[Music] foreign [Music] thank you for taking time from your busy day to watch this special presentation from the El Paso County Medical Society I'm Dr Joel Hendricks president of the El Paso County Medical Society and it is my hope that you will find our program of great interest educational and informative about the medical care provided by some of our best physicians in our country right here in the Borderland from all of us at the El Paso County Medical Society please enjoy tonight's program foreign [Music] that affects almost 12 million Americans dull cramping pain in the legs hips thighs calves and buttocks numbness or tingling anywhere in the leg the foot or the toes changes in the skin temperature color and infections or sores that do not heal all of these things could be some of the warning signs of peripheral artery or arterial disease otherwise known as pad the arteries of the peripheral vascular system carry blood to the arms and the legs and the feet but over time and with certain risk factors clogged arteries can result from a buildup of fatty disposits or plaque that most commonly are found in the legs and the feet complications result in 150 000 amputations each year and you do not want to get to that point we'll discuss that later so there are some preventative factors that you can look into the most important thing is to remember remember that this disease is easily detected and it is more importantly easily treated you just need to find it out on time get diagnosed and get treatment during the next hour we have experts answering your questions about peripheral artery disease again arterial disease as well and we want to thank tenant hospitals of Providence for bringing the show to you we also want to thank the El Paso County Medical Society for bringing this show to you each and every month I'm Catherine Berg and you're tuned into the El Paso physician foreign [Music] thanks again for tuning in we have a show tonight on Peripheral arterial disease pad and critical limb ischemia and that's a mouthful I know we have two experts one who's a veteran and he's been with us for quite some time Dr lekaraja Who is an Interventional cardiologist and also an endovascular specialist and we also have Dr Ricardo costarakis and he is the same title again Interventional cardiologists and endovascular Specialists I know both of you guys practice the same thing but you have different Specialties within that practice and on that note Dr Raja since you are the veteran I'm going to ask you how do you describe to the audience we talked about your title but what is it that you do all day every day when you're describing the endovascular specialist and Interventional cardiologist in this world of Peripheral arterial disease how does that all play into that very good question so this peripheral vascular disease which is as you described blockage developing in the legs and people losing their limbs so treat that it's not only one specialty which is doing it actually it's in a big evolution it's going on in the beginning years ago vascular surgeons were the one doing most of the vascular work and which was mostly Surgical bypasses with time everything is changing and rather than having surgeries things are done by endovascularly like small cathodes balloons so the recovery is quick and you know patients stay Less in the hospital so Interventional cardiologists we are very very trained doing all this wire and pluning in the heart so we have a basic skills built into us so with time and with the need like me I started doing my practice 22 years ago in El Paso as an Interventional cardiologist and with with need and with the interest I started developing more and more skills into endovascularly meaning treating patients with blocked arteries the concept is the same blocked arteries in the heart or arteries in the legs so many techniques they kind of overlap each other so Interventional cardiologist means the cardiologist has been trained to treat the heart somebody has a heart attack any kind of other things related to the heart they treat them very well now endovascular specialist is a part of the it's not only Interventional cardiologists it could be a vascular surgeon whose trained with endovascular procedures or Interventional Radiologists so these are the three main Specialties who are doing this and they call endovascular specialists in my practice myself my practice more endovascular than Cardiology right this is because I wanted it to be that way my I have a very passion for what I do and so peripheral vascular disease can be treated so we I want to identify ourselves who is more into this field Than Just A cardiology so that is beautifully explained so you don't have to say anything I'm just kidding no but that's nicely explained because you're looking at Cardiology everybody just thinks it's of the heart period And yes there's the whole the freeway system and then the byway system and this system that's this and you deal with all of that um Dr kosarakis if you were to also explain what you do all day every day I know in complement to what uh Dr Raja is talking about how would you describe your role uh very different from Dr Raja we are both Interventional cardiologists and we both we both have training and then the vascular procedures but in my practice I see primarily coronary artery disease and about 20 30 percent Peripheral arterial disease but as Dr Raja was mentioning Interventional cardiologists are traditionally trained in doing the same things we do in the legs but in the coronaries smaller arteries a little more precise medicine so we have training in the same same type of tools are very similar the ones we use for the heart and the ones we use for the leg except that they're a little bigger and bulkier so the training there's a lot of overlap but since there's been so many advances in Interventional Cardiology as all of medicine transitions to a less invasive approach there's so many different things even within Interventional Cardiology that not all Interventional cardiologists practice endovascular medicine some just specify a specializing coronary interventions there are those that specialize in valve and structural interventions okay and there are some that do a little bit of everything okay nicely explained that that's great too because that helps me direct different questions in different