Peripheral Arterial Disease and Amputation Prevention

WHAT IS PERIPHERAL ARTERIAL DISEASE? 

If somebody had a stroke, you would automatically assume they were sick.

But what if I told you that if a person had a blockage in their legs, that means they could also be sick?

A heart attack is a blockage in the heart. Peripheral Arterial Disease (PAD) is a blockage in the legs.

Most people don’t think that legs are also important to cardiovascular health, but this assumption couldn’t be more off base.

For people who have blockages in the leg, their outcome is often no better than people who already had a heart attack or other cardiovascular issues.

Most people understand what a heart attack is, but unfortunately, most people do not understand what a diabetic ‘foot attack’ is.

The purpose of this article is to prevent any misconceptions around PAD to prevent a ‘foot attack’ and possible amputation from occurring before it’s too late.

FACT: Almost 25% of coronary artery disease (CAD) patients have some form of PAD.

Why is it crucial to check for peripheral arterial disease?

Failure to recognize the signs of PAD will cause a significantly higher risk of cardiovascular disease, which otherwise goes undetected.  It is important to identify patients at risk of PAD or cardiovascular disease because everyone should reduce cardiovascular risk factors.

Leg pain with walking, skin ulcers, and gangrene are very debilitating for PAD patients. There’s a concept of limb loss with amputation, but oftentimes, patients suffer from limb loss without amputation. This happens through functional limb loss, where patients have wounds, diabetic foot ulcers (DFU), severe rest pain, or discoloration that leads to amputation.

PAD & Diabetic Foot Problems

Many people do not realize that clogged arteries in the legs can be a warning sign that there are blockages in other parts of the body. One of the most significant warning signs of PAD is foot ulcers that do not heal, specifically in diabetic patients. But unfortunately, PAD starts well before that and is often not detected or misdiagnosed.

Podiatry foot facts:

1. Seventy-five percent of Americans will experience foot health problems of varying degrees of severity at one time or another in their lives.
2. Your feet mirror your general health. Such conditions as arthritis, diabetes, and nerve and circulatory disorders can show their initial symptoms in the feet — so foot ailments can be your first sign of more serious medical problems.
3. About 5 percent of the US population sees a Podiatrist every year. There were more than 55 million patient visits in 1995 from about 14 million people.
4. In 1998, the average number of yearly patient contacts with a Podiatric Physician was 4,488.

Lower limb vascular assessment techniques of podiatrists 

“National guidelines recommend PAD is tested for using a combination of clinical history taking, pulse palpation, Doppler waveform assessment, ankle-brachial index (ABI), toe systolic pressure and toe-brachial index (TBI) as well as measures of skin perfusion, e.g. transcutaneous oximetry.”

“The types of testing methods used by podiatrists were shown to be influenced by their practice setting (public versus private), with public podiatrists significantly more likely to undertake lower limb blood pressure testing compared to podiatrists in private practice.”

Key Takeaway: Many doctors and primary care physicians are not examining patients’ feet as much as they should. 

PERIPHERAL ARTERIAL DISEASE: TOP 7 PAD MISCONCEPTIONS

Peripheral Arterial Disease (PAD) is full of medical misconceptions. In honor of limb loss awareness month and wound healing awareness month, I wanted to shed some light on the biggest misconceptions surrounding PAD. Why? Because the more we educate doctors and patients on these misconceptions, the greater chance we have to do the following:

Save a Limb and save a life!

PAD & Limb Loss Awareness Video

In this article on critical limb ischemia and peripheral arterial disease, you will learn: 

• What causes peripheral arterial disease
• Peripheral arterial disease screening and risk factors
• PAD risk prevention
• Symptoms of peripheral arterial disease & treatment for PAD
• Peripheral arterial disease and diabetes management tips
• Coronary Artery Disease (CAD) vs. peripheral arterial disease (PAD)

PAD Misconception #1: Peripheral arterial disease (PAD) must not be common or we would hear about it more in the news.

As physicians, we sometimes only see the obvious, but do not see what is taking place beneath the surface. PAD is a very common disease, but unfortunately, it does not receive a lot of publicity in consumer-facing media outlets.  It certainly receives much less publicity than regular cardiovascular issues because there is a general lack of awareness about what peripheral arterial disease is. It’s also not recognized by many doctors, and the effort to increase public awareness is limited because people don’t truly understand the risk factors associated with PAD, specifically as it pertains to diabetes.

Although PAD and amputation are not highly publicized medical issues, they are life-threatening and a leading cause of mortality, especially among those with diabetes. When we look at mortality rates, the only thing with a worse mortality rate than amputation over five years is stage 4 lung cancer.

“Five-year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer”₁ published in the Journal of Foot and Ankle Research.

 

According to the National Heart, Lung, and Blood Institute (NLBI)₂, 18 million individuals in the United States are afflicted with some form of peripheral arterial disease (PAD).

