(upbeat music) - [Announcer] The region's premier medical information program, "Call the Doctor."

- Circulatory systems, those maps of blood vessels in the body affect every organ.

Vascular disease is the name given to any number of conditions that can inhibit that system.

We're gonna discuss some of the more common vascular diseases with the experts.

We'll talk about how they're found and how they can be treated.

Vascular disease on this episode of "Call the Doctor."

(mysterious music) Welcome, hello, we are so glad you're with us for this season and this episode of "Call the Doctor."

We're gonna be discussing vascular disease, vascular issues, and the vascular system in general, and I can't wait to get right to tonight's panelists.

We've been speaking the last hour or so, and really excited to introduce you all to them.

Thank you all for being here.

We're really, really glad you could join us.

I would love to start by just asking you to introduce yourselves and talk a little bit about where people can find you.

- My name is Deepika Kalisetti.

I'm an interventional cardiologist.

We are a group of 10, 11 cardiologists, hyphen, interventional cardiologist and electrophysiologist, a group called Great Valley Cardiology, part of Commonwealth Health System, located in Scranton, Pennsylvania.

- Great, thank you.

Welcome.

What about you?

- Hey, Julie.

Thanks for having me.

My name's Ben Keyser.

I'm a vascular surgeon from Evangelical Hospital in Lewisburg, Pennsylvania.

As a vascular surgeon of vascular practice, we focus on, my partner and I, we focus on diseases of the arteries and veins throughout the body.

- All right, great.

Welcome.

What about you, sir?

- I'm Yaqoob Mohyuddin.

I'm a general cardiologist.

I am with the Lehigh Valley Health Network, and I practice in Hazleton.

I've been there 14 years, and we take care of general cardiology, heart health, and then we are responsible for really identifying patients that need further interventions and referring to our colleagues in vascular surgery and interventional cardiology.

- Great, should be a good panel.

Thank you all for being here.

I realize this first question is kind of, might be silly for all of you who have your medical degrees and have been working for how many years, but I would love to talk about first the importance of the vascular system, what it is, how it works, what it does, and then we can get into what happens when it malfunctions.

So I'll give that to anybody who might want to take that one.

- So the vascular system in our body consists of about 60,000 miles of blood vessels.

- [Julie] 60,000 miles.

- That's correct, 60,000 miles of blood vessels in the human body.

That can be arteries, veins, small arterials, capillaries.

The heart is responsible for pumping blood out, and the arteries carry the blood to the rest of the body, and then capillaries are where the veins and the arteries burst together.

All the nutrients, the oxygen is delivered to the tissues, and then the blood returns to the heart through the veins.

- When I was thinking about this, researching this, I thought, "How often do we even think about our vascular system for all the important things it's doing?"

Go ahead.

You were gonna say something?

- Well, I think the interesting is, to piggyback on what you were saying, the diseases of the cardiovascular system, it's really a systemic problem.

It's not specific to one of those areas of blood vessels.

And so by systemic problem, what I mean is that it's the buildup of typically we're talking about plaque and blockages in these arteries.

That can manifest in a wide variety of different ways throughout the body, the brain or in the neck, in the carotid arteries in the neck, it can manifest as a stroke.

In the legs, it can manifest as pain when you walk or pain at night and at rest, or ulcers or wounds forming on the feet.

In the abdomen, it can result in pain after you eat and weight loss, things like that.

Of course, in the heart it can manifest as a heart attack.

But this is all the same systemic process just manifesting in many, many different ways.

- So what I'm hearing really is that there are many different types, and they're all going to present in many different- - Various manifestations.

- Ways.

- Of where typically the problem originates, of like Dr. Keyser mentioned.

If you are talking about the arteries that supply nutrients and blood to your brain tissue, it manifests as neurological symptoms like, for example, what everybody knows as a stroke.

Of course, there's many, many kinds of stroke.

Your individual symptoms might vary, but it's called a stroke.

Similarly for your legs, like wounds, pain, and pain when you walk, pain at rest at night, is because of blockages that happen to the arteries of your extremities, similarly to the legs and your hands.

Similarly, there are coronary arteries having blockages, manifest as chest pain, trouble breathing, shortness of breath, and heart attacks.

Again, abdominal pain, meaning pain in your abdominal area as a result of blockages that supply, blockages in the vessels that supply blood to your colon, your liver, your spleen.

And similarly, even the arteries to your kidneys, where you have uncontrolled hypertension, blood pressure.

I mean, kidney disease blockages to the kidney arteries can manifest as such.

- I heard you mentioned arterial versus venous, and I understand that there's a difference between arteries and veins, but can you discuss, is it just size or what is it exactly that, what is it about?

