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My name is Thomas Reifsnyder, and I'm a vascular surgeon at Johns Hopkins.
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My job as a vascular surgeon basically is one of education.
Every patient that we see we try to educate not
only about their disease but about what the treatment options are.
And I try to guide them to what
would be the best treatment modality for their disease.
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One of the things that absolutely amazes
me is that people will undergo an amputation
of their lower extremity and not get
a second opinion before their leg is removed.
Peripheral arterial disease requires a lot of expertise and a lot
of experience to be able to treat in the best fashion.
I frequently get phone calls from physicians and family members of patients.
Telling me that their loved one is going to require an amputation.
And when I see those patients as a second opinion.
Frequently the repair or the re, or the necessary surgery to save that limb is
known as, it, is easily done and
something that can absolutely change the patient's life.
Its much better than to do a fairly significant operation
and save a limb than it is to undergo an amputation.
Many surgeons and many physicians out there
believe that an amputation solves the problem.
You can get an, a prosthesis and you'll be able to walk again.
And you don't have to undergo multiple procedures to try to save that limb.
Most patients can actually undergo one or two sophisticated operations
and save a limb, which will absolutely change their life.
Peripheral Arterial Disease which, which used to be called Peripheral Vascular
Disease basically is blockage of the arteries going to an extremity.
Technically, it could involve blockage of arteries going to the arm or hand.
But that's uncommon.
The most common is blockage to the lower extremities.
Millions of Americans have peripheral arterial disease.
The most common presentation is no symptoms whatsoever.
In other words, they go to their doctor, and the doctor cannot feel their pulses.
There are millions of people in America
who have decreased circulation in their lower extremities,
but because they're getting older, they're not
as mobile, they don't have any symptoms whatsoever.
Those patients we don't typically see as a vascular surgeon.
The more common presentation for a patient with peripheral arterial disease,
is someone who develops pain in their calves or legs when walking.
That is called lower extremity claudication.
In the past, we didn't treat that very aggressively because
it's not a threat to the patient's life or limb.
However in this day and age where we have a variety of minimally invasive
techniques particularly in the younger patients who have this
problem we may aggressively treat it with angioplasty and stenting.
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The, the risk factors for peripheral
arterial disease include smoking, diabetes, high
cholesterol, and one that we don't really think about, but just aging.
As people get older their blood vessels tend to wear out.
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Peripheral Arterial Disease is manifested most commonly as.
No symptoms what so ever.
the.
The patients gets a routine physical examination and the doctor.
Can't feel pulses.
Unfortunately a lot of Americans don't exercise enough.
And if you don't exercise.
Or don't walk very much.
Then, there's not a large requirement for blood flow to the legs.
And so you could have peripheral arterial disease and not know it.
The most common symptom for peripheral arterial
disease is what we call lower extremity claudication.
And the term claudication actually means to limp.
Patients don't actually limp with this.
But what they do get is they get pain in
their calves or thighs after a certain distance of, of walking.
The nice thing about peripheral arterial disease
is that it's very easy to diagnose.
People with lower extremity claudication have that
symptom every day whenever they walk that distance.
It's not like one day they can walk a
block, and the next day they can walk a mile.
It's at one block their calves start hurting
or a calf starts hurting consis, consistently every day.
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The patients that are the toughest patients to treat are those who
present with poor circulation to their
lower extremities and severe peripheral arterial disease.
These patients can present with a lot of pain in
the foot clearly they won't be able to walk too far.
And sometimes they'll actually present with ulceration or gangrene of the foot.
These people clearly are clearly need to be treated and
or otherwise, they could end up losing the function or, or actually losing their
leg depending upon the location of the disease.
Whether it's in the arteries near the
aorta versus the arteries in lower extremity.
These patients can be treated with angioplasty and stinting,
or they can be treated with lower extremity bypass procedures.
A totally different group of patients are the diabetic patients.
Diabetes tends to not only effect the lower extremity arteries,
but also extra it also affects the lower extremity nerves.
And the root cause of almost all diabetic foot problems is
the fact that diabetics don't have normal sensation to their foot.
This doesn't this, this doesn't allow feedback from their foot so that if they
develop a blister they continue to traumatize
that blister until it turns into a ulcer.
And in the worst cases, that ulcer then
gets infected and can threaten the whole foot.
Diabetics sometimes will have normal circulation to their foot
and sometimes they will have poor circulation to the foot.
So treatment of a diabetic ulcer of the foot really depends upon
whether or not it's infected.
And then whether or not the patient has poor circulation.
The treatment of the diabetic foot problem can involve
just local wound care, it can involve partial reconstruction
of the foot, or partial amputation of toes, toe, or toes of the foot.
And or it might involve restoring normal circulation depending upon the situation.
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In the last couple of decades the treatment
of peripheral arterial disease is really undergone a revolution.
There have been a large number
of minimally invasive techniques that have they've
really become quite common, and are quite widely available across the United States.
And what I'm talking about is angioplasty and stinting.
Angioplasty is inserting a balloon into a blood vessel and
opening up the balloon and therefore opening up the blood vessel.
Years ago, you might do angioplasty on a blood vessel
that is narrowed but only narrowed over a short distance.
And nowadays, the techniques are available where we can actually take
totally blocked up blood vessels and be able to reopen them.
Generally, this, this also involves putting in a stent,
which is sort of a metal scaffolding that sorta
looks like a Chinese finger trap, and that helps
keep open the artery over a longer period of time.
In the worse cases the patient would need a lower extremity operation or
a lower extremity bypass operation to be able to restore the blood flow.
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The concept is really very straight forward and very simple, they
have a blockage and you need to bypass from above the
blockage where the circulation is still normal to below the blockage
where the circulation ha been reduced, so the idea is very straightforward.
The actual surgical part can be a little tricky at times and most of the time
what we do is, is we create a new blood vessel out of the patient's own vein.
So you are taking a vein which normally carries blood to the heart.
And making it into an artery which now will be supplying blood to the extremity.
As with most procedures in American medicine nowadays.
We've gone to more minimally invasive techniques.
And in vascular surgery, minimally invasive techniques involve
angioplasty and stinting, or reopening blood vessels with
a balloon or a, a little metal stint or scaffolding to keep the blood vessel open.
The real advantage to these procedures are that they're
minimally invasive and therefore are low impact on the patient.
Most of these procedures are done as outpatients they can be
done under local anaesthesia with just a tiny bit of sedation.
And generally take one to two hours to
perform, and the patients then are, are recovered for
only an hour or two, sometimes three or four
hours and then can go home that same day.
Most patients really feel nothing other than maybe a
little soreness at the site where the procedure is done.
Which will go away in a couple of days and basically can
re, resume normal or more activity than previously within a day or two.
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Johns Hopkins has a wealth of experience in
treating lower extremity arterial disease, or peripheral arterial disease.
Over the last decade Johns Hopkins has added two new endo suites.
Which are operating rooms that, where you
can not only perform angioplasty and stenting.
But also operating rooms where you can do open operations.
Or you can combine those two techniques.
The new Johns Hopkins Hospital will, will be opening.
Which has even more sophisticated facilities
for the treatment of peripheral arterial disease.
I think the most important aspect of the treatment of peripheral
arterial disease is having an experienced surgeon taking care of you.
It's not only the techniques involved, but it's
the decision making that is most, most important.
Aggressive treatment of lower extremity arterial disease will result in
limb salvage and maintain the amb, mbulatory status of the patient.
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