An Interview with Dr. John H. Rundback on Peripheral Arterial Disease

Dr. John H. Rundback on Peripheral Arterial DiseasePeripheral Arterial Disease occurs when blood flow to the extremities – in most cases legs and feet – becomes blocked due to the buildup of plaque in the arteries. American Endovascular’s Dr. John H. Rundback, regarded as one of the nation’s most respected interventional radiologists, specializes in complex endovascular interventions. The following Q&A with Dr. Rundback shares the risks, signs, and symptoms of PAD to help patients get treatment early.

Q: What are Peripheral Arterial Disease symptoms?

A: Most people are familiar with the hardening of the heart arteries or neck arteries, which causes a heart attack or stroke, but maybe less familiar with atherosclerosis (hardening of the arteries) affecting leg arteries, which is Peripheral Arterial Disease. When blockage begins in the leg arteries, patients may at first have no symptoms. As the blockage gets worse, patients may notice that, as they start to walk or exercise, they get heaviness, fatigue or cramping in their legs. That’s because the muscle’s needs for blood flow and oxygen are not met due to blocked circulation. As the condition gets worse and blockages become more severe, affected people may have pain at night when they elevate their legs and gravity no longer helps the blood flow. So, they have to wake up and either dangle their legs or walk around to relieve the pain.

In the worst form of Peripheral Arterial Disease, the circulation gets so bad that patients feel pain all the time, or get wounds that won’t heal, or even potentially develop gangrene. That’s called critical limb ischemia or critical limb-threatening ischemia, which implies those patients are at high risk of amputation if a procedure is not done to restore blood flow to the legs.

Q: What causes Peripheral Arterial Disease?

A: Peripheral Arterial Disease, due to hardening of the arteries, shares the same risk factors you’d get for Coronary Artery Disease – diabetes, high blood pressure, high cholesterol, smoking or smoking history, family history. Sedentary lifestyle, that’s bad. Our diets are not particularly good, we always recommend a western diet, and of course, if you already have coronary artery disease or blockages in other locations in the arteries in your body, you’re at risk for having the peripheral artery disease as well.

Q: What are the signs of Peripheral Arterial Disease?

A: Peripheral arterial disease may be asymptomatic. The first signs that people may notice include discomfort, cramping, or heaviness when they walk, particularly in the calf. That’s called claudication. Actually, it’s interesting, it’s named after the Roman emperor Claudius, who had a limp, although his limp turned out not to be due to poor circulation.

When you have claudication, you find that when you walk, you get cramping, but if you stop walking and rest, the pain goes away. Again, the symptoms can progress so they can be all the time or patients may have wounds all the time.

People may notice also they have brittle nail beds, they lose hair on their skin or their skin becomes shiny, or the muscle mass in the legs gets worse. Those are all associated signs.

Q: How is Peripheral Arterial Disease diagnosed?

A: Peripheral Arterial Disease is diagnosed when an individual who’s concerned about it knows to go see a doctor. That’s actually very important because the peripheral arterial disease often goes under-looked. Peripheral Arterial Disease is a coronary equivalent, it’s a hardening of the arteries affecting the leg arteries—you’re at higher risk for heart attacks and strokes.

So, if you understand the severity of Peripheral Arterial Disease, you may be more likely to see a doctor in the first place. Getting a diagnosis may not just save your limb, it may save your life.

Clearly, once you go to a doctor, some sort of evaluation is necessary and that generally starts with a good physical examination, listening to the arteries, and feeling for pulses at all points. Sometimes we can use an ultrasound which is held in your hand to evaluate this. In more detailed examinations, we’ll use a more specialized ultrasound, or CAT scan, to look for areas of blockage which might help with subsequent treatment if needed.

Q: How is Peripheral Arterial Disease treated?

A: Peripheral Arterial Disease treatment, fortunately, has evolved dramatically in the 27 years that I’ve been doing this. Certainly, when we first started, we were doing very basic things in angioplasty, which is the balloon procedure. It’s an interesting story that angioplasty was developed by an unconventional radiologist, who put sequential or serial plastic tubes in the artery, to stretch open the artery. He thought you were just taking this plaque from the artery and remodeling it like clay in a lead pipe, but in reality, what happens when you put a balloon into the artery and stretch it, is you cause some cracking in the artery and cracking in that plaque. So that you now restore a larger flow diameter of the artery.

The mainstay is certainly angioplasty (the balloon procedure), but we’ve evolved over the years to use many different tools including something called atherectomy, which can use lasers or other methods to physically remove or change plaque, or to remove the calcium deposits. We have devices that are called stents, which can tack open the arteries. We now have balloons and stents that can deliver a specialized drug to prevent scar tissue or re-blockage of the artery. We have tools that fix tears in the artery that happen to occur during angioplasty. Long story short, we have many different tools.

The precise treatment is often a decision made at the time of caring for the patient, so we can provide the best technology for any individual patient at any given time.

Q: Can you reverse Peripheral Arterial Disease?

A: Peripheral arterial disease can’t be reversed per se, but with optimal medical therapy, it can be slowed down. If you take 10 patients who have claudication, with good medical therapy, in 7 out of 10 patients, the disease won’t progress. You won’t necessarily reverse Peripheral Arterial Disease, but certainly, you can stabilize it.

The mainstay of any atherosclerosis treatment is good management of diabetes, high blood pressure, and high cholesterol. Statin medication is extremely important in these cases and monitoring and maintaining appropriate blood sugar levels.

Exercise can’t be stressed enough. We tell patients that if they take appropriate medications and walk, very often they can double the distance they walk before they get pain, although this takes several months to do.

If you take statin medications, other appropriate medications, and maintain a good diet and exercise, you can stabilize Peripheral Arterial Disease and may never need treatment.

Q: Is Peripheral Arterial Disease hereditary?

A: Peripheral Arterial Disease is hereditary, just like Coronary Artery Disease is hereditary. All these are manifestations of the hardening of the arteries, which can clearly be passed on through families.

Not only that, but the risk factors of Peripheral Arterial Disease are also hereditary – such as high blood pressure, diabetes and high cholesterol.

Q: Who is prone to getting Peripheral Arterial Disease?

A: It can be anybody, but certainly if you have a family history, you’re at risk. There’s an old Scottish expression, ‘What’s bred in the bone, will out in the flesh.’  If you have a predisposition toward this, or if anybody in your family has had a history of Peripheral Arterial Disease, heart attacks, or strokes, you are at increased risk.

Certainly other than that, patients who have those risk factors we talked about: Diabetes, high blood pressure, high cholesterol, smoking or history of smoking, and sedentary lifestyle; if you’re overweight if your diet is bad, those are the people at risk. If you have hereditary risks, and/or you notice symptoms, you should see a doctor right away, so you can get appropriate medications to help prevent a heart attack. We can get you to exercise programs to help you reduce or avoid or limit the number of procedures you need for your legs, and most importantly, so you can feel better and lead a balanced, healthy life.

Q: Is Peripheral Arterial Disease painful?

A: In its early forms, Peripheral Arterial Disease is not painful. As the disease progresses and blockages in the arteries limit blood flow to the legs, it can become painful. The first pain is claudication – as I mentioned, named after the Roman emperor Claudius who had a limp – where you have insufficient blood flow to your legs that’s not painful at rest, but when you start to walk and the muscles demand more blood flow, you experience pain because that demand can’t be met due to the blocked arteries.

As the disease progresses further you may feel pain as you rest. Or you may feel pain when you elevate your legs because gravity stops assisting blood flow.

In the worst cases, you get pain all the time, or painful wounds, which aren’t healing adequately. That’s an emergency – critical limb-threatening ischemia – and you’ll need a procedure to restore blood flow as quickly as possible to prevent an amputation.

Q: How common is Peripheral Arterial Disease?

A:  Peripheral Arterial Disease is actually fairly common. In the United States, our sedentary lifestyles have led to rising risk factors for obesity, diabetes, metabolic syndrome, and chronic kidney disease.

An old study, conducted in Boston, showed that 1.8% of the population under the age of 60, 3.6% over age 60 and 5.3% over age 70 had experienced symptomatic Peripheral Arterial Disease. So, as many as 5% of patients experience it. But the truth is probably some 20% to 40% of patients may actually have Peripheral Arterial Disease.

Unfortunately, in this country where we have bad habits, a tendency towards sedentary lifestyles, obesity and risk factors, those numbers are rising, and diabetes and metabolic syndrome and chronic kidney disease, all of which are risk factors, are also rising.

We’re seeing a rise in the prevalence of the peripheral arterial disease. Even more concerning, we’re seeing a rise in the rate of limb-threatening peripheral arterial disease or limb-threatening ischemia—patients who are approaching amputation. Those are the patients that we’re increasingly treating; patients who have pain or wounds that are just not relieved. Those patients stand at a high risk of amputation.

Just so you realize, up to 90% of amputations could be avoided if patients would see doctors who specialize in amputation prevention, as we do here at New Jersey Endovascular and Amputation Prevention.

Don’t let Peripheral Arterial Disease stop you.

As you’ve seen, you can help control PAD through many steps – by stopping smoking, eating well, getting active, and taking good care of yourself. But sometimes, the only solution is medical. That’s where American Endovascular is uniquely qualified to help you.

If you or someone you know is experiencing debilitating symptoms of PAD, schedule a consultation with American Endovascular today. We have the experience, team, and technology needed to unblock clogged arteries and treat Peripheral Arterial Disease.

“I have worked with both Dr. Herman and Dr. Rundback. They saved the limb of one of my patients that the Endovascular surgeon told me was unsalvageable. I have not found too many doctors willing to restore flow to the foot and the plantar arch and who have been successful. If we want to pride ourselves in being the best we need to associate with the best.” – Dr. Debra Manheim DPM, FACFAS, FACFAOM

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