty of the left superficial femoral artery. The procedure aimed to restore blood flow and alleviate the debilitating claudication symptoms and nonhealing wound on the left foot toe that had significantly impacted the patient’s quality of life. The post-procedure assessment brought about a rapid and remarkable improvement in claudication symptoms. The patient reported a dramatic enhancement in mobility and a significantly reduced reliance on pain medications. The intervention successfully addressed the 90% stenosis, with post-intervention evaluations confirming improved blood flow and a return to normal or near-normal waveforms throughout the left lower extremity. This case exemplifies the transformative potential of minimally invasive vascular interventions. In the face of severe claudication and extensive atherosclerosis, the patient experienced substantial relief and enhanced quality of life through balloon angioplasty. This success underscores the importance of early diagnosis and prompt intervention in the management of peripheral arterial disease, particularly in patients with significant comorbidities. It serves as a testament to the positive impact of cutting-edge vascular procedures on patients’ lives.
Case 2: Figure 1: Angiogram prior to revascularization procedure.
Case 2: Figure 2 showing a balloon going through the Left Superficial Femoral Artery (SFA)
Case 2: Figure 3 showing the final angiographic result.
“Nobody cares how much you know until they know how much you care.” – Theodore Roosevelt.
LETTER FROM DR. SHAH TO HEALTHCARE PROVIDERS
Peripheral Arterial Disease is extremely common, and it has a huge impact not only on the quality of life of our patients but also on their family members and overall survival. It saddens my heart when I see a patient wheelchair-bound, living their life in a nursing home because they lost a limb due to a circulation issue, especially when they did not even get a proper opportunity to assess their circulation. Medical science, and especially the field of endovascular procedures, has advanced so much that it’s unfair to our patients if they don’t go through a proper assessment and team effort for limb salvage. It is our moral, ethical, fiscal, and medicolegal responsibility to do everything in our capacity as a team to help people who are threatened with limb loss. Not only this, but we should also have a more comprehensive and holistic approach to assess not just for circulation but to look at their other comorbidities, simultaneous cardiovascular risk, and the challenges these patients face, which are oftentimes a combination of social issues. These are the very people who have poor socioeconomic status, poor access to healthcare, poor understanding of the disease processes, substance abuse and other mental health issues, and a very poor outlook on life. They are not just looking for ‘Experts’ who can open their blockages, but also someone who’s gonna be a true champion advocating for their overall physical, mental, and social health. After all, as Roosevelt had said ‘No one cares how much you know until they know how much you care”. As a vascular and cardiac specialist in some of the most densely populated and low-income areas of New Jersey, I am passionate about treating vascular disease and improving vascular health. Sometimes, people have so many risk factors they don’t understand. Unfortunately, I am seeing an increase in the number of amputations as a result of undetected peripheral vascular disease. Peripheral vascular disease is one of the primary areas that is often missed by healthcare providers. Peripheral vascular disease is more common than you think. Peripheral vascular disease impacts 20 million Americans. Vascular issues like peripheral artery disease or peripheral vascular disease are actually relatively easy to detect, fix, and prevent. At Apex, the staff will be wearing white socks as high as your knee to bring awareness to our community about this silent but deadly disease.
However, we can’t find what we aren’t looking for. That is why I am on a mission to educate healthcare providers and the community at large about the early signs of vascular disease.
Dr. Shah Dr. Anuj Shah, MD Executive Director Apex Heart & Vascular Care
Economic Burden Of Peripheral Arterial Disease
PROJECTIONS THROUGH 2035 IN AMERICA
- The rising prevalence of PAD is set to become an economic and healthcare crisis. Current projections indicate that nearly 21 million Americans could be dealing with PAD by 2035, significantly straining the healthcare system.
- PAD treatment needs to be as diverse as the communities affected by it. Telemedicine, coordinated care, and cultural competence are crucial in optimizing treatment and reducing healthcare costs. The economic impact is especially devastating in underdiagnosed populations, such as women and low-income areas.
- PAD is linked to high rates of lower-limb amputations, carrying both emotional and significant economic repercussions. These involve not just the immediate costs of surgical procedures but also the long-term costs of prosthetics, physical therapy, and potential disability benefits. Mortality rates post-amputation also contribute to lost earnings and productivity.
“By 2035, the economic toll of PAD is projected to exceed a staggering $135 billion. Behind these numbers are lives irrevocably changed” — limbs lost, families disrupted, dreams deferred.