ways what I'd like to do is start off relatively generically and plainly in describing what and I know we've called it several different things there's Peripheral arterial disease peripheral vascular disease are those interchangeable number one and number two if you can describe what is happening in the body when we call it a disease it's something that is chronic you know sometimes there's things that are chronic but benign this is not benign this is something that can go forward unless it's treated so if we can describe what that is to the audience so they understand what we're talking about does that make sense sure yes um well the peripheral vascular disease or Peripheral arterial disease kind of a overlap but identifying exactly Peripheral arterial diseases disease of the arteries so let me explain a little bit so when the heart pumps the blood clean blood goes to the entire body by arteries so their clean blood gives oxygen to the entire body but when the oxygen is utilized and the blood has to go back into the heart to go to the lungs to clean up so it goes by the veins so it's like a arteries out veins in yeah since I-10 one is going this way one is coming that way then next to each other but they don't connect with each other so if you're talking about a disease of both so it's more like peripheral vascular disease these are vessels arteries and veins they're all vessels right so but if you're talking about just the arteries then you call it Peripheral arterial disease Okay so so the symptoms of how it happens it takes longer time and you know if you look at the different risk factors they are almost the same like coronary artery disease what are those diabetes which is if if it's not very well controlled high blood pressure which is not very well controlled your cholesterol is high and for particularly for Peripheral arterial disease if I have to really pick two or three main conditions which can lead to a diabetes smoking and kidney disease so it's not that diabetes leads to this the disease leads to diabetes for the most part no diabetes leads to yes all right so diabetes can be diagnosed way ahead of time and so this is another risk factor another outcome so when we talk about preventive medicine so if the diabetes is very well controlled you can really slow down the progression of peripheral vascular disease and coronary artery disease and others so here's a question and Dr kosarakis I love your name where's that from by the way you said you prefer to to pronounce it in the Hispanic way in the Spanish way what name is that for completely off the subject right it's it's Greek from the island of Crete so the kis ending is very characteristic of Greeks from Crete but I was raised in Mexico so okay so that's why you said I want to say the Spanish project I love that so kosarakis so I'd like to know is this something that is genetic so often we talk about Cardiology right you were talking about coronary disease arterial disease Etc how much of it is genetic and how much of it is lifestyle if it is genetic can you help by lifestyle etc etc because I know we're going to get to amputations eventually right um so genetics let's first start there how how much of this condition in both coronary and arterially and peripherally is a genetic it's all nature versus nurture and we essentially don't know exactly there's no specific Gene that makes you develop uh atherosclerosis or Peripheral arterial disease but there are genetic conditions that cause lipid disorders or disposed patients to having type 1 or type 2 diabetes or other risk factors that will eventually lead to early arterial disease or atherosclerosis uh so there is no specific Gene uh there have been studies where they look at even Twins or uh or next of kin and they look at different risk profiles and they'll separate their environments or twins that were raised in different environments they were adopted by different family members and they'll look at their different Lifestyles even if they have a high genetic risk multiple family members with with heart attacks or strokes but their lifestyle is very different your lifestyle can actually overcome your genetic risk in most cases so there is that nature versus nurture Theory but it doesn't mean that because it's in your genes you're gonna get it for sure Bingo and I I so am glad that you said that because I think some people think well I'm going to get it anyway and on that note again a lot of what we do with this program is prevention and if it's not prevention it's early detection so on that note a risk factor a is factor is genetics fine a small one but a risk factor and Dr Raja can you talk about other risk factors and then eventually we're going to go into if you know you have a risk factor how do you start countering those risk factors so that this may not get to a point where you do need an amputation right so one of the main lar the biggest risk factor is uncontrolled diabetes and diabetes um where the blood sugar is not utilized by the cells and it creates so much inflammatory process and it leads to multiple conditions and which is coronary disease if you really look into diabetes there are few things this condition does people who loses their the kidneys chronic kidney disease on dialysis that's one of the main complications of diabetes losing eyesight diabetic retinopathy is another one of the major thing diabetes leads to blindness and that is vascular is that correct right it's all related to uncontrolled diabetes okay and third is coronary disease and peripheral vascular disease so dummy that down for me a little bit so we're saying that is related vascularly so what is happening when you have diabetes and you're losing your eyesight what is happening to the vascular system are they is it just being constricted is there loss of blood flow Etc just ex if you pretend we have a model in front of us or a graph in front of us and and what is exactly physiologically happening so diabetes creates a kind of a chronic inflammatory process in your body's in the vessels the the the glucose sugar is not getting utilized appropriately by the cells and all of these leads to uh collection and development of atherosclerosis and you have the buildup of cholesterol in your In Your Vessel wall causing blockage and clogs Dr kostarakis you want to add something right so the underlying diseases atherosclerosis it's was collateral from fat it's lipid deposits in the vessel walls it can affect any artery in the body arteries in the eye so reducing the brain are reducing the heart and the kidneys then it eventually leads to Peripheral arterial disease coronary disease retinal disease blindness Strokes renal failure all those things the way it affects the vessels is by forming those lipids but those plaques the innermost layer of the arteries communicates with the bloodstream and depending on the conditions it can dilate or constrict to improve or or decrease blood flow when you have plaques those areas that are covered in lipid or scar tissue or inflammatory cells are not communicating very well with the bloodstream and it leads to what we call endovascular dysfunction first which is usually abnormal vasoconstriction and eventually occlusion and blockage from disease progression okay and so what we see is coronary disease Peripheral arterial disease kidney failure blindness are sort of the end complications of atherosclerosis okay in so I want I want to get away from diabetes for a minute I know we have a huge a very very large population basis diabetes in town um in this area in general but aside from diabetes are there Lifestyle Changes lifestyle what exactly can people do if they know that they're at high risk whether it's diabetes genetics or just that they know that their vascular system is compromised in whatever way what is it that they can do to prevent further damage to their system so we call it there are something there are some risk factors you can do something and there are certain risk factors you can't do anything right like age you're gonna get old you can ever yeah I'm learning how to stop that I just want to let you know no but I get it right yeah or apart as we talk about genetics there are certain things you carried not that much but there are certain things which you do have a control over it for example high blood pressure right high blood pressure has same sort of effects on the organs if it's not well controlled right second thing is smoking right right so smoking is uh so much of a preventable condition which also affects the heart the kidneys brain stroke heart attacks and all that lifestyle exercise or is the one of the best thing you can do overweight obesity like sedentary lifestyle all of these things leads to you are not burning you're fat right right so this fat has to go somewhere and that starts building in your in a simplest way uh building clogging your arteries and you're start developing all these conditions So when you say exercise I think sometimes that scares people away so it literally could be walking right and we could just start off with walking and the reason I'm saying this is of some we have an audience and that's something's like oh yeah diet and exercise diet next so what does that mean to them and again we're looking at this is basically a disease that affects again what we're talking about in the beginning your feet your legs your knees your buttocks your thighs so everything that's on the bottom part of you if you simply get up and walk around at least start with that and feel free to to compliment on that yeah so I think uh it's a exercise I like to separate walking is okay it's better than nothing but it's a very low bar most of us good point yeah and Roger did this I don't know if he did it consciously or not but he separated sedentary behavior and exercise because you could be sedentary and exercise two or three times a week but then you go home and you turn on the TV and that's all you do right so being active walking around you know walking to the grocery store if it's closed walking your kids going to the park walking your dog that's avoiding that's being active avoiding sedentary behaviors but then there's exercise exercise has the same purpose as not being sedentary but I also use it as a warning sign I tell patients if you're gonna have problems with your vasculature you're gonna notice it if you exercise your chest is going to hurt if you exercise before it starts hurting when you're resting same thing with the legs right good point so a lot of people don't separate those two so I appreciate you saying that very much um I'd like to talk about so I know that there's a CLI program at Memorial and I'd like to talk about what that is so it's critical limb ischemia program what exactly is that and we can kind of talk about the program at Memorial from there as well okay so critical Lim ischemia it's uh if you start a condition um one two three as it gets three four it gets worse and worse and worse so like Peripheral arterial disease the fourth symptom is uh clortication there's a term called meaning that when you're walking after walking a block or so your calf starts kind of uh tiring and start hurting or cramping you have to stop for a while and it goes away so that's just like a we call it rather for class three that among the definitions of it that's because the arteries which takes the blood to your legs are narrowing or some of them are blocked but still you're getting enough blood that you are okay if you're not walking or all that so and are they narrowing because of the buildup that's in the arteries is that specifically why they're narrowing exactly okay it's narrowing by the plaque okay the fat build up into the arteries okay or they're becoming hardening their calcific calcification developing and you're feeling it when you're walking because that's when the blood's going through right so when you're sitting down your leg muscles they don't need too much blood right right I get your point so when you're walking your muscles need blood and if the artery is narrowed you're not getting enough blood so suddenly you have a lack of blood and the symptom of that is pain it's just like when you walk and start having chest pain that means one of the arteries of the heart is blocked so you slow down you stop it goes away now take it to the extent where you have so much lack of blood to your feet that you start developing wounds right okay you have you know for example diabetes is where one of the things in diabetes is a neuropathy uh you start losing sensation on the feet they've kind of become numb right so it's very common that you have diabetes you have a neuropathy and you're walking barefoot at home and you hit something a nail