EXPERT SPEAK: Peripheral Vascular Disease
Peripheral vascular disease (PVD) is an important cause of morbidity and its presence is a sign of systemic atherosclerosis. PVD puts patients at high risk for cardiovascular events like stroke, myocardial infarction and loss of limb due to gangreneThe risk factors for PVD include smoking, diabetes, hypertension, dyslipidemia, family history of cardiac or vascular disease, obesity, and sedentary lifestyle.While surgical bypass is the gold standard for extensive vascular occlusive disease especially involving the common iliac & femoral arteries, endovascular interventions, including percutaneous transluminal angioplasty and stent placement, are being used more frequently.
Dr. Hemant Deshmukh, MD is Professor and Head of the Department of Radiology at the Seth GS Medical College & KEM Hospital, Mumbai. His speciality is Vascular and Interventional Radiology. As one of the big guns in Interventional Radiology, he has virtually seen Interventional Radiology grow to its present status and play a part in almost all clinical vascular settings. He sits down with IndianRadiologist (IR) to discuss the treatment options for PVD as an alternative to surgical bypass.
IR: Hello Dr Deshmukh, and thank you for consenting for this interview. Firstly, in your speciality, what is the percentage increase in the number of cases of PVD that you have encountered, compared to say 15 years ago.
HD: I have seen that there is an absolute increase in the number of patients presenting with PVD. The numbers are frightening and we have seen that the incidence of PVD has increased by almost 30%.
IR: So, in other words, the numbers have increased; do you believe lifestyle changes have a role to play in this?
HD: The increased incidence is to be blamed, as well as an increase in the diabetic population, stress related to modern lifestyle and longevity of patients.
IR: What are the newer treatment options that are available today, as compared to earlier, in both acute and chronic PVD?
HD: The newer treatment options include Angioplasty with Drug Coated Balloons, Drug Eluting Stents, Atherectomy and availability of very Long Stents (upto 200mm) for treating Thigh Arteries. The Technique for accessing arteries has also become more innovative with various options available with the treating Interventionist.
IR: Can all patients take the option of angioplasty or stenting or are there any prerequisites?
HD: Infact, there are no prerequisites. The only indication sometimes for Bypass Surgery is ‘Failed’ Angioplasty!
IR: What is the life span of the stents that are placed today, and how do they compare with open surgical bypass surgical grafts?
HD: I suppose you are talking about the durability of Stenting. Stents outlive the patients. However, the atherosclerotic disease can always catch up with the patient and unless there are drastic changes in the lifestyle adopted by the patient, the stents (or for that matter, the Bypass Graft) will re-occlude. The long-term patency or durability of Stenting can be enhanced by modifications in the lifestyle, which includes cessation of smoking, regular exercise, keeping the blood sugar and cholesterol levels under control and adopting a stress-free life.
IR: Is there any treatment option available today for infra-popliteal arterial narrowing?
HD: Yes. We have Drug Coated Balloons and Atherectomy Devices to treat all types of occlusive infra-popliteal arteries.
IR: How valuable is the role of the Radiologist in limb salvage situations compared to the vascular surgeon?
HD: The Interventional Radiologist and the Vascular Surgeons, both are competent to salvage limbs.
IR: How important is the link between PVD and coronary artery disease (CAD)?
HD: All patients with CAD are more likely to have PVD and vice-versa. Any patient with PVD is more likely to suffer a Cardio-Vascular event like Stroke, Heart attack or Limb Loss due to amputation.
IR: Are there any screening tests to diagnose PVD and associated conditions that high-risk patients need to do?
HD: The best Screening Tool for PVD is Ankle-Brachial Index (ABI). It is a simple Tool by which the Ankle Blood Pressure is expressed against the Upper Limb Pressure. Normal ABI is 1 or above 1 and any ABI less than 0.7 needs further Investigations.
IR: Will this lead to a turf war between Interventional Radiologists and Cardio-Vascular Thoracic Surgeons?
HD: There is already a turf battle between an Interventional Radiologist, a Vascular Surgeon and Cardiologists! At the end of the day, it will be a Vascular Specialist who cures the patient, who will win the battle!