True to its rich history in south Texas, Peripheral Vascular Associates (PVA) provides full-spectrum treatment for peripheral arterial disease (PAD) ranging from risk-factor modification to endovascular interventions to surgery.
Diagnosis and treatment of PAD — atherosclerotic narrowing of the peripheral arteries, most commonly in the legs — has undergone significant evolution in recent decades, and the generations of vascular disease experts who have practiced at PVA reflect the dynamism of the field. Established in 1975, PVA has grown into a regional destination for PAD care that features 21 physicians and the same number of locations throughout south Texas, including an office on North Main Avenue in downtown San Antonio and another office in the South Texas Medical Center with catheterization laboratories for endovascular interventions.
Close-to-home expertise in peripheral vascular care remains as essential now as it was more than four decades ago. PAD is a common diagnosis, especially in the elderly — up to 20 percent of individuals older than age 60 may have the disease, according to the CDC. Experts are divided as to whether PAD is on the rise, along with some of its major risk factors, including diabetes and hypertension, or its prevalence is due to greater awareness among and more diagnoses by primary care physicians. They agree, however, that PAD has significant implications for health and quality of life.
A Spectrum of Symptoms
For many individuals, PAD is asymptomatic, but for others, it can cause symptoms that range from mild to severe.
“Claudication is usually the first symptom of PAD,” says Boulos Toursarkissian, MD, RPVI, vascular surgeon at PVA and Adjunct Professor at the UT Health Science Center San Antonio. “That is pain in an extremity brought on by activity or ambulation. Most commonly, claudication is caused by blockages in the thigh or calf arteries, but that may not be the only location that’s affected. As the degree of blockages increases and perfusion to the lower leg decreases, individuals may experience symptoms of pain at rest that usually affect the feet. When lying down, the pain may improve by dangling the legs off of the side of the bed.”
After claudication and rest pain, individuals may develop nonhealing wounds on the lower legs, feet and toes as plaque in the arteries above restricts the delivery of oxygen and nutrients in the blood. In severe cases, critical limb ischemia can develop, potentially necessitating amputation.
Even though only a small percentage of patients will require an amputation, PVA has developed a state-of-the-art prosthetic department that can manufacture a prosthesis within hours instead of waiting days or weeks.
Diagnosis and Conservative Treatment
To determine whether PAD is present, vascular surgeons rely on physical exams and the taking of patients’ health history, as well as certain diagnostic tests.
“If a patient has an abnormal pulse in the extremities, that typically indicates there’s some amount of PAD,” says Michael Peck, MD, vascular surgeon at PVA. “If that finding suggests further assessment is needed, we start with an ankle-brachial index test, which allows us to compare blood pressure in the ankles with that in the arms. We can also perform complex ultrasound tests, and angiograms that can lead to immediate treatment.”
All individuals with PAD, regardless of whether it is mild, moderate or severe, need to make lifestyle adjustments to prevent the disease from worsening or to complement other treatments, according to Jesus Matos, MD, RPVI, vascular surgeon at PVA. For individuals with claudication, lifestyle modifications are typically the front-line therapy.
“I always discuss with patients why they developed PAD and what we need to do to prevent it from progressing,” Dr. Matos says. “For individuals who just have claudication, we try to stay as conservative as possible by using exercise, medication and risk-factor control. I follow patients who are on conservative therapy for three months to see whether they improve. If they don’t, we discuss more aggressive options.”
Minimally Invasive Interventions
A small number of individuals with PAD need bypass graft surgery, but in recent decades, an overarching trend in vascular surgery has been toward ever-less-invasive treatments. Minimally invasive therapies are a staple at PVA, where vascular surgeons offer the full gamut of catheter-based endovascular interventions, including angioplasty, atherectomy and stenting. Patients with claudication who find no relief with conservative measures, or those who have rest pain or nonhealing wounds at initial presentation, are often candidates for endovascular treatment. PVA vascular surgeons can perform most endovascular procedures at one of the two practice’s flagship offices either in downtown San Antonio or the Medical Center.
“Once an angiogram helps us figure out where the blockage is, we can reopen the vessel by performing a balloon angioplasty or placing a stent, or in some cases, by introducing tissue plasminogen activator [tPA] into the artery to break up the clot,” says Lois Fiala, MD, FACS, vascular surgeon at PVA. “If a patient has a bypass graft that has clotted, we can start a tPA drip in the office and then transfer him or her to the hospital for inpatient admission. We can also perform atherectomy to remove plaque from an artery, typically in combination with balloon angioplasty or stenting. We are on the cutting edge of every peripheral vascular intervention.”
As endovascular treatments have evolved, so has vascular surgeons’ understanding of when and where each type of intervention is appropriate.
“We now have a better understanding of how durable different repairs can be in different locations, and which techniques work best for each level of disease, depending on the size of the blood vessel,” Dr. Peck says. “We can select the treatment that has the best likelihood of having long-lasting benefit. It’s often best to perform procedures that can be repeated in the future if plaque accumulation crops up again. Performing balloon angioplasty, for example, may allow the surgeon to do it again later at the same site, but placing a stent too early in the disease process can scar the artery and preclude additional treatment in the future.”
“Vascular disease is relentless and requires repeat surveillance and intervention. That’s why vascular disease patients are usually a lot like internal medicine patients — they see vascular surgeons throughout life, and we develop relationships with them.”
— Michael Peck, MD, vascular surgeon at Peripheral Vascular Associates
To perform an endovascular procedure, vascular surgeons typically access the circulatory system through the femoral artery in the groin. Sometimes, however, approaching an arterial obstruction from above, as is the case with the femoral technique, is not ideal. When that is the case, PVA surgeons use a technique called pedal access to approach the blockage from below, through the foot.
“If a blockage is severe, the literature shows that plaque tends to be harder on the upper part of the blockage, so going from below, where it’s a bit thinner, makes it easier to deal with,” Dr. Matos says. “That’s when we may use pedal access, or when an infection or recent surgery in the groin makes femoral access impossible.”
After a typical femoral-access procedure, patients must lie still and supine for two hours to ensure the puncture site heals completely, according to Dr. Fiala.
“Something that’s unique about PVA is that the patients whose endovascular procedures we perform in the office typically have shorter lie-flat times than patients who have those procedures in the hospital,” she says. “That speaks to our vascular surgeons’ expertise and the close, post-procedure monitoring patients receive from nurses in our office.”
While patients lie flat, they undergo an ultrasound exam to obtain baseline images of the artery. Surgeons compare those images to a follow-up study a week or two later to assess the success of the treatment. Patients return home the day of the procedure, typically with instructions to avoid heavy lifting for several days and a prescription for antiplatelet medication to help the newly opened vessel remain clear of blockages. They can resume normal activities the next day, and they often notice swift, significant relief of symptoms such as rest pain. Patients can visit one of PVA’s many satellite clinics throughout south Texas for surveillance.
The Versatility of Vascular Surgeons
To Dr. Toursarkissian, the strength of PVA lies in its clinicians’ ability to tailor treatment plans to patients’ needs — a product, he says, of vascular surgeons’ well-rounded expertise in PAD care.
“We’re not limited to medical management, wound care, endovascular procedures or surgery alone,” he says. “We offer the whole spectrum of treatment. We don’t have to worry about transforming every problem into a nail because the only tool we have is a hammer. That’s the advantage of turning to PVA for PAD. Another important point is that PAD is not an afterthought for vascular surgeons — it’s what we were trained to treat, and it’s what we deal with every day. PAD is our bread and butter.”
For information about PVA’s physicians, treatments, locations and more, visit pvasatx.com or call 210-237-4247.