or something you never felt it or never felt it right so now you develop a tiny wound usually within a week just goes away but if you don't have blood if there's blood yes right so if you don't have blood so then that wound is gonna get bigger and bigger and that's one of the main reasons you lose your limbs right so that is called critical ischemia people who have a very Advanced peripheral vascular disease where the chances or risk of having a major amputation is very high so in Memorial we have developed a very strong program called critical ischemia program which actually got accredited by a joint commission what does that mean is it a big entity in this country which comes and sees what are we doing okay there are different standards and are we fooling all these standards what are our outcomes what is our amputation rate and all that and then if they agree that we are doing what a center of excellence does then they give you an extradition you'll be surprised to know that in the entire country of United States there are only two no centers who have Center of Excellence by a joint commission for Peripheral arterial disease and we have one here and Memorial it's one of them way to go memorial right be sure for the last and we collect our own data right um and we have a committee so this disease itself you can stop me because I can keep talking no this is good because I didn't know that before coming here so this is good to know so this condition itself critical Lim ischemia it needs more than one doctor more than one person why uh because it needs somebody to diagnose it right somebody need to go and fix the circulation it could be endovascularly surgically but that's a part of it after that if somebody has a wound you need infectious disease doctor to take care exactly right to take care of the infection you need a wound care physician to take care of wound you need a podiatrist if you need any sort of a minor amputation so you need uh we call it a Circle of Care so we have developed a CLI team we have more than 10 different Specialties working together the whole purpose is how can we help this patient with very Advanced disease to prevent amputation So when you say very Advanced disease give me an idea of what that means so if you're looking at and again this is about prevention right so we're at a point where and let's just say uh to bring you into this discussion as well let's just say there is a person has diabetes or they're feeling numbness in their feet diabetes or not and now there's a wound that's starting and the wound's not healing and like many of us we're like oh that'll get that that'll fix itself eventually and what I'm trying to get to here too is when does somebody know when to go to the doctor because they know they have diabetes let's say they know this and they they know that it just takes a lot longer for things to heal when did they know it's bad enough to go and that is to me one of the biggest questions where people just there are some people who are hypochondriacs and go right away there's a large percentage of people that's like how do you describe to a family member that you need your your person to come in and get this checked out I would say anyone with risk factors anyone that has diabetes high blood pressure smokers strong family history who has to wound anywhere in the lower extremity below the need that worsens over a period of a week or two or doesn't heal over a period of three to four weeks that size that there's something wrong with either the healing process or the blood flow or oxygenation to that part of the leg so anyone with any of those should have some kind of vascular study ultrasound or some other type of uh screening study okay so let's now think that somebody's watching this at home and they don't know where to go and is this something that they would go and maybe and there's quite a few people in this town that don't have a primary dog that don't have an internist should they go to the emergency room should they go to a clinic should they go to where should they go if they don't have a doctor already and I know that's a tough question to throw out there but when people are watching and listening they're like okay yeah sure but now what and then that's where the overwhelming portion comes in it's like well I don't know what to do I don't exactly know who to call can they call Memorial can they call this department I mean that's just a general question that the audience would like to know one of the benefits of having a CLI program is that there is always someone on call for the program it's like having a a heart attack doctor on call every day in the hospital by having a CLI call team meeting so there's always going to be someone taking those patients at Memorial Hospital to diagnose the disease right away how advanced it is and whether the patient needs medical therapy only an Interventional procedure or an amputation or some other type of therapy so the CLI program is only at Memorial so I would say if there's any concern go to Memorial okay but other ERS other urgent care clinics and primary care physicians can also refer the there's the word goes out there but the memorial is not the only one there's other clinics that do similar types of procedures but are not accredited for CLI management like Memorial is so that would lead me to my next transitional question of diagnosis you're having these issues you're having these problems and how do you know what's going on so how is it that that you all diagnose what's and maybe it's someone who hasn't been diagnosed with diabetes yet or etc etc but they're having these issues what is the process of of scanning diagnosing these patients well it starts with the symptoms okay so it depends how advanced the condition is it could be just achiness and heaviness on walking to an extent though you already have a wound right so usually what usually happens is if someone develops a wound they think it's problem in the foot and they go to a podiatrist the football center right so actually foot doctors are kind of Gatekeepers of Peripheral arterial disease it's just very interesting because uh patient most of the time they don't think they have a vascular problem they think they have a toe problem so first thing what we did and obviously I think most of our Podiatry colleague they know is the education of how uh