Cardiovascular Report
Winter 2017

For many patients with peripheral artery disease (PAD), the early signs of these blockages that typically target blood vessels in the legs are nearly imperceptible—a twinge while climbing up stairs or after a long walk and pain with exercise. Eventually, that pain, also known as claudication, progresses to persistent discomfort, even while at rest. Finally, these insidious symptoms become impossible to ignore, morphing into ulcerations on the feet or even gangrene that requires amputation.

But this doesn’t have to be the story for most people with PAD, say Johns Hopkins vascular surgeons Ying Wei Lum and Christopher Abularrage, who specialize in treating this condition. Personalized care with a team approach can preserve patients’ limbs, function and quality of life.

As part of a patient’s first visit, schedulers ensure that the patient is seen as quickly as possible by the appropriate specialists. In this multidisciplinary approach, the specialists seen may include vascular surgeons, surgical podiatrists, wound care experts and often endocrinologists, because PAD is frequently a consequence of poorly controlled diabetes.

Appointments typically include testing in the Intersocietal Accreditation Commission-accredited Johns Hopkins Noninvasive Vascular Laboratory to confirm the diagnosis and extent of PAD in the patient. Studies conducted may involve physiological testing of the legs—including an ankle brachial index with waveform analysis—to give an overall diagnosis of the extent of the disease or a duplex ultrasound to view the anatomy and the blood flow within the different arteries to determine the precise location of the disease.

Once Lum and Abularrage interpret these findings, they and other members of the team suggest a treatment plan. For those in the early stages of PAD, Abularrage explains, conservative management is often enough to permanently prevent a patient’s disease from progressing. “Exercise therapy, controlling blood pressure and cholesterol, managing blood sugar, or smoking cessation may be all that many patients need,” he says. “It’s important not to overtreat.”

As patients develop rest pain, ulcers and tissue death—symptoms of critical limb ischemia—treatments become more aggressive. For short blockages, angioplasty and stents can be placed with endovascular techniques. Longer blockages require a surgical bypass. For intermediate-sized blockages, Lum is leading Johns Hopkins’ efforts in a multicenter trial known as BEST-CLI to investigate which of these therapies is the most appropriate.

A central goal in very advanced cases, marked by ulceration and gangrene, is to help patients avoid amputation, Lum says.

As patients follow up after treatment—every three to six months for the first year, then less often if their recovery is progressing well—the focus of the entire team is to help them live full lives, Abularrage says. “People want to play golf, walk without pain,” he notes. “The goal is to get them back to normal life.”