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My name is Thomas Reifsnyder, and I'm a
vascular surgeon at Johns Hopkins.
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My job as a vascular surgeon basically is
one of education.
Every patient that we see we try to
educate not
only about their disease but about what
the treatment options are.
And I try to guide them to what
would be the best treatment modality for
their disease.
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One of the things that absolutely amazes
me is that people will undergo an
amputation
of their lower extremity and not get
a second opinion before their leg is
removed.
Peripheral arterial disease requires a lot
of expertise and a lot
of experience to be able to treat in the
best fashion.
I frequently get phone calls from
physicians and family members of patients.
Telling me that their loved one is going
to require an amputation.
And when I see those patients as a second
opinion.
Frequently the repair or the re, or the
necessary surgery to save that limb is
known as, it, is easily done and
something that can absolutely change the
patient's life.
Its much better than to do a fairly
significant operation
and save a limb than it is to undergo an
amputation.
Many surgeons and many physicians out
there
believe that an amputation solves the
problem.
You can get an, a prosthesis and you'll be
able to walk again.
And you don't have to undergo multiple
procedures to try to save that limb.
Most patients can actually undergo one or
two sophisticated operations
and save a limb, which will absolutely
change their life.
Peripheral Arterial Disease which, which
used to be called Peripheral Vascular
Disease basically is blockage of the
arteries going to an extremity.
Technically, it could involve blockage of
arteries going to the arm or hand.
But that's uncommon.
The most common is blockage to the lower
extremities.
Millions of Americans have peripheral
arterial disease.
The most common presentation is no
symptoms whatsoever.
In other words, they go to their doctor,
and the doctor cannot feel their pulses.
There are millions of people in America
who have decreased circulation in their
lower extremities,
but because they're getting older, they're
not
as mobile, they don't have any symptoms
whatsoever.
Those patients we don't typically see as a
vascular surgeon.
The more common presentation for a patient
with peripheral arterial disease,
is someone who develops pain in their
calves or legs when walking.
That is called lower extremity
claudication.
In the past, we didn't treat that very
aggressively because
it's not a threat to the patient's life or
limb.
However in this day and age where we have
a variety of minimally invasive
techniques particularly in the younger
patients who have this
problem we may aggressively treat it with
angioplasty and stenting.
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The, the risk factors for peripheral
arterial disease include smoking,
diabetes, high
cholesterol, and one that we don't really
think about, but just aging.
As people get older their blood vessels
tend to wear out.
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Peripheral Arterial Disease is manifested
most commonly as.
No symptoms what so ever.
the.
The patients gets a routine physical
examination and the doctor.
Can't feel pulses.
Unfortunately a lot of Americans don't
exercise enough.
And if you don't exercise.
Or don't walk very much.
Then, there's not a large requirement for
blood flow to the legs.
And so you could have peripheral arterial
disease and not know it.
The most common symptom for peripheral
arterial
disease is what we call lower extremity
claudication.
And the term claudication actually means
to limp.
Patients don't actually limp with this.
But what they do get is they get pain in
their calves or thighs after a certain
distance of, of walking.
The nice thing about peripheral arterial
disease
is that it's very easy to diagnose.
People with lower extremity claudication
have that
symptom every day whenever they walk that
distance.
It's not like one day they can walk a
block, and the next day they can walk a
mile.
It's at one block their calves start
hurting
or a calf starts hurting consis,
consistently every day.
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The patients that are the toughest
patients to treat are those who
present with poor circulation to their
lower extremities and severe peripheral
arterial disease.
These patients can present with a lot of
pain in
the foot clearly they won't be able to
walk too far.
And sometimes they'll actually present
with ulceration or gangrene of the foot.
These people clearly are clearly need to
be treated and
or otherwise, they could end up losing the
function or, or actually losing their
leg depending upon the location of the
disease.
Whether it's in the arteries near the
aorta versus the arteries in lower
extremity.