wound on the toe is related to a poor circulation so usually what happens is a patient shows up either in in the hospital or in the podiatrist first thing the thing is they just check the pulses check and then think oh there's no pulse so they call the Physicians like CLI Specialists we call them and so what we do is then we start our workup for example examining where the pulses the poor pulses and Sensations and all and then there's some basic simple tests available for example arterial ankle brachial indexes just like checking a blood pressure in the ankle and the arm let's say you blood pressure and the arm is 120 or 80. and the ankle is 50 over 30. oh my right so why is so low is because there's some blocked arteries not letting the blood go down to the food so that right away tells you something is not correct so then you can go in detail developing a sonogram so sonogram is you're kind of looking at those arteries and see oh there's a blockage here and it kind of and eventually uh the gold standard is an angiogram which is uh going putting a catheter and taking a pictures of all the arteries where they start and where they end how long is the blockage and then just describe that if you don't mind so the angiogram what are they they're putting a Catherine to the groin into the artery in the groin right because I find this fascinating that you can do this so describe how that test is done so um angiogram is we don't use much groin anymore okay we use wrist oh wow it's because it's uh I've been doing this for too long lost all the new stuff yes last time when I came and now it's there's so much change oh my goodness yeah for good better change right right so uh one of the issues used to be that you know going to the groin it can bleed cause yeah so this is much more secure easily controlled relating and all okay so when the heart pumps blood it Blends pumps up all over so the all the arteries that connected to the heart right right so I don't interconnected with each other right yeah so you can put a catheter from here and go all the way down to the legs see now I'm just thinking your limbs are there's there's so much more room to get to from here to the heart versus the groin to the heart but we have long Catholics yeah okay so then we go all the way down to the aorta and down into the arteries and all like all we can go all around to the knee and take pictures all the way down to the toes wow and it gives you a beautiful picture of what's happening right yeah because all these other tests like abis or sonogram they are not 100 sure you can miss something so that's the once you've done angiogram you you know exactly how severe is the disease and then depending upon that you make a decision how kind of a treatment procedure he or she needs that is a perfect transition into treatment right so now we we see that there are things wrong going into treatments now and and that will lead to amputations when it when and if they're needed so treatment plans for different people I know everybody's different every case study is different but give me some case studies or some ideas of treatments that that go on from there the treatment really depends on the so the disease is a spectrum so it depends on how far Advanced you are in the disease Spectrum that's those are your available therapies when we talk about CLI that's sort of the end stage of Peripheral arterial disease those patients need usually need interventions they have complete blockages usually more than one artery of the leg so they need some form of intervention but you can start treating the disease in the beginning stages when it's just early atherosclerosis or early stages asymptomatic but with signs of of buildup you treat with Aspirin cholesterol medicine and what we call risk factor modification controlling the diabetes controlling the blood pressure controlling the cholesterol levels and exercise good diet and avoiding sedentary Lifestyles the more advanced you are in the disease and the later you catch it the worse the blockages are going to get we sort of separate CLI from claudication because patients with claudication usually have severe blockages but not usually complete blockages patients with wounds from arterial disease will have complete blockages so the treatment is a little different but most times the first step is to do the angiogram diagnose the severity and the location of the disease and some kind of endovascular procedure that means balloon angioplasty putting tiny balloons crossing the blockages with little wires expand playing the patients are like the the strings in the piano they go in from the wrist or from the groin you cross the blockages with that tiny wire you use that wire as the tracks on the train and over those tracks we advance tiny balloons for extensive needed into the vascular inside of the artery because your arteries have to be pretty strong to be able to to handle that I mean it's uh they're pretty sturdy yeah you have to have I like to think we have some degree of finesse right uh but they you know but I think that we have some degree finesse but they are pretty sturdy you know a lot of this artists are heavily calcified uh sometimes you can see the artery without injecting and it looks like almost like bone like thin bone right because there's able to take that out while in this process or I know you're opening it up but are you I don't know if that's even a possibility to be able to take some of this plaque it's one of the therapies once you figure out exactly what's making up the plaque if it's calcium if it's mostly just fat there's different devices uh we call them atheractomy and the whole idea as to what we call the bulk so you're trying to take as much of the stuff out of the artery before you balloon or put a stent into it that so that's interesting to me is I always think about coronary I know this is not peripheral but coronary artery disease when you go into the the neck as is that a possibility to do in the neck uh arteries as well uh yeah it's done stents uh most commonly is surgeons will do an endotherctomy where they'll actually open it and clean it but if the patient is not a surgical candidate they'll put a stent in there okay they don't usually do the bulking or atherectomy because pieces will go to the brain oh goodness it's tiny pieces go down in the leg we have special filters they