PAD Misconception #2: Peripheral arterial disease only impacts the elderly.

Peripheral Arterial Disease becomes more apparent as people age, but precursors of atherosclerosis are present from a young age. In the Framingham Heart Study₆they looked at the top peripheral arterial disease risk factors.  They found that every 40-milligram increase in LDL, your odds ratio was 1.2, which means there is a 20% higher risk of getting peripheral arterial disease. For every ten cigarette smokes per day, your risk of PAD went up 40%. For mild diabetes, the odds ratio was 1.5 and for mild hypertension, it was 1.5 moderate hypertension 2.2, and for diabetics it was 2.6.

• A study derived from results of a National Health and Nutrition Examination₃ projected that the prevalence of PAD continues to grow with age. When people are in their 40’s to 60’s, we see about 1 million cases of PAD, but we see around 4 million cases of PAD of people in their 70’s to 80’s and it continues to grow.
• A study by the New England Journal of Medicine in 1999₄, estimated that the number of people with PAD was eight to nine million and projected the number would continue to go up in the next decade with a number coming around 12 million in 2020.
• A study published by Vascular Disease Management in 2016₅ found that we have already significantly surpassed that number and currently PAD prevalence is estimated at 18 million.

When we look at the independent factors of peripheral arterial disease, diabetes and smoking are the two biggest ones and the odds ratio is around four for diabetes. It’s almost a 400-fold increase in peripheral arterial disease.

PAD Misconception #3. Peripheral Arterial Disease is only a nuisance. It won’t kill you.

In the “Reduction of Atherothrombosis for Continued Health Registry”₇ The American College of Cardiology looked at major adverse cardiac events, or what we call the major adverse cardiac event (MACE), in three different populations: people who had documented coronary artery disease (CAD), people who had Cerebral vascular disease, and people who had peripheral arterial disease. In other words, somebody who already had a heart attack, somebody who already had a stroke, and somebody who had pre-existing peripheral arterial disease.

When we look at the various cardiovascular risks, cardiovascular death, non-fatal myocardial infarction, non-fatal stroke and stroke combination, or MACE, it’s consistently similar across the board and that’s why vascular specialists say peripheral arterial disease is CAD risk factor equivalent.

When a patient has PAD, the risk factor of future mortality and morbidity are significantly higher and there is also tremendous overlap. Patients that have coronary artery disease are oftentimes the same patients who have PAD, and they are the same people who end up suffering from a stroke.

In the study “Ten Year Mortality in Different Peripheral Arterial Disease Stages: A Population Based Observational Study on Outcome”₈ , it was found that over ten years, the all-cause mortality rate for PAD patients was 33.1%. The percent of deaths that were attributed to cardiovascular issues as the main cause of death was 35.6% and 15.8% of deaths cited cardiovascular issues as a contributing factor in the cause of death.

The study found that the risk of cardiovascular mortality was approximately twice as high for age adjusted PAD patients and the risk increases significantly as the patients progress through the stages of PAD (Asymptomatic PAD, Intermittent Claudication and severe Critical Limb Ischemia).

The history of peripheral arterial disease is very similar to coronary artery disease (CAD), where a patient has stable CAD and then develops acute coronary syndrome.  Similarly, you have stable PAD (claudication), when people have pain when they walk, but it gets better when they stop walking, but the stable PAD later changes into critical limb ischemia (CLI).

If you look at claudication’s, which are “stable PAD patients,” the risks of non-fatal myocardial infarction (MI) and stroke is around 20%. This is a CAD risk factor equivalent and the death rate is 15 to 30%.

When people develop critical limb ischemia (CLI), which is a more vigorous form of peripheral arterial disease, the outcomes are abysmal.

PAD STATISTICS

According to “High mortality risks after major lower extremity amputation in Medicare patients with peripheral artery disease”₉

• Only 75.8% of PAD patients without lower extremity amputation are alive with both limbs at one year. The mortality rate after 3 years is 43.2%.
• Within one year, 51.7% of PAD patients with a lower extremity amputation will die of myocardial infarction, stroke, or another cause of death.
• When we follow these patients up to three years, 70.9% of them will be dead.

In a study published by the Atherosclerosis Journal₁₀, it was found that PAD patients with leg amputations on entry were five times more likely to have a subsequent amputation and had a nearly two times higher increase in rates of cardiovascular death (and all-cause mortality) and an increase in the composite outcome of MI, stroke, cardiovascular death, or hospitalization. The study also found that critical limb ischemia (CLI) is associated with a 1-year mortality rate of 20% and a 1-year limb loss rate of 20%

PAD Misconception #4: Detection of Peripheral Arterial Disease is difficult.

