Advancing Regional Care for Peripheral Artery Disease at Winthrop-University Hospital
Friday, June 24, 2011
Peripheral artery disease (PAD) affects an estimated 8 million Americans, according to the American Heart Association. At Winthrop-University Hospital, patients benefit from access to multiple treatment options for management of PAD.
Photo: Scott Schubach, M.D., Man Hon, M.D., and George Hines, M.D., of Winthrop-University Hospital. Photo © Don Dempsey, White Light Photography
Winthrop-University Hospital patients benefit from access to multiple treatment options for management of PAD.
The Department of Thoracic and Cardiovascular Surgery at Winthrop-University Hospital in Mineola, NY, provides all-inclusive diagnostic modalities, as well as minimally invasive and open surgical alternatives for patients with a wide range of conditions, including lung cancer, cardiovascular disease, aortic aneurysm, atrial fibrillation, hypertrophic cardiomyopathy and heart failure.
Through the Division of Vascular Surgery — a unit of the Department of Thoracic and Cardiovascular Surgery — a multidisciplinary team of physicians utilizes state-of-the art technology to provide comprehensive diagnostic and therapeutic care.
“We, as a department, provide a full range of thoracic and cardiovascular services, including complex lung resections and advanced open and minimally invasive cardiac surgical procedures,” says Scott L. Schubach, M.D., FACC, FACS, FCCP, Chair of Thoracic and Cardiovascular Surgery at Winthrop-University Hospital and assistant professor of clinical surgery at Stony Brook School of Medicine. “Specifically, through the Division of Vascular Surgery, we offer both open and catheter-based arterial and venous surgeries for treatment of occlusive disease and stenosis in the carotid and peripheral arteries. Through a comprehensive array of services, we are able to treat all forms of venous disease — from milder forms, characterized only by the presence of spider veins, to more severe cases where patients are at risk of losing a limb.”
Recognizing the Signs of PAD
According to George L. Hines, M.D., Chief of the Division of Vascular Surgery at Winthrop-University Hospital and professor of clinical surgery at Stony Brook Medical School, primary care physicians should be cognizant of three main symptoms of PAD. These include claudication, decreased pulse in the foot or lower leg, and pain that occurs in the affected limb while the patient is resting.
A symptom unique to PAD, rest pain is characterized by pain in the foot and toes that occurs, generally at night, once the patient puts his or her feet up. To find relief from rest pain while they are trying to sleep, patients often have to position themselves with their feet dangling from the side of the bed, which helps enhance blood flow. While many patients misconstrue rest pain for nighttime cramping of the calf muscle, it is important to note that nighttime calf cramps are rarely a sign of PAD.
If patients have any symptoms of PAD — especially if they have decreased pulse in their legs — care must be taken to rule out other forms of cardiovascular disease, as well, as PAD is often a sign that patients either have or are at an increased risk for developing other types of heart disease.
“More physicians have become aware that patients with PAD are at a markedly increased risk for developing other types of cardiovascular disease, such as carotid artery disease,” says Dr. Hines. “When a patient presents with symptoms of PAD, it can often be beneficial to begin adding medications to his or her protocol to help lower the likelihood of a cardiac event or the development of heart disease.”
In cases of severe PAD, patients may also notice the presence of nonhealing wounds or ulceration on the affected limb, as well as gangrene.
Diagnosing PAD
To diagnose the extent of a patient’s PAD, physicians at Winthrop-University Hospital perform comprehensive physical examinations on patients at the hospital and in an office setting at Winthrop Cardiovascular & Thoracic Surgery, P.C.
Several imaging modalities are available that provide timely access to a myriad of vascular screenings, including pulse volume recording studies, Doppler ultrasound and differential blood pressure measurements. Other imaging modalities, including CT and MRI angiograms, standard diagnostic angiography and digital subtraction angiography, are readily available, as well.
Performed by interventional radiologists, diagnostic angiography involves injecting contrast dye into an artery to determine the location of possible blockages or areas of narrowing. Access to the artery is gained through a small puncture in the groin made while using local anesthesia. A catheter is then threaded to the affected vessel, allowing physicians to easily identify areas of concern.
Depending on the extent of disease, angioplasty or stenting, or atherectomy may be performed following angiography. If the problem is not amenable to those types of minimally invasive surgeries, the results of the angiography study can be used to provide vascular surgeons with a map of the patient’s arteries, which is beneficial during peripheral arterial bypass surgery.
“The diagnostic workup for peripheral artery disease is fairly straightforward and usually noninvasive,” says Man Hon, M.D., Chief of Vascular and Interventional Radiology at Winthrop-University Hospital and assistant professor of clinical radiology at Stony Brook School of Medicine. “Because of this, primary care physicians should consider referring all patients who are having symptoms or who are at increased risk of developing PAD for a consultation.”