The Looming PAD Epidemic
Peripheral Arterial Disease (PAD) has long been the silent player in the arena of cardiovascular diseases, often overshadowed by conditions such as heart disease or stroke. However, the silence masks a burgeoning crisis, both in healthcare and economic terms. A decade ago, PAD affected a small percentage of the American population. Current data, however, shockingly reveals that nearly 21 million Americans could be grappling with PAD by 2035, thereby unraveling a parallel financial catastrophe. This isn’t merely a linear progression but an exponential one, exposing the underpreparedness of the healthcare system to manage this impending avalanche.
Projections – PAD Costs Through 2035 in billions.
WHEN IT COMES TO GETTING SCREENED… YOU CAN’T GET COLD FEET
PVD is a serious circulatory condition caused by the same fatty deposits and plaques that clog up hearts. These deposits can also build up on the walls of the arteries leading to the limbs, causing pain, numbness, and chilled feet and hands. At Apex Heart & Vascular Center, our physicians specialize in vascular care and can treat vascular issues at the source. Help us bring awareness to this disease affecting over 8 million Americans.
PREVENTING AMPUTATIONS TO KEEP YOU IN THE GAME…
From a vascular perspective, amputation represents a point of no return that changes an individual’s life in profound ways. The loss of a limb disrupts not only basic mobility but also impacts circulatory health, potentially exacerbating existing vascular conditions and creating new health challenges. The onus is on multispecialty healthcare providers and patients to work collaboratively to halt the progression towards this severe outcome. With advancements in vascular therapies, early and accurate diagnosis, and community awareness about diseases like PAD, we have the tools at our disposal to make amputations a last resort rather than an inevitable consequence. By working together, we can aim to keep patients whole in every sense of the word.
Gwen Can Dance Again!
For Gwen, walking her usual half a block at a time without being in pain used to be out of the question. Gwen would go to work and do her job, and she would walk to church, but it was never a monumental task when it came to walking, so she did not notice how bad the pain had become. It wasn’t until she decided to go to a party from the local gospel group that she realized she had put herself in a seriously dangerous spot. Her Primary care provider referred her after a complex diagnosis, and this was the beginning of her new life. “I have suffered with PAD for 10 years. I was diagnosed the wrong way because of a spinal problem, but my primary care put me in the arms of an angel that God led me to, to heal my legs.” Gwen said.
What Was Stopping Gwen From Enjoying Her Life Normally?
Upon examination and testing, it was determined that Gwen had a blockage in the arteries of her right leg and a partial blockage in her left leg. She was diagnosed with peripheral artery disease (PAD). Gwen, a 66-year-old female with a past medical history of hypertension, hyperlipidemia, coronary artery disease, and PAD, presented to Apex Heart and Vascular Care Vein Clinic with life-altering claudication in both her right and left lower extremities. First, we successfully completed a PAD intervention on her left leg.
During that intervention, we also discovered a complete occlusion of the right SFA. We couldn’t stop at that point. After two weeks, we made another attempt and succeeded in our second intervention for her right leg. The result was as successful as the first intervention. We had finally done it.
“When I say Severe Pain, God Knows I Mean Severe Pain, Because I Spent Crying Many Days and Many Nights.”
Figure 3A-C: Pre-intervention angiography showing occlusion of right SFA (A). IVUS of reference vessel – 5 mm (B). Successful revascularization of right SFA using atherectomy and balloon angioplasty.
How Did We Help Gwen Dance Again?
The patient was prepared for the procedure with necessary measures, including anticoagulation using heparin. Utilizing a guidewire, we successfully crossed the proximal cap of the stenosis. Post-crossing, intravascular ultrasound (IVUS) identified a heavily calcified plaque within the reference vessel. Subsequently, we conducted an atherectomy followed by balloon angioplasty, effectively reducing the 100% stenosis to less than 10%.
“I was completely blocked in my legs. I had no feeling in my legs every time I walked.”
ESCAPE THE PAIN
Peripheral Vascular Disease can mean unsightly and unpleasant feelings in the legs. This does not mean patients have to live with pain. At Apex Heart & Vascular Center, our physicians specialize in vascular care and can treat vascular issues at the source. Help us bring awareness to this disease affecting over 8 million Americans.
IT’S CRAZY THAT IN 2023, PEOPLE STILL CONSIDER CUTTING A LEG TO BE A CONSERVATIVE TREATMENT WHILE VIEWING PERIPHERAL ANGIOGRAPHY AS AN AGGRESSIVE APPROACH.
FIGHTING PVD IS A TEAM GAME, AND ALL DIFFERENT SPECIALTIES NEED TO BE A PART OF OUR EARLY DIAGNOSIS CAMPAIGN – PLEASE JOIN US!