Many patients will come in with symptoms including leg pain, so this is not entirely true. However, patients do often have atypical symptoms of PAD. The classic symptom of peripheral arterial disease is intermittent claudication. Claudication is when you start walking, you get an exertional calf pain, usually related to one muscle group, whether it’s in the gluteal region or the calf and it resolves within ten minutes of rest.

Unfortunately, less than one third of PAD patients have classic claudication symptoms. A majority of patients will have atypical leg pain symptoms, where the pain is not exertional leg pain, which is not just the calves, but other muscle groups. This pain may not even stop the patient from walking or fail to relieve with rest. There are many clinical variations of PAD symptoms. This is a large part of the problem as to why it becomes so difficult for primary care physicians and podiatrists to detect PAD.

When we look at the rate of foot exams in primary care offices, from my personal experience, I would estimate that less than 5% of the overall population gets their feet examined. Many cardiologists also routinely fail to get annual foot exams, so as a group we are not much better.

PAD Misconception #5: PAD does not impact every other organ and system in the body.

A PAD diagnosis completely changes people’s long-term prognosis.  Atherosclerosis causes coronary artery disease and the same atherosclerosis can happen in all other vessels. Essentially, it all stems from the same vascular tree. When it happens in the cerebral system, it causes Transient Ischemic Attack (TIA) and ischemic stroke. In the heart, it causes myocardial infarction and unstable angina. In the kidney arteries, it causes renal artery stenosis, renovascular hypertension, and intestinal ischemia. Mesenteric ischemia comes from PAD. Erectile dysfunction often stems from PAD, either from Leriche syndrome (aortoiliac occlusive disease) or from potential arteries or internal iliac arteries with stenosis. Claudication, critical limb ischemia, gangrene and amputation are all systemic manifestation of atherosclerosis.

PAD Misconception #6: The health of one limb does not impact the health of the other limb. 

What happens to one limb can directly impact what happens to the other limb. The level of amputation directly relates to the pressure you put on the contralateral limb. Many times, the people who have a transmetatarsal amputation (TMA) are the same people who will get a below-the-knee amputation (BKA) in that leg.

These are the same patients who will end up getting above knee amputation in their leg and the same people will get a contralateral limb amputation.

These patients will end up going to nursing homes, they will develop decubitus ulcers and they will catch infections. They will then have decubitus ulcers and will need a Foley catheter.  They may also develop a urinary tract infection (UTI).

This creates a vicious cycle where patients come to the hospital and become susceptible to catching a hospital acquired infection. They then go back and their entire trajectory after one amputation will constantly change and thus the vicious cycle repeats. 

PAD Misconception #7: PAD can only be detected by one type of medical specialist.  

DYK: Less than one third of PAD patients will have classic symptoms?

I believe in a comprehensive approach to medical treatment that empowers physicians to screen and test for the symptoms of PAD.  All doctors and medical professionals have an ethical responsibility to test for and detect PAD because it directly affects mortality and morbidity. As health care providers, we have great power, but great power comes with great responsibility.

There are medical and legal responsibilities when patients have peripheral arterial disease and it gets missed and unfortunately, somebody will ultimately end up getting an amputation as a result.

PAD is not difficult to screen for. The problem is that unfortunately, many physicians don’t screen for it at all.  Oftentimes, a medical history and physical exam is all it takes. Sometimes, additional testing for PAD is required. We use the ankle-brachial index (ABI), which is one of the easiest ways of detecting peripheral arterial disease in an earlier setting.

We need to differentiate intermittent claudication or peripheral arterial disease from venous claudication and neurogenic claudication.

“I always tell my patients that the legs are like a plumbing system. You have to look at the ‘electricity’ of the legs.  Legs are like a factory. You need good blood flow and a good electrical system.”

Each claudication has different characteristics.  We need to differentiate from the other type of claudication and we also need to make sure we’re not missing DVT (deep vein thrombosis). Often, musculoskeletal disorders, like osteoarthritis and restless legs, can be confused with PAD, peripheral neuropathy and spinal stenosis.  Within the ulcers, people develop critical limb ischemia and there are different types of diabetic foot ulcers (DFU’s) that doctors need to pay attention to.

Just like real estate, it’s all about location.

If the pain is in the buttock or the hip area, it’s typically iliac or the Leriche syndrome (LS) where people can get erectile dysfunction from that.  If the pain is in the thigh, then it’s typically common femoral or proximal superficial femoral artery (SFA) and if the pain is in the calf, it’s usually distal SFA/popliteal artery. In the distal third of the calf, it’s typically the tibial vessels and a physical exam is important.

Amputation Prevention for Peripheral Artery Disease

The cost of peripheral arterial disease.

The Journal of Vascular Surgery₁₁ published a study on the cost of the diabetic foot and found that the treatment of diabetes and its complications generated more than $116 billion in direct costs. The same study found that appropriate educational and preventative measures could lead to a 50% reduction in incidences of amputation, saving approximately $2.7 million per year.