These patients can be treated with
angioplasty and stinting,
or they can be treated with lower
extremity bypass procedures.
A totally different group of patients are
the diabetic patients.
Diabetes tends to not only effect the
lower extremity arteries,
but also extra it also affects the lower
extremity nerves.
And the root cause of almost all diabetic
foot problems is
the fact that diabetics don't have normal
sensation to their foot.
This doesn't this, this doesn't allow
feedback from their foot so that if they
develop a blister they continue to
traumatize
that blister until it turns into a ulcer.
And in the worst cases, that ulcer then
gets infected and can threaten the whole
foot.
Diabetics sometimes will have normal
circulation to their foot
and sometimes they will have poor
circulation to the foot.
So treatment of a diabetic ulcer of the
foot really depends upon
whether or not it's infected.
And then whether or not the patient has
poor circulation.
The treatment of the diabetic foot problem
can involve
just local wound care, it can involve
partial reconstruction
of the foot, or partial amputation of
toes, toe, or toes of the foot.
And or it might involve restoring normal
circulation depending upon the situation.
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In the last couple of decades the
treatment
of peripheral arterial disease is really
undergone a revolution.
There have been a large number
of minimally invasive techniques that have
they've
really become quite common, and are quite
widely available across the United States.
And what I'm talking about is angioplasty
and stinting.
Angioplasty is inserting a balloon into a
blood vessel and
opening up the balloon and therefore
opening up the blood vessel.
Years ago, you might do angioplasty on a
blood vessel
that is narrowed but only narrowed over a
short distance.
And nowadays, the techniques are available
where we can actually take
totally blocked up blood vessels and be
able to reopen them.
Generally, this, this also involves
putting in a stent,
which is sort of a metal scaffolding that
sorta
looks like a Chinese finger trap, and that
helps
keep open the artery over a longer period
of time.
In the worse cases the patient would need
a lower extremity operation or
a lower extremity bypass operation to be
able to restore the blood flow.
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The concept is really very straight
forward and very simple, they
have a blockage and you need to bypass
from above the
blockage where the circulation is still
normal to below the blockage
where the circulation ha been reduced, so
the idea is very straightforward.
The actual surgical part can be a little
tricky at times and most of the time
what we do is, is we create a new blood
vessel out of the patient's own vein.
So you are taking a vein which normally
carries blood to the heart.
And making it into an artery which now
will be supplying blood to the extremity.
As with most procedures in American
medicine nowadays.
We've gone to more minimally invasive
techniques.
And in vascular surgery, minimally
invasive techniques involve
angioplasty and stinting, or reopening
blood vessels with
a balloon or a, a little metal stint or
scaffolding to keep the blood vessel open.
The real advantage to these procedures are
that they're
minimally invasive and therefore are low
impact on the patient.
Most of these procedures are done as
outpatients they can be
done under local anaesthesia with just a
tiny bit of sedation.
And generally take one to two hours to
perform, and the patients then are, are
recovered for
only an hour or two, sometimes three or
four
hours and then can go home that same day.
Most patients really feel nothing other
than maybe a
little soreness at the site where the
procedure is done.
Which will go away in a couple of days and
basically can
re, resume normal or more activity than
previously within a day or two.
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Johns Hopkins has a wealth of experience
in
treating lower extremity arterial disease,
or peripheral arterial disease.
Over the last decade Johns Hopkins has
added two new endo suites.
Which are operating rooms that, where you
can not only perform angioplasty and
stenting.
But also operating rooms where you can do
open operations.
Or you can combine those two techniques.
The new Johns Hopkins Hospital will, will
be opening.
Which has even more sophisticated
facilities
for the treatment of peripheral arterial
disease.
I think the most important aspect of the
treatment of peripheral
arterial disease is having an experienced
surgeon taking care of you.
It's not only the techniques involved, but
it's
the decision making that is most, most
important.
Aggressive treatment of lower extremity
arterial disease will result in
limb salvage and maintain the amb,
mbulatory status of the patient.
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