As a New Jersey Vascular Specialist, my goal is to empower other New Jersey physicians who work with diabetic patients to reduce diabetic foot complications and amputations. Apex Heart and Vascular wants to collaborate with other physicians who work with diabetic patients throughout the New Jersey region. As NJ vascular specialists, we believe that primary care physicians, internists, podiatrists, endocrinologists, infectious disease and wound care specialists, urgent care center providers, and other specialties play a critical role in the early identification of peripheral vascular disease. Because primary care physicians and podiatrists are the providers of foot exams in the New Jersey community, we work very closely with them to regularly do foot health exams to detect PVD. This disease often has other connotations for the patient, including depression and mental health issues, which inevitably cause them to need a lot of hand-holding. We need to work together to keep these patients engaged and prevent them from falling through the cracks and, ultimately, not receiving the care they need.
Follow the American Heart Association, SALSAL Foundation, Amputee Coalition, and other organizations bringing awareness.
The White Sock Campaign is a national campaign to raise awareness of peripheral vascular disease (PVD) and the prevention of amputation. Our staff members wear one white sock to raise awareness in our community about PVD and the importance of preventative care and early screening.
During PVD Awareness Month, we encourage you to use the tools we have developed to raise awareness of the disease amongst your colleagues, patients, friends, and communities throughout September. These include sample social media posts, a PVD Awareness Month handheld sign, encouraging doctors who are helping patients save their limbs every day to take a photo using CVC’s handheld “I saved a limb today!” sign.
HIGHLIGHTS FROM OUR PAD AWARENESS EVENT FOR 2023
(Peripheral Arterial Disease) Awareness Month holds a special place in our hearts here at Apex Heart & Vascular Care Vein Clinic. As the month winds down, we find ourselves reflecting on the criticality of awareness, education, and collective action in battling this pervasive disease and the phenomenal success of our recent PAD Awareness Event.
BRIDGING EXPERIENCES: THE PAD SYMPTOM SIMULATOR
A standout feature from the event was the innovative “PAD Symptom Simulator,” a creative and immersive experience designed to help individuals grasp the nuanced and sometimes elusive symptoms that PAD patients encounter.
The PAD Ice Bucket Challenge exposed participants to the chilling limb sensations reported by PAD patients, while the Cinder Block Challenge metaphorically materialized the heavy, dragging sensation in the legs that many experience. Each simulation was crafted based on genuine patient testimonials, aiming to foster empathy and understanding among healthcare providers, caregivers, and the wider community. It was not just an experiment but an eye-opening journey through the untold struggles faced by PAD patients every day.
Attendees navigated the Barbed Wire Challenge. A simulation that encircled participants with the idea of legs with a constraining, albeit safe, barbed wire, evoking the relentless and sharp pains often described by PAD sufferers. Through this visceral encounter, the simulation forged a palpable connection between spectators and the insidious pain lurking in the shadows of everyday PAD battles, spurring a collective sigh amidst the onlookers.
The Cinder Block Challenge was a real eye-opener at our PAD Awareness Event. Attendees had cinder blocks strapped to their feet and tried to walk. Simple as that. It was a quick and direct way for them to get a glimpse into what some PAD patients describe – a heaviness in their legs that turns a simple walk across the room into a challenge. The echoing drag of the blocks on the floor served as a reminder of the often unnoticed and unseen struggle PAD patients endure. A straightforward but impactful experience, the cinder block walk was a step into the shoes of those fighting against PAD, offering a tangible connection and an enriched understanding of their journey.
Our Shoe Tie Challenge was a thought-provoking element of the event, prompting participants to tie their shoes while having one leg rendered unavailable. This simulation, although merely a glimpse, provided a stark look into the daily life of individuals who’ve lost a limb due to Peripheral Arterial Disease (PAD) complications. Participants hopped, balanced, and struggled with the seemingly ordinary task, uncovering the hidden battles that amputees often face in executing what many deem a trivial activity.
FORWARD, TOGETHER IN UNCEASING STRIDES AGAINST PAD
As the month draws to a close, our dedication to the continued battle against PAD, amputations, and cardiovascular diseases surges forward undeterred. Your continued engagement and advocacy are not only welcomed but crucial as we persist in our collective crusade against PAD and its pervasive repercussions. Heartfelt thanks to each and every one of you for making this event not merely a gathering but a poignant symphony of shared struggles, unified commitment, and collective resilience against PAD. For those who missed it or wish to relive the moments, stay tuned for an evocative video recap, which will spotlight the key moments, emotional narratives, and collective spirit that defined our PAD Awareness Event this September.