338: From Bypasses to Stenting: Modern Approaches to Treating Peripheral Arterial Disease

Dr. Riz  00:00

I don't want anybody out there to get what I treat. And the best way to do that is to prevent it from happening. When I treat is actually a temporizing measure. I'm just bypassing a blockage, or opening up by blockage. But the disease process that caused it to get there isn't going away. Just because I open up an artery.

Maