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Return to As Obesity and Diabetes Rise, Surgeons Expect Peripheral Artery Disease to Follow Overview

More on As Obesity and Diabetes Rise, Surgeons Expect Peripheral Artery Disease to Follow

As Obesity and Diabetes Rise, Surgeons Expect Peripheral Artery Disease to Follow

New York (Jul 5, 2011)

Clinicians screen for vascular disease with an ultrasound
Clinicians at NewYork-Presbyterian screen for
vascular disease using an ultrasound.
(photo credit: Ageliki Vouyouka, M.D.)

Vascular surgeons are concerned that an increase in the number of Americans with diabetes – projected by the U.S. Centers for Disease Control and Prevention to be as many as one in three adults by 2050 – will also bring a dramatic increase in the number of patients with peripheral artery disease (PAD). More than half of people with diabetes develop PAD.

It is not entirely clear how diabetes leads to PAD, though it appears that in diabetics, injury to the basement membrane of the blood vessels occurs. Atherosclerosis (hardening of the arteries) gradually develops, leading to stenosis (narrowing) and occlusion (blockage) that can dramatically reduce circulation to cause clinical conditions called "claudication" and "critical limb ischemia."

text from article

People with PAD may experience pain, numbness, achiness, cramping, and a feeling of heaviness in the legs, most frequently when walking or climbing stairs (claudication). If not treated and controlled, severe reductions in blood flow can cause pain at rest, ulcers, or gangrene (critical limb ischemia) and, ultimately in some cases, require amputation of the feet or legs. Indeed, each year in the United States, there are about 60,000 major amputations, more than 80 percent of which are due to PAD.

"Diabetes is increasing in the population, so we can assume we will see an increase in associated complications as well," predicted Darren B. Schneider, M.D. Obesity is a leading cause of diabetes in adults, fueled by declining rates of physical activity and the plethora of unhealthy dietary choices that many people opt for every day.

Darren B. Schneider, M.D.
Darren B. Schneider, M.D.

Professional organizations such as the Society of Vascular Surgery are spearheading national awareness efforts to encourage people with diabetes to learn how to control their blood glucose and to seek treatment early when they have symptoms of PAD. NewYork-Presbyterian has also recently opened two centers that specialize in peripheral artery disease: the Limb Preservation Center at NewYork-Presbyterian/Weill Cornell Medical Center and the Critical Limb Ischemia Program at NewYork-Presbyterian/The Allen Hospital.

Such programs bring together clinicians from various specialties, including podiatrists, plastic surgeons for wound management, endocrinologists, diabetologists, nephrologists, vascular surgeons, and nurses. Assembling a patient's healthcare team in one location expedites the delivery of the multidisciplinary care that people with diabetes need to head off PAD.

PAD most often arises in the legs and feet – most likely due to the dynamics of blood flow – but can also develop in the arms and hands later in the course of the disease. "PAD is a marker for systemic disease. So if we're seeing signs of it in the legs and feet, it is also likely to be affecting arteries in the kidneys, brain, and other parts of the body," explained Danielle R. Bajakian, M.D., F.A.C.S.

Danielle R. Bajakian, M.D., F.A.C.S.
Danielle R. Bajakian, M.D.,
F.A.C.S.

It is not possible to reverse the effects of PAD in the body, but it is possible to prevent further progression. For some patients, preventing PAD progression may be accomplished through lifestyle changes such as quitting smoking and managing high blood cholesterol and hypertension (high blood pressure). These changes slow or halt the build-up of plaque in the arteries. "Prevention for the diabetic is critical," said James F. McKinsey, M.D.,
F.A.C.S. "It is easier and more effective to prevent complications than to treat them."

In people with diabetes, blood glucose control requires the expertise of an endocrinologist (hormone specialist) who can help the patient achieve a hemoglobin A1C level below 7. (A1C is a blood test that measures how well blood sugar has been controlled in the previous three months.) "If we can get the hemoglobin A1C level under control, patients have a better chance of saving their legs and of achieving better outcomes if they need PAD treatment," noted Dr. Bajakian. Taking diabetes medications as prescribed, getting regular physical activity (one hour of cardiovascular exercise at least three to four times a week), and eating a low-fat, high-fiber diet are excellent ways to control blood glucose levels.

James F. McKinsey, M.D., F.A.C.S.
James F. McKinsey, M.D.,
F.A.C.S.

People with diabetes must also take meticulous care of their feet, Dr. McKinsey added. Diabetes can cause nerve problems that diminish sensation in the feet, making it difficult for patients to know when there are blisters or sores present that may become infected, and which may take longer to heal because of the reduced blood supply due to PAD. Patients are advised to wear comfortable footwear, trim their toenails carefully, and take common-sense precautions to protect their feet.

For some patients, however, lifestyle changes alone may not be adequate to control PAD, and doctors may recommend a procedure to reopen or bypass blocked arteries and enhance blood flow to the affected limbs. "We have to be aggressive in trying to revascularize the limbs of people with diabetes and PAD to reduce the risk of amputation," explained Dr. Schneider.

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Today's revascularization techniques include bypass surgery, in which the surgeon uses a vein or a manmade tube to divert blood flow around the blockage; and minimally invasive approaches such as angioplasty, where surgeons insert a balloon that widens the artery in the narrowed area; stenting, which is done during angioplasty to insert a small mesh tube into the narrowed blood vessel to keep the artery open after angioplasty (some stents are coated with medicines to prevent further blockages); and atherectomy, which utilizes special catheters that can remove plaque from the inside of arteries.

In a person with diabetes, the best approach is to see his or her health-care team early to prevent PAD before it develops or to halt its progression if it has already started. Concluded Dr. McKinsey, "The more we can work with patients to be proactive rather than reactive, the more active they can be, and the better their health will be."

Contributing faculty for this article:

James F. McKinsey, M.D., F.A.C.S. is the Chief of the Division of Vascular Surgery at NewYork-Presbyterian/Columbia University Medical Center and an Associate Professor of Clinical Surgery at Columbia University College of Physicians and Surgeons.

Darren B. Schneider, M.D. is the Chief of Vascular and Endovascular Surgery and the Director of the Center for Vascular and Endovascular Surgery at NewYork-Presbyterian/Weill Cornell Medical Center. He is also an Associate Professor of Surgery at Weill Cornell Medical College.

Danielle R. Bajakian, M.D., F.A.C.S. is the Director of the Critical Limb Ischemia Program at NewYork-Presbyterian/Columbia University Medical Center and an Assistant Professor of Clinical Surgery at Columbia University College of Physicians and Surgeons.

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