- So arteries bring the blood from the heart out to the periphery in the body.

So the heart pumps, blood goes through those arteries either to the brain or to the arms or legs or intestine, wherever it needs to get to.

The blood then filters through whatever organ it's going to, say it's to the kidney, does the job that it needs to do for that organ, supplying that organ with nutrients and oxygen, and then it needs to get back to the heart so it can continue to go through the lungs, pick up more oxygen, cycle through the heart, and go back out again.

But to get back to the heart, it goes through veins, okay?

And so when we're talking about peripheral vascular disease, usually we're talking about plaque building up in those arteries.

In other words, blockages in the road for blood to get to where it's going out in the periphery.

Venous disease is very different in that a lot of times what we're talking about is blood having a hard time getting back to the heart, and that can come about for a variety of reasons.

Perhaps a DVT or, in other words, a blood clot.

A history of that can cause an obstruction or a blockage in the veins, and it's harder for blood to get back.

That can cause swelling, pain, things like that.

Wounds and ulcerations in the leg.

Other things that can occur with the venous system or veins actually have valves in them.

So I call them one-way check valves that help blood get back against gravity, back to the heart.

When blood is going through an artery, it's being pumped by the heart, and so it's under a lot of pressure.

- Forced pressure.

- Forced pressure.

Where as veins, there's no pump to send the blood back, so we depend on valves in those veins.

Those valves can wear out over time.

It's very common.

And when that happens, blood doesn't move as effectively or efficiently as it should, and it can pool in the veins, it can cause a buildup of pressure in our veins, and that's how you get things like varicose veins, swelling, and, like we said, some ulcerations in the legs.

So two very different systems, two very different problems that you can get.

- I'll go to you Dr. Mohyuddin.

Oh, you wanted to say something on that?

Go ahead.

- One of the things that also differentiates the arteries and the veins, the arteries tend to be thicker.

They're more muscular, thicker, smooth muscle because the pressure in the arteries are higher, and, like Dr. Keyser said, the pressure on the veins are lower, the veins tend to be thinner, more fragile.

Another way, I think, to think about the vascular system or the arteries, I'm gonna make it a little simple, is think about the highways of the streets.

Blood vessels are really no different than that.

So you can have potholes on those streets, in our streets, and I'm sure none of us like those.

(Julie chuckling) So same thing happens with the arteries.

If the arteries, the biggest risk factor for vascular disease, especially arterial vascular disease, is hypertension or high blood pressure.

So increased pressure can cause tearing and shear injury and that can cause tearing and problems and disruption of the inside of the blood vessel, the arteries, and then the body repairs it.

You have plaque deposition.

Plaque consists of calcium, cholesterol, and the cells that heal those plaques, and that is what causes a plaque.

Those plaque can constantly rupture.

So when those plaques rupture, they can cause an occlusion of the blood vessel, can cause a heart attack if it's the artery in the heart.

It can cause a stroke if it's in the carotids and a piece of plaque goes to the brain, or same thing in the leg.

So vascular disease, arterial vascular disease, is the same regardless of where it is, whether it's in the arteries of the neck, the belly, or lower extremities.

- What are some of the more common types of vascular issues that you see in your practice?

I mean, there's gotta be, there have to be- - All of this.

- Countless of them.

But you see everything all the time?

- All the time.

(Julie chuckling) - Yes.

- So it's funny that you mentioned streets and roads because I was just thinking about that on the way here.

I was driving on Route 80 coming from Lewisburg, and there was an accident or something, I don't know what it was, but Route 80 is shut down.

And I use this analogy all the time with our patients.

The highway route, in fact, I usually say if you're going from Lewisburg to State College, you would normally would wanna take Route 80.

In my case here today, I was going the other direction, and the road was closed.

So what did I do?

Well, I got off Route 80 and I took all these back roads.

I was going through towns I've never heard of (everyone chuckling) and Route 3, 39 and 93, and then eventually I ended up here.

I was late, got here late, but I got here.

And it's the same thing in, let's say, you said, "What situations do we see?"

Let's talk about the legs.

And I mentioned the word claudication before.

Claudication is pain in your leg when you walk or when you exercise.

And the reason you get that is because when you're at rest, when you're sitting here like this, the blood, if there's a blockage in the main artery in your leg, or maybe not even a 100% blockage, maybe a 80% block, whatever it is, blood is having to take the back roads.

It's getting off the highway and taking the back roads.

Our body is incredible in that there aren't, there's not just one main highway to get from here to your leg.

There's a bunch of back roads.

And so if there's a blockage, the blood will get there, but it might not be as efficient.

It might be late getting there.

And so if when you're sitting there at rest, it's no big deal.

- It's okay.

- But as soon as you get up to move, you go up a hill, a lot of people complain of, "Pain in my calf or my thigh when I go upstairs or go up a hill, or if I walk more than two blocks, I get horrible pain.

I have to sit down and rest, and then the pain goes away."

That's because as you're exercising, your muscle's demanding more oxygen, and it just can't get it as efficiently as it should.

And so if those blockages build up slowly over time, your body actually develops more and more back roads.

- Side roads.

- Yeah, it's like PennDOT, if they have time, can build bypasses around a road that's chronically, like the Schuylkill Expressway in Philadelphia.

- Right (chuckling).

Please.

- They're constantly trying to build roads around it.

Your body does that too.

And if you, over time, if the blockages come slowly, and actually if you keep, and we can talk about this a little bit, but if you keep exercising and pushing it through the pain that you have, your body will grow more and more what we call collateral blood flow around a blockage.

- You can teach your body.

Basically.

- Correct.

Correct.

Now to allude to what he was saying, if it happens (snaps fingers) rapidly, so you mentioned plaque rupture.

So if we have plaque in our body that's causing a blockage, say it's an 80% blockage, and all of a sudden a piece of that plaque breaks off and goes sailing down your leg, it can clot the whole system off.

The artery goes from a 80% blockage to a 100% blockage.

That happens in the heart, that's called a heart attack.

It happens in the leg, and then all of a sudden it's an emergency.

It can lose your leg over that.

It happens anywhere in the body.

But that's what he was alluding to.

- Well, before we get it to that point where it's coming up your leg or it's going straight to your heart, where...

I'll start with you.

How do we know if we even have these issues?

Is there a genetic component?

Will I feel pain?

Will I feel any, how do I know if I have an issue?

- So the risk factors for vascular disease are high blood pressure, smoking, high cholesterol, inactivity.

They're fairly common with the risk factors for heart attack, stroke, and blood vessel health in general.

So most of the time, people, what they don't realize is that we don't really become symptomatic from obstructive vascular disease, meaning vascular disease because of blockages, till the blood vessel really becomes 60 to 70% stenosed or narrowed.

So the process of of plaque formation or narrowing of the blood vessels actually starts fairly early.

Back in the '70s, they did studies in recruits to the Air Force, and they found that 5% of 'em had plaque, early signs of plaque developing at the age of 18.

So this is a lifelong process, and by the time a person becomes symptomatic, they usually have a blockage that's 60 or 70% at least.

And the symptoms of vascular disease, the most common symptom for vascular disease in the legs is claudication, like Dr. Keyser said, meaning pain with walking.

Or the other way to think about is angina of the legs.

It's no different than having pain in your chest when you walk, and you stop, it gets better.

That's classic claudication.

Now folks can have pseudoclaudication from back pain, narrowing of the nerves coming out of the spine, but that actually does not get worse with activity and doesn't get better with rest.

So classic claudication, classic symptoms of vascular disease, are pain in the chest with walking or activity or emotional stress or pain in the legs for peripheral arterial disease with walking and better with rest.

- But, Dr. Kalisetti, I heard you say earlier that sometimes you're seeing people, and it's very, very late by the time they've discovered there are problems.

Are there ways to get people earlier?

- Yes, early recognition of symptoms, right?

When I, for example, I'm just gonna give, the only way I can tell you what I mean is giving you an example.

For example, I get a new referral for a patient to be seen for chest pain that's been going on.

So I almost always screen every patient that comes through my office for vascular disease because when they have what we call coronary artery disease, meaning the same disease pattern, and 50% of them have vascular disease.

And when you do vice versa, almost all patients with vascular disease have coronary artery disease.

- Ah.

- So it's all about, because the patients themselves probably don't recognize their symptoms, because they don't know where it's coming from or what's causing it.

So early recognition, meaning questioning your patients when you meet your first patient.

Screen them, screen them with questions, screen them with questions of what it would mean if you had this.

So early screening is very important, and actually identifying their risk factors.

Once you identify the risk factors, appropriate management.

Getting their diabetes under control.

Of course, I'm not gonna be doing that, but that's what you would recommend.

Getting their lipids under control, their cholesterol numbers under control, getting their blood pressure under control.

Tobacco use.

Extremely unforgiving addiction, (chuckles) right?

I mean, it is the epitome for vascular disease probably.

It causes vascular injuries straight off the bat and progressive disease.

You could just be a smoker and have this and have no other risk factor.

- [Julie] Wow.