do have them in the brain too but the risk is much higher in the brain than it is in a couple of toes but that's one of the things we do before we do atherectomy we use specialized filters that'll catch little debris from going down to the distal leg okay and so when you're talking about these off breaks that I think we often use the word just clot when we think about Strokes or whatever so that would be designated a clot so to speak right and going see this this is yes finesse is a good point um so now let's do talk about a point where a person is getting to the point where they're going to have to have some kind of a an amputation and I'd like to kind of start with toe amputation then food amputation and then going up from there does that usually and always start with a wound that won't heal does it start with you know like you said there's a lack of blood flow a lack of oxygen to whatever lemon I'm just thrown out to to either doctor either Dr Roger or Dr costarakis um whoever wants to take that first and feel free to kind of piggyback on each other too okay well let me talk a little bit about amputation and then get a little more detail about this amputation okay as you uh you're uh showing is saying telling the statistics about the 150 000 amputations uh are done every year in this country and if you look at those amputation of 150 000 how many of those patients really had the angiogram what we are talking about or some kind of intervention something done earlier than getting to the point of amputation no before if somebody shows up with a wound or a tall gangrene uh 70 to 80 percent of the patients they go directly to amputation without even trying to figuring out maybe I can save this lag this is I'm talking about nationally and internationally some people they think some there's a I hope this is all thinking but it's still there many people that think including doctors that if someone has uh gangrene of the toe if you amputate the toe you are done with the problem right so that's wrong why if you look at the statistics of people who have major amputation meaning below any amputations 25 are dead within a year and 50 percent of the Dead within three years worse than breast cancer and a colon cancer right so this is just a little bit about amputation amputation is the last things you should ever think of the bottom line is it's not the answer it's not amputation absolutely it's not the answer so having said that so if someone has let's say oh wound on the great toe big toe of the foot the problem is not the toe problem is the entire leg right circulation to the left yeah circulation Could Be Blood above the knee below the knee right so there was a concept and there is a concept now that well I'm diabetic well I'm gonna lose my toe and eventually I'm gonna lose half my foot and I'm gonna lose all my legs why because nobody ever fixed the circulation which is the bottom line problem right right right so when we see these patients with a toe is black it's a gangrene of course the toe is no more alive and needs to be amputated but what I'm thinking is how can I save the rest of the leg because you can have amputated toe and you have a good blood flow and it heals and you can wear the same shoes and you have a normal life right but if you are not treated correctly then eventually you're going to lose the entire leg right exactly so this is the concept of critical and ischemia program that we have this policies May build in that if you see somebody with this okay first thing is angiogram where is the disease let's get together all of us and figure out how can we best treat that and if you do that like in our Memorial curriculum ischemia program our amputation rate major amputation is five percent nationally is 15 to 17 oh my yes okay so I'm going to go back to you because I want I want to I think it Bears repeating the treatment measures so we are again you're finding patients who are not at risk I mean they're full-blown in the disease and then treatment of them not getting to the point of amputation again walk me through that unless I'm just not unless I'm not getting it so we're talking about these Interventional you're going in you're opening up the arteries you're opening up the vascular system is that the treatment and how good is that so we're talking about stints that are going in there do those last forever do those last for several years does a patient come back and and check on it later or is that only done because they're having more symptoms that's where I'm trying to to find out it's like once you know you've got this problem you want to avoid the amputation what are all the steps that are being taken to get to that point so it says Dr Raja explained it's a multi-specialty approach uh in the the part that I do and Dr Raja does is the sort of the revascularization process but also the continuous follow-up once you open the blockage the mentality when we're treating patients with CLI it's the whole life or limb mentality from old Warfare and emergency medicine anything that's going to risk a lamb or your life we should go all in against that and try to treat it so the first step is to revascularize and we sort of take a similar stepwise approach the first thing you do is the most simple the less risky which is balloon angioplasty and when we're revascularized seeing the the legs Perfection is not what we're looking for like when we're revascularizing the arteries in the heart you want to make sure that the residual blockage is zero in the horn exactly and bolex is a little different the the outcomes we're looking for are one wound healing and second amputation prevention so you may restore blood flow and have a not perfect result but as long as you avoid amputation and heal the wound the patient can reocclude the same artery and as long as they don't develop any wounds they may not need other interventions okay so that's where the continuity of care comes in because more than 50 percent of patients that have a peripheral vascular intervention will have reocclusion within three to five years that's changed based on the different techniques and technologies that have been developed in the last few years but they need a continuative care they need medical therapy aspirin Plastics but also anticoagulants at low doses the stent is sort of reserved as the last resort because once you put metal