Exhausting Conservative Measures
The Division of Vascular Surgery’s team of physicians is conservative regarding which patients receive intervention for treatment of PAD. In some cases, longevity and quality of life are best preserved if patients are monitored for continued disease prevention. In other instances, lifestyle modifications — such as following an exercise regimen, smoking cessation and eating a heart-healthy diet — are effective. Medications may also be used in appropriate candidates.
“Through the Division of Vascular Surgery, we give honest opinions regarding who we believe would benefit from an interventional or surgical procedure,” says Dr. Hines. “Our goal is not to perform surgery on every patient we see, but rather to tailor treatment plans to suit individual patients.”
When conservative measures are not enough, physicians offer a wide range of cutting-edge modalities, including angioplasty, stenting, laser therapies, open and catheter-based endarterectomy, and peripheral arterial bypass.
Managing Severe Cases of PAD
When patients present with advanced stage PAD — characterized by the presence of nonhealing wounds, ulceration and/or gangrene on the affected limb — limb salvage methods may be employed to prevent amputation. At Winthrop-University Hospital, physicians utilize an individualized approach to care — determining what modalities should be used on a case-by-case basis, rather than using one modality or treatment protocol on all patients who present with severe PAD.
“With limb salvage, we address each patient as an individual,” says Dr. Hines. “We must first see what procedure would be necessary to salvage the limb and then determine if we believe the patient is healthy enough to withstand an interventional or surgical procedure. We must also ensure that we would be able to provide a significant improvement in quality of life. In patients who make good surgical candidates and who will have a high functional capacity following surgery, we are fairly aggressive with our limb salvage techniques.”
For some patients, wound healing services may be necessary for limb salvage because of the extent of ulceration. Winthrop-University Hospital has a Wound Healing Center and Hyperbaric Medicine Program that provides the full spectrum of wound healing modalities, including pain management, proper wound bandaging, hyperbaric oxygen therapy, compression therapy and use of antibiotics to resolve infection.
“A large part of treating severe cases of PAD is addressing the accompanying wounds and nonhealing ulcers that occur as a result of compromised blood flow,” says Dr. Schubach. “Patients with both diabetes and PAD are at an especially increased risk of developing nonhealing ulcers. By working closely with wound care specialists and the Wound Healing Center and Hyperbaric Medicine Program, we can help provide optimal outcomes.”
When Amputation May Be the Best Choice
In some cases, pursuing rigorous limb salvage techniques is not in the patient’s best interest.
“For nonambulatory, elderly patients who have wounds that would take months of aggressive treatments and interventions to resolve, amputation may be the best choice,” says Dr. Hines. “No patient wants to think an amputation is necessary; however, it isn’t beneficial to make patients in this population undergo months of intervention if initial angiogram findings predict that chances of limb salvage are poor. In these cases, amputation often provides a higher survival rate and does not directly impact quality of life or functional status.”
An Interdisciplinary Approach to Care
Physician collaboration is a key component of the Division of Vascular Surgery, and cardiothoracic surgeons, vascular surgeons, interventional cardiologists and an interventional radiologist all work together to ensure that patients achieve optimal outcomes.
“One of the unique aspects of our program is the collaborative effort between interventional cardiology, interventional radiology and vascular surgery,” says Dr. Hon. “We meet as a team every Monday morning to discuss interesting and/or challenging cases, and each of these specific service lines brings something different to the table. This allows us to discuss all possible alternatives and determine which option will be best for the patient.”
Interventional radiologists, vascular surgeons and interventional cardiologists routinely review images together, and physicians also work closely with the wound care team, which includes podiatrists, plastic surgeons, vascular surgeons, general surgeons, internists and endocrinologists.
“Because of our multidisciplinary approach, we are able to rely on the expertise of our colleagues if we have a question or if we feel that additional input is needed to determine the correct treatment course,” says Dr. Hines. “This not only ensures that we are using the most appropriate modality, but also allows the patient to benefit from the expertise of multiple physicians. For example, if one of my colleagues encountered a similar challenging case and achieved success using a certain modality, I can use his or her experience to help formulate my treatment plan.”
“Having multiple specialties involved allows for enhanced management of comorbidities,” adds Dr. Schubach. “If patients have multiple comorbidities, we will generally also include the patient’s primary care physician in the treatment decision.”
To learn more about services offered through Winthrop-University Hospital, visit www.winthrop.org.
Winthrop-University Hospital
Photos © Don Dempsey, White Light Photography
MD News June 2011, Long Island