Aug 2, 2019 The Dangers of Poor Circulation

Leg pain and wounds that don't heal can be signs of a serious disease.

leg painGetting older comes with aches and pains, so it’s easy to assume that all of them are normal. In some cases, however, leg pain can be a sign of a serious medical problem. Consider the case of a Monmouth Medical Center Southern Campus (MMCSC) patient who commuted to New York City for his job. He had smoked all of his life, and his legs were aching. The pain became so debilitating that he had trouble walking from the bus station to his office and had to take disability leave. He made an appointment with Aditya Mehra, MD, Director of the Vascular Institute at MMCSC, and discovered that he had peripheral vascular disease (PVD), in which cholesterol builds up inside arteries, which carry oxygen and nutrients to tissues throughout the body.

This reduces blood flow to limbs and sometimes leads to complete blockages. Dr. Mehra’s patient had severe arterial blockages in both of his
legs, which caused his walking problems. Dr. Mehra placed stents in the patient’s arteries to improve blood flow, and the patient’s life changed dramatically. “He went back to work and is fully functional now,” says Dr. Mehra. “And his lifespan has increased.” PVD affects about 8.5 million Americans, according to the Centers for Disease Control and Prevention (CDC). About 12 to 20 percent of people older than 60 have the condition, which also interferes with wound healing (especially in the lower extremities, such as the feet and legs). “We talk about heart disease, but we don’t talk enough about PVD,” says Rajesh Mohan, MD, Chief Medical Officer at MMCSC and an interventional cardiologist.

“About one-third of patients who have heart disease also have PVD. Consequences of PVD do not appear to be as catastrophic as those of a heart attack. However, decreased mobility, pain and amputations are tragic results of untreated PVD that negatively impact quality of life. When blockages in the leg are treated and adequate blood flow is restored, patients can walk without leg pain and with a smile on their face.”

Comprehensive vascular pain 
“The Vascular Institute at MMCSC was established with the vision to provide comprehensive vascular care—from noninvasive and invasive diagnosis to interventional, minimally invasive treatment and state-of-the-art wound care by a highly trained and qualified multidisciplinary team,” says Dr. Mohan. The team at the Vascular Institute diagnoses and treats PVD, as well as an
array of vascular problems, including aneurysms, carotid artery disease, wounds that don’t heal, and varicose veins. This team includes interventional cardiologists, radiologists, interventional radiologists, vascular surgeons, podiatrists, infectious disease specialists, primary care physicians and nutritionists. “We collaborate on patients’ care in order to give them the maximum benefit,” says Dr. Mehra.

The Vascular Institute is the only center of its kind in Ocean County with such a comprehensive, team-based approach to caring for patients who have PVD. PVD is, unfortunately, underdiagnosed. If a person has a leg wound that isn’t healing, he or she may not be aware that a vascular problem is to blame. “If a person doesn’t have adequate blood supply to the lower extremities, the wound won’t heal,” says Dr. Mohan. “If a blockage in an artery is causing the problem, it needs to be fixed. Once blood flow is restored, it will help heal the ulcer or the wound.”

Similarly, many people dismiss their leg pain, like Dr. Mehra’s patient. “People know that chest pain might be serious, but they may ignore their legs because they don’t realize the problem is vascular,” says Dr. Mehra. “If a person has leg pain or a wound that’s not healing, it puts people at higher risk for stroke or a heart attack, and it could lead to limb loss.” “The team at the Vascular Institute at MMCSC takes pride in calling themselves the Limb Salvage Team, since this team-based approach is used to minimize the chances of limb loss by avoiding preventable amputations,” says

Minimally invasive screening and treatment
About 50 to 60 percent of patients who have undergone limb amputations have never been screened for PVD, says Doug Gibbens, MD, an interventional radiologist who served as Chair of Radiology at MMCSC. Screening is simple. A 10-minute test, called an ankle-brachial index, can help diagnose the disease. It involves placing a blood pressure cuff on your arms and legs to compare blood pressure in those limbs. The result tells the physician how well blood is flowing. If the result is abnormal, your physician may refer you for further testing. The next step is usually an ultrasound exam—which uses high-frequency sound waves to create images of the body—of the lower extremity arterial system, from the groin to the toes. “This tells us how well the blood is flowing,” says Dr. Gibbens. “It can detect a blockage and atherosclerotic disease (hardening of the arteries).”

Not long ago, if a patient was diagnosed with a vascular blockage, he or she would need bypass surgery of the blood vessels in the leg. “Over the last decade, more and more vascular blockages can be treated in minimally invasive ways—with tiny balloons, wires and catheters,” says Dr. Mehra. Interventional radiologists and interventional cardiologists use what’s known as endovascular therapy—minimally invasive procedures for treating PVD—such as balloon angioplasty or stenting. If a blockage is suspected, MMCSC physicians recommend an angiogram, in which a dye is injected into the arteries to make them visible on an X-ray. This test can identify any blockages. If a blockage is found, it can be treated at the same time. With a balloon angioplasty, the physician threads a tube with a balloon on the end through a blood vessel in your arm or groin to the site of the blockage. The balloon is inflated to restore blood flow to the clogged artery. In some cases, a stent—a small mesh tube—is used to keep the artery open. The patient is given conscious sedation, so he or she is awake during the procedure but doesn’t feel pain.

The procedure takes between 30 minutes to an hour, and most patients can go home the same day. “This procedure is even more effective than a bypass,” says Dr. Gibbens. The limb salvage rate for patients having endovascular procedures is 20 to 25 percent better than it is for those having surgery, he says.

Treating wounds that won't heal
Lower extremity ulcers—wounds that don’t heal or recur frequently—are often caused by diabetes, PVD and chronic venous insufficiency. Venous ulcers are caused by blood that pools in the lower legs due to abnormal vein function, and arterial ulcers are caused by reduced blood supply to the lower leg.

A wound that won’t heal is dangerous. About 30 percent of patients with a chronic lower extremity ulcer die from it, according to Matthew Regulski, DPM, a podiatrist. Those who have diabetes are at even greater risk: About 47 percent of people with a diabetes-related foot ulcer die from it. Even if you survive, you might need an amputation. About 84 percent of all lower extremity, non-traumatic amputations are preceded by a foot ulcer, says Dr. Regulski. People who undergo amputations are at increased risk of dying within three years.

Sixty-five percent of people who have below-the-knee amputations die in that time frame, while 80 percent of those who have above-the-knee amputations die in that time frame, says Dr. Regulski. Lower extremity diabetic and arterial ulcers are typically treated by restoring blood flow to the area. Venous wounds are treated by compression bandaging, which helps to reduce pain and swelling and improves blood flow in the area. “If you save a limb, you save a life,” says Dr. Regulski.

Should you be screened?
If you have any of the following risk factors, consider being screened for peripheral vascular disease:

• A history of smoking

• Age 65 or older

• High cholesterol

• High blood pressure

• Diabetes

• A family or personal history of heart disease

•You’re experiencing pain while walking

• You have a wound that won’t heal

Vascular screening at MMCSC

The screening test is simple and painless. It includes an ultrasound exam for aortic aneurysms and carotid artery disease, as well as a noninvasive measure of blood flow in the legs. Test results are reviewed by board-certified radiologists who develop a report that is forwarded to your primary care physician. For more information and to register, call 732.886.4363.

To learn more or to schedule an appointment at the Vascular Institute, call: 732.886.4363.