in the artery the risk of forming blockages actually goes up so we leave it as a last resort once the other therapies fail in the last few years special balloons that have a medical coating on them have been developed and the results are promising so the the risk of what we call re-stenosis or reocclusion has been decreasing over time so the balloon stays in no the balloon is used temporarily stretches it out and then comes out and then comes out okay those medicine coated balloons stay there for about four or five minutes and then it comes down and but that always comes out the stent States so whatever vascular uh entity it is ballooning how long does that stretching last does that make so if you're going in you're stretching out um that that earrings I know people have their esophagus stretched and like once every two or three years they have to go in and have it stretched again because cause they've got a you know hernia or whatever is that the same with the vascular system that it's just something you have to stay on top of um and and that's where do the symptoms come in in order for them to say okay I might have to have this done again and I guess that's done through sonograms at that point too right the diagnosis so this disease um what we are doing we are not curing right right and that's you know what I didn't say that right so this is chronic this is something you have for your life this disease it is no cure to it there's no cure to it but if we can prevent amputation for 10 years right I mean that's great absolutely absolutely so any sort of a treatment would be what we do uh you're talking about stretching um so yes stretching if you um is full of plaque and you go and you just push with a balloon uh the art is going to open and 50 of the time it's just gonna recoil because plaque has to go somewhere right exactly right so that's why we have atheorectomy where we shave off all the plaque so that we removing all this plaques so now that there's much much less plaque in in the artery the Lumen is bigger but again we are worried about that this tissue is going to grow again right so we use drug coated balloons and then the shaping of the plaque is that also what we're talking about earlier that you're you're worried that some of that might fall off or so that's part of the correct so we call it uh distal protection device embolization okay so you sort of cutting this and no matter how great the device is because you're so much plaque right right part of that can break loose so then we protect it so when you say shaving off and I'm just trying to follow through in my head how this is working you're shaving off some of that plaque and with the uh the stent or the the tools that you're using does it that suck in the plaque out immediately as you're shaving so there's a try to be mechanical about it does that make sense so there are different devices one of the devices is that there's a blade cutter and underneath there's a this much is is a nose cone which is like of a packing so every time you cut you pack inside that cone nose cone so one that's full you remove it and you take the plaque out see next time we do this video throw a video our way okay that would really bring I love the toys I gotta tell you because you can see what's going on it it helps me with my knucklehead brain to to understand what's going on but a video or two you know would be fantastic you'll be amazed how much advancement in peripheral vascular diseases happen for the last 10 years I I'm already amazed because I'm already talking even just now not going through the groin anymore you know I mean how how long has has the wrist been more of the option versus the groin has that been the last 10 years about 10 15 years jeez Louise okay it started in in the coronary space and pieces that went to the heart to the hospital with heart attacks uh when people started using the wrist the the mortality for the heart attack actually decreased from a decrease in bleeding complications less risk of hematoma pseudo-anoris those blood transfusions something so simple but because artery in the groin is easier to access it's bigger you could put bigger devices in it that's what we use for for 10 20 30 years right right exactly so another nice transition is is the future where where are we going now I mean we're looking at you know the differences from 10 or 15 years ago where do you see us 10 or 15 years from now and we're kind of bit like that that 10 minute Mark in the program anyway so I like to know about advances and I also would like to throw out to both of you if there's something we haven't talked about yet that we really want to get across this evening to kind of have that in the back your head to talk about before we close up but what do you see as advances in the next decade or so from the endovascular standpoint obviously um I don't think there is any patient we could call it we can't do anything for you so that's the first thing okay anybody uh who goes to any physician and is it's all well there's nothing can be done and uh you need amputation they need to have absolute second opinion and they look for physician who are doing come seek you out there's something you can do yes yes there's a lot of difference in different places so from that standpoint there are different procedures are getting developed uh one of them which actually I'm part of this is called uh uh deep vein arterialization procedure what does that mean is that people with critical ischemia the one with the wounds and gangrings about 10 to 15 percent of them they have absolutely no arteries and it's just got blocked a bit calcified and they don't exist anymore oh my they don't exist anymore you cannot find them Jesus we call them desert foot so it's like the body just kind of it's just calcified and it become like threads wow and those patients are like 100 major amputations right so a few years ago there's a new concept developed that how a partner each artery as I was saying is next to the vein the artery goes this way when goes that way but they're close together so the concept we how about we connect the artery to the vein and convert the vein into artery oh wow so you're converting it you're converting the artery right to the wind and to the vein so the vein now actually taking notice the unoxygenated blood but oxygenated blood opposite direction to the