The projected lifetime health care costs of those who undergo an amputation are projected to be around $509, 275, according to a study titled “A Cost-Utility Analysis of Amputation versus Salvage”₁₂.

An article in Podiatry Today₁₃ on costs and long-term outcomes of amputation cited that critical limb ischemia accounts for between 65,000-75,000 major amputations, costs $25 billion in healthcare expenditures annually and has a higher five year mortality rate than coronary artery disease and breast cancer.

The health care costs associated with PAD and amputations are astronomical, but the cost of life is just as significant.

• Mortality rates after a primary amputation is performed average around 40% one year postoperative and 80% at five years postoperative.

Based on my experience, I would estimate that the cost for PAD is more than four times the cost for CAD and stroke patients combined.

When we review below the knee (BKA) amputation stats, there is also in hospital mortality.  When the same patients go in for above the knee amputation, the mortality rates skyrocket to 15-20 percent. Nursing home care is also extremely expensive.

DYK: More than $100,000 per patients is spent annually on nursing home care with PAD patients.

Peripheral arterial disease treatment in New Jersey  | Vascular assessments for PAD Testing

My Mission: Every patient deserves a limb salvage attempt.

If you have risk factors of PAD, you should be screened for peripheral arterial disease once a year even if you are asymptomatic. Any effort to prevent amputation goes a long way, which ultimately comes down to early screening for PAD and prevention of amputation and limb loss.

As a limb ischemia specialist, the entire vascular tree is my responsibility. If you would like to schedule an appointment to get tested for PAD with a New Jersey vascular specialist, contact us today.

Diabetic Foot Exams performed by New Jersey Podiatrists 

As a New Jersey Vascular Specialist, my goal is to empower other New Jersey podiatrists 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 a NJ vascular specialist, we believe that podiatrists play a critical role in the early identification of peripheral arterial disease. Because they are the providers of foot exams in the New Jersey community, we work very close with New Jersey Podiatrists to regularly do foot health exams to detect for PAD. We are growing our list of recommended providers in New Jersey who test for PAD. If you would like to be added to our recommended PAD referral podiatry list in the towns of Clifton, Passaic, or Irvington, New Jersey, please reach out today.

We want to highlight the podiatrists who are proactively identifying early signs of PAD in patients. We are launching a social media campaign to show the proactive steps New Jersey podiatrists are doing to work with Vascular specialists to tackle peripheral arterial disease. Contact us today if you are a New Jersey podiatrist who is interested in participating in our health care awareness campaign for PAD.

Contact us today if you are interested in being part of our New Jersey PAD Podiatry Spotlight Social Media Awareness Campaign. To apply, submit a high-resolution headshot and what you are doing with patients to raise awareness for PAD. We will create a custom free graphic for you and tag your social media practice page and spotlight you on our social media pages!

 

PERIPHERAL ARTERIAL DISEASE (PAD) DOCTOR IN NEW JERSEY 

ABOUT DR. ANUJ R. SHAH

 

 

 

 

 

 

 

 

 

 

Dr. Shah is an interventional cardiologist and an endovascular specialist originally trained at Mt. Sinai.  He has been in practice for 11 years and is passionate about the improvement of leg circulation and peripheral arterial disease. He is currently the Director of Apex Heart and Vascular and still has privileges at Mount Sinai as an assistant professor.  He is a regional authority on peripheral arterial disease and critical limb ischemia and frequently is featured in the media and podcasts on diabetes management.

AMPUTATION PREVENTION RESOURCES AND ADDITIONAL READING ON PAD:

1. Five Year Mortality and Direct Costs of Care for People with Diabetic Foot Complications Are Comparable to Cancer
2. Facts About Peripheral Arterial Disease (PAD)
3. Prevalence of and Risk Factors for Peripheral Arterial Disease in the United States
4. Mortality over a Period of 10 Years in Patients with Peripheral Arterial Disease
5. Reducing Amputation Rates in Critical Limb Ischemia Patients Via a Limb Salvage Program
6. Framingham Heart Study
7. Reduction of Atherothrombosis for Continued Health Registry
8. Ten Year Mortality in Different Peripheral Arterial Disease Stages: A Population Based Observational Study on Outcome
9. High Mortality Risks After Major Lower Extremity Amputation in Medicare Patients with Peripheral Artery Disease
10. Fate of Individuals with Ischemic Amputations in the REACH Registry: Three-year Cardiovascular and Limb-related Outcomes
11. The Costs of Diabetic Foot: The Economic Case for the Limb Salvage Team
12. A Cost-Utility Analysis of Amputation versus Salvage
13. Limb Salvage Versus Amputation: A Closer Look At The Evidence, Costs And Long-Term Outcomes