It does that much damage?

- Yes, so when I said they're so far gone, first, this is how you recognize patients early in the process of this disease process.

When patients come to you sometimes, it's pretty late in the game.

These are patients with wounds, like Dr. Keyser was mentioning, and they've been in wound care being treated for a wound on their foot, for example, for months.

I think recognition is important.

The basic problem probably is the patient doesn't give it much thought.

They go to see a doctor pretty late in the game.

They've had a wound already for three to four months or they've been through wound care for some unknown, like, I don't know, what would you say?

- Months.

Yeah, yeah, yeah.

- Like a lack of recognition probably.

I think you have to screen these patients with wounds for vascular disease straight off the bat, as soon as you know they have a wound.

- And when you say screening, you mean a simple conversation?

- Conversation and testing.

- [Julie] Oh, and testing, so what kind of test?

- And it's very simple testing.

It's a duplex study.

It's a 20 minute test.

It's a ultrasound of the arteries, of the affected area, and an ultrasound of the veins because even venous problems, problems of the veins, causes wounds and ulcerations, which can be long term and very, very morbid.

So simple test.

That's how you recognize this disease pattern early on.

I mean, once they've had a wound, it's not early on, but then at least they can be referred to the right pathway, like to a surgeon or a specialist who wants to work on them early on than wait months.

And because that would eventually mean tissue loss, meaning amputation of some sort, a toe or a foot or a below-knee or an above-knee amputation, depending upon how bad, unfortunately, their extremity looks like.

- The good thing though is that early recognition and risk factor modification can really, in most cases, keep people out of the operating room.

And so what it sounds like, you guys probably do the same thing in your practice, but if I meet somebody who maybe came to us for leg pain, and we're trying to figure out, is it the result of vascular disease?

We do an ultrasound is where you start.

And that's a quick, cheap, easy way to determine if that's what the problem is.

If it turns out that, yes, you have peripheral vascular disease, okay, couple other things need to get done.

We need to screen you for coronary disease, for heart disease, okay?

So a stress test or what have you.

And I'm not a cardiologist, but our office is in the same office as a cardiology group, and we work hand in hand.

And so if we see somebody for the first time, and they've never had a stress test, well, then they get to go see the cardiologist and get their stress test to determine, is there a problem there?

I also get carotid ultrasound on these people to make sure there's not significant plaque in the carotid arteries, which could cause a stroke.

If you have plaque in your legs or peripheral vascular disease, you've got at least a 30% chance of having something here and a 30% chance of having something in the heart, and so those things need to be looked at.

And we go through, what are the risk factors, so are you a smoker?

We know that smoking, active smoking, increases your risk of cardiovascular, so either heart attack, peripheral vascular problem, or a stroke that increases your risk automatically, 25% right there, and so- - [Julie] It's pretty high.

- So that's that high cholesterol, we know that, and a lot of people are on statins, so you've heard people being on Lipitor and things like that.

Getting that cholesterol under control is critical.

We know that if we can get your LDL levels down to, say, under 70 or so and do that on a statin pill, we can reduce your risk of cardiovascular complications and stroke by at least 20%, okay?

So these are numbers that are not insignificant.

And so being on an aspirin, that's important too.

There's a lot out there about, especially in the last year or two, we heard- - Aspirin or no aspirin.

- Maybe don't be on aspirin.

- It depends upon the patient though.

- And so, yeah, there's a big study that came out that kind of scared everyone into- - [Deepika] Not taking aspirin.

- Thinking maybe they shouldn't be taking aspirin, and I think that's an important topic to touch on.

We know that aspirin also reduces your risk of cardiovascular complications by 25% or so, and where that study was, it didn't really tell us anything new.

What we know is that people who don't have risk factors for cardiovascular disease probably should not be on an aspirin.

- On aspirin, yeah.

- If you're in our office, (Deepika chuckling) you're there because you have cardiovascular problems, so you're gonna be on an aspirin, but any of these risk factors we've talked about alone usually is a reason to be on an aspirin as well.

So managing those risk factors, and then diabetes as well, keeping your A1C.

We know that for each rise of one point in an A1C, it's another 20% risk of- - Vascular.

- Of complications from vascular disease.

- Ugh.

- So that's really important, yeah.

- I think it used to be that whenever somebody turned 50, we would say, "Here, take an aspirin daily."

- Right.

- There you go.

- That's gone.

- Right.

Right.

- So initially when the news that the U.S. Preventive Services Task Force came out with a recommendation, it caused a lot of confusion in our practices, and we see patients who have established vascular disease.

