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Melanie Cole (Host): Welcome, we’re talking today about peripheral vascular disease. Do you know what it is? Do you know what the symptoms are and who is at risk? Well we’re going to find out from my guest, Dr. Brian Tiu. He’s a vascular surgeon and a member of the medical staff at Temecula Valley Hospital. Dr. Tiu, explain a little bit about peripheral vascular disease. What is it? And does it differ from peripheral arterial disease? Are they the same thing?

Dr. Brian Tiu (Guest): That’s a good point, actually yes. It’s just a different term – they’re just different terms for the same disease. Generally we say peripheral vascular disease, but in fact it is a disease of the arteries, and what it entails is blockages that prevent blood flow from getting through the muscles and skin and tissue of our legs or feet. That’s the peripheral part of the disease and it just – are these blockages that can cause some problems down the road.

Host: Who is at risk for these kinds of blockages?

Dr. Tiu: The patients that are at risk are usually the elderly. Unfortunately as we age the arteries tend to get harder, and they start to develop blockages, and these blockages are – people with an increased risk include patients who are hypertensive, patients with diabetes, patients with elevated cholesterol, and the number one risk patients are those who smoke cigarettes. You know, people try to concentrate on the lung effects of cigarettes, but a lot of the other toxins that are in the smoke that they inhale will actually damage the artery then cause blockages themselves. And so actually when I talk to patients that’s the number one risk factor that I tell them if they could stop smoking, they can possibly prevent this disease from occurring or even getting worse in the future.

Host: Dr. Tiu as you talk about those risk factors, and when we talk about symptoms, many people get a pain in the calf when they’re exercising or when they’re just sitting there and they think to themselves, okay is that a blood clot in my leg? Or do I have peripheral vascular disease? Is there anything that specifically would point symptom wise to someone to say, you know what maybe I better get in and get this checked because we get a lot of pains in our legs, and especially women who maybe have varicose veins or any of these other things, how do we know what it is?

Dr. Tiu: Another good point. So peripheral vascular disease develops over time, so usually the symptoms will be gradual. So there’s different stages as to how these symptoms develop. First the patients usually get pain with walking, so that’s the first essential step. The reason we get that is, as we walk the muscles and skin require more oxygen and nutrients and energy in order to continue walking, so when that demand is higher than the amount of blood that can get down there, that’s when we start to develop pain. Then the next level is when the blockage is so bad, patients start to get pain just at rest, and the reason why patients usually get them in the calves in terms of peripheral vascular disease, is the area in which gets blocked is usually around the major vessels in the thigh and just above the knee, that’s just the area that’s more prone to developing these blockages, and so to compare it to the pain usually with a blood clot, the blood clots usually have other symptoms associated with the pain. Sometimes patients will have swelling, they may have skin changes in terms of their – in the color, but the pain associated with peripheral vascular disease is a little deeper as well. Usually it’s the muscle itself that’s exhibiting this pain and it’s sort of crampy, there can be a little bit of burning, not necessarily stabbing in nature.

Host: So that was a great explanation and thank you for that because people do get confused and some of it all kind of ties in together with those risk factors. So how do we diagnose it? What are some of the imaging studies or treatments that, you know, diagnosis that you might use if somebody comes to you and they have those types of leg cramps or pains above the knee and those muscles, and maybe they have some of those risk factors. How do you diagnose whether they do have peripheral vascular disease?

Dr. Tiu: Right, so the diagnose again is always with a history and physical. I have the patients come in. We talk about their lifestyle and I ask them about the risk factors themselves, whether they’re hypertensive or not, if they have a history of diabetes, do they smoke. Does any vascular issues run in the family? For example, I ask them whether they’ve ever had a heart attack or a stroke or has anyone in the family has because those are the genetic risk factors that may increase their risk of peripheral vascular disease. So once we get that basic history, I’ll take a look at their pulses – that’s the basis of every vascular exam is to check the pulses, whether they be pulse in the arms. Sometimes they can be weaker the further out you go, especially towards the feet and I take a look at the quality of their skin. Is it dry, is it shiny? And just to see how their sensation and strength are in terms of their legs. So once we finish the physical exam then I’ll usually get – the very first step is what’s called an AVI. That’s checking the blood pressure and comparing the blood pressure in their legs to their arms. That gives us kind of a quick and dirty way to see how much perfusion is going down the legs compared to the arms, just because the legs are usually more involved. The next step I would likely get is what’s called an arterial duplex, which is just an ultrasound. With this, we’re able to look inside the blood vessels, check how much blood flow is going through the major arteries in our legs, and it can estimate how much of a blockage there is. And then depending on how much of a blockage there is, and in combination of the patient’s symptoms, that’s when we’ll talk about treatment.

Host: So then what does treatment look like? If you’ve determined after those kinds of tests that yes there is some blockage in there or yes there’s some build up of plaque in these arteries of your legs, what do you do first for the person?

Dr. Tiu: Yep, so it definitely depends on the level of their disease in terms of how symptomatic they are. So if the patient’s coming to me and telling me after maybe 5, 6 blocks I start to develop this calf pain, that’s early stage disease, and we can talk about treating the patient medically and that involves trying to reduce all the risk factors that we had previously spoken about, making sure they’re on their blood pressure medication, their diabetic medication, making that they stop smoking, and then we talk about the diet and exercise. You know, we want the patient to be on a low cholesterol diet, low fat diet, avoid salty foods to help control that cholesterol, and an exercise program. We essentially use the same exercise program as the American Heart Association, where it’s a 30 minute brisk walk three times a week, and what that does and what I explain to the patient, is your body will start to adjust. When you walk that far and you start to feel a pain, your body knows that I need more blood to areas that are developing pain, so the patient’s – the branches along the arteries will start to develop and become larger and help bring that – and deliver that blood down to the leg. So then when the symptoms start to get worse, say the patient comes in and can only walk maybe a block or two, that’s when we’ll offer them an intervention. So interventions range from minimally invasive procedure, all the way to surgery. So we always start with the minimally invasive procedure, and that’s what’s called an angiogram. With that, I’m able to access directly the blood vessels, shoot a picture using x-ray and dye in order to highlight the blood vessels and localize where these blockages are, and then with the use of wires and balloons and maybe even a stent, open up these blockages and allow the blood to continue on. And that way, if the blockages are small enough that we can use the balloons and stents then that’s it for the intervention, but if the blockages are too large and unable to be crossed with the wire or with the balloon, then we’ll talk about a surgery which could be anywhere from just cleaning out the blood vessel or what’s called a bypass.

Host: What about medication? Would blood thinners or anything along those lines be used if a person does have a restricted blood flow in their legs or arms?

Dr. Tiu: Yeah, currently though the blood thinners are used just to essentially alleviate symptoms and prevent blockages from getting worse. Unfortunately, even in 2019, there’s nothing that can reverse the disease. So some of the medications we’ll use include baby aspirin, that does thin the blood out a little bit and allow the blood to traverse all these blockages and get to where they need to go. I’ll also make sure the patient’s on a statin, make sure their cholesterol’s controlled, again because it’s these cholesterol deposits that create the plaque in our artery. Sometimes we’ll go even a little stronger than the aspirin. Sometimes patients will be on Plavix. It’s just a stronger version of aspirin, again it is somewhat of a blood thinner. And then there are medications, one in particular, called Pletal that is used to deal with the pain that’s associated with PVD, but it’s hit or miss with a lot of patients so I don’t prescribe it too much, but it’s mostly about controlling the risk factors rather than trying to just cover up the symptoms with medications.

Host: That would seem to be what really all of this is all about, you know prevention so that you don’t have to control some of those risk factors. Give us your best advice, Dr. Tiu, for preventing peripheral vascular disease in the first place.

Dr. Tiu: Yes that’s great. So pretty much every doctor will tell you diet and exercise, and it really does go a long way in terms of your circulation and peripheral vascular disease because the healthy diet will ensure that your blood pressure is controlled. It will ensure that your sugars are controlled for diabetes. It’ll make sure that your cholesterol’s controlled, and all three of those things unfortunately when combined make your risk even higher. So really just a healthy lifestyle, having some daily exercise if possible, otherwise every other day type of thing. It really goes a long way in terms of keeping your circulation in check, and preventing the blockages that are associated with the peripheral vascular disease.

Host: Thank you so much Dr. Tiu, it’s such important information for those of us to hear, and to hopefully prevent it. Thank you again for joining us. You’re listening to TVH Health Chat with Temecula Valley Hospital. For more information, please visit temeculavalleyhospital.com. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole, thanks for tuning in.