foot okay so uh there are multiple different clinical trials the recently in Union general medicine uh promise II trial um was published which shows about 70 percent six months amputation free survival I mean people 70 of the people they didn't have amputation when they were all 100 were scheduled to have amputation and I'm very thankful to Memorial that now we are part of that clinical trial third phase trial so we are bringing the technology to a memorial hospital because this is not available anywhere else these are non-option Pages yeah two in the country you said yeah that's impressive so that's one of the advantage of being you know yeah Center for excellence right so I see in the future Surgical and Vascular all sort of new technique every time you go to a conference it just gets amazed new catheters new wires do this this is like explosion yeah it's like a field trip every time yeah so when the doctors describe that it's like it's a field trip and we're buying stuff my wife says that uh for me it's going to the Disneyland I bet I bet it is and every year you don't know what's going to be so the rides are different every time that's right I like that I like that is there anything that we haven't talked about yet that you'd like to get across or anything that you want to add about what you foresee in the future yeah I think uh awareness awareness awareness one awareness about the diagnosis how to identify the disease the different screening studies and options and ABI is covered by every single insurance it's easy to do is non-invasive and I think every patient should have one during their annual exams um but also um who which Physicians Specialties to refer and when so that patients know their treatment options a lot of times they're referred to one specialty and that specialist says there's nothing to do and then the patient thinks there's no options so I think awareness about the different treatment options and different Specialists that provide that type of care is also very important and there's a huge lack of awareness about that even within the same specialty with another cardiologist about what Interventional cardiologists do in the peripheral space so I have a question on a normal General person who is not in the field of medicine and you know how Dr Google works right is there a website or a place that you would like to send people and and I do want to say this too with the El Paso County Medical Society if there's a question that you all have by watching this and I know that this is airing and you're like okay we it's it's over but if you can email your question to info epcms so the El Paso County Medical Society epcms.com regarding peripheral artery disease if it's something that we didn't hear about this evening or something that you heard and want to have an answer to email a question there because in the next show we'll be able to answer them for you because we're going to take a little bit of each show from the previous show and answer some of those questions on the point of online questioning now you can go to Google but it's Google I do a lot of my research on WebMD with this particular situation is there a Cardiology website that you like to point people to to educate themselves or not I just thought I'd throw that out because you were talking about information and informing yourself how would you have patients do that before getting to you but you but at the same time you don't want them coming up with all this stuff saying this is what I've got you know there's a there's a there's a fine line right okay so WebMD is a good start but it'll usually end up referring you to some kind of doctor 100 of the time yeah and that's that's my question not not for it to be an Advertiser if it's more for I want to learn about this disease and what are my options I think the American College of cardiologyacc.org website has a patient section where there's a bunch of different topics and they talk about diagnosis prognosis management options uh there's also the Society of cardiac angiography and interventions uh say that slowly Sky s-c-a-i Society of cardiac and geography and interventions and there's also a patient section there and this is more specific for interventions uh what type of options are there for patients but the American College of Cardiology is usually the the main one that I use for patient resources okay and I'll repeat those and also I'll give you a way to watch the show again but that's acc.org is one of them again ACC dot org another one is s-c-a-i dot org s-c-a-i.org on that note too if you are just watching this and you um would like to watch it again or there are some other things that you have questions about there are several places you can do that you can do PBS El paso.org and just look for local programs and you'll find the El Paso physician on there you can also go to the El Paso County Medical Society website that's epcms just think of El Paso County Medical society.com and then also and again you'll find the the program on there just through the logo and then YouTube so YouTube is one of those easy ones Everybody's Got YouTube and you can do youtube.com and just look up the the word the El Paso position the El Paso position and the great thing about looking it up that way is that as Dr talking to uh Dr uh raskis earlier and I said oh because you watched a couple of Cardiology shows before coming here and I said well how exactly did you find them because people find them in different ways but you went to PBS.org and it took to kcos and then you looked up Cardiology and it showed you all the different shows in the area of Cardiology you can do that with whatever type of program we have so um but again if you have a question regarding this show um talk to or ask via an email info at epcms.com but I want to thank you very much again we've had Dr Lake Raja with us who and I will say it again Interventional cardiologists and endovascular Specialists because that's a mouthful and a half and thank you for explaining what that is and uh Dr Ricardo costarukas I did it wrong so it's actually Greek but we're making it Spanish why not uh and we'll do it that way but you have been watching the El Paso physician thank you for for tuning in I'm Catherine Berg good night [Music] thank you [Music] foreign [Music] [Music] foreign [Music] [Music] foreign [Music] [Music] foreign