So if they have established vascular disease, meaning if they've had a TIA, a stroke, heart attack, blockages in the arteries of the heart, blockages in the arteries of the legs, they absolutely need to be on an aspirin, a baby aspirin.

So those are not the patients that can forego the aspirin.

Aspirin is a good medication, it prevents vascular events, but the reason that the recommendation was taken away for everyone is because aspirin can increase the risk of bleeding.

So when we weigh the risk and benefit in someone who does not have established vascular disease, that risk and benefit does not favor aspirin, but for the patients that we are seeing, they absolutely need to be on aspirin.

- I mean, just check with your own doctor, I'm sure, is absolutely always the way to go 'cause everyone's different.

- Yes, absolutely.

- With just a few minutes we have left, I'd like to get into treatment, and I know there's no way for one treatment for all of these diseases we've been talking about, but I know since, there is surgery as an option, you mentioned a couple of medications.

What might be, I guess we'll go around, what might be your first or what might be some of the conversations you have with your patients?

- Patients, yes.

It's all patient-centered.

Okay, I mean, of course these, again, I think this, here comes here guidelines come into play, and, of course, sometimes it's all patient-dependent.

We have to throw guidelines out of the window, unfortunately, in certain situations, right?

So when it comes to, briefly, when it comes, every segment has its criteria for treatment, like there's guidelines written in stone, for example, for carotid disease, right?

We only treat when it reaches a certain level of severity, meaning the certain amount of narrowing of that artery.

And this day and age, carotid disease, there's role for surgery, 100%.

There's role for stenting.

There's role for medical management, depending upon the severity.

It all depends upon the patient's symptoms and the narrowing of the carotid artery.

When you talk about the legs, again, symptomatic patient, do you medically manage them or do you want to offer them treatment right off the bat in other means or fashion?

Yes, medical treatment, there are a couple medications that you wanna try them out.

They don't take the disease away.

They improve their walking distance.

If they could only walk a block before, they might be able to walk maybe a block and a half or two, and this only works in a third of patients, mind you.

- [Julie] Hmm.

- So 2/3 of the patients are coming back to you in three months in their follow-up visit saying, "This is not for me.

This has done nothing for me."

- Hmm.

- And that's when you sit down and talk about what needs to be done or what can be done.

- About one minute left, so go ahead.

- Oh.

- No, you're welcome.

You didn't finished (chuckling) - So, and when it comes to that, we are figuring out whether these patients have disease that belongs on an OR table with a vascular surgeon or somebody who would do in a minimally invasive fashion in the cath lab or in any, in a catheterization laboratory, in an endovascular technique, which is a minimally invasive option where we could, the patients, their same day of procedures most of the time, and they go home, get to home the same day.

But depending, that option, it all depends upon what they have.

It's very different from patient to patient.

- I can imagine that is true.

- Yeah, so basically if I, we don't have a lot of time, but break it down into two things, one being symptoms in the leg, same thing.

What I do is we put people through, at our hospital, we have a very good cardiac rehab program that actually works on the legs as well.

It's kind of a newer thing over the last two years or so, where we put them through a program on a treadmill three times a week, where they walk.

It's sort of like walking with a coach there, and it forces people to walk further and further and further every time.

And we're finding that people are typically walking three times further before they have pain, three times further distance when they're done with that program, and it's extremely effective if and when that, well, that pretty much always works.

But if it doesn't or patients who are more severe, say they can't walk at all or they have pain at rest, in that case, then I offer them either a stent, like what she was referencing, a stent, and if that doesn't work, a bypass, so think open heart surgery, but in the leg.

We take your own vein, we take it out, I sew it in right somewhere here and tunnel it and put it down, and sew it in down at the bottom of the leg.

- If you say so.

(chuckling) - To deliver blood.

Exactly.

And then the same thing for the carotids in the neck.

We're trying to prevent a stroke there, and we know we don't do carotid surgery on anyone typically.

If they're not having symptoms, we don't do it typically if they're less than an 80% blockage.

A lot of people are alarmed when they get an ultrasound and it says 60% blockage.

And I try to tell people to don't worry too much.

With medical management, we can really reduce your risk of a stroke.

Once we get over 80%, then your risk of a stroke starts to rise.

- [Deepika] Go up a little higher.

- And then depending on the anatomy, it's either an open carotid surgery where we make a big incision on the neck and clean out the plaque by hand or I put a stent in, depending on patient specific.

- Well, I wish we had more time.

I really do have a lot more questions, and I appreciate your time very, very much.

That's gonna do it for this episode of "Call the Doctor."

We're so glad you've joined us.

For all of us here at WVIA, thanks for watching, and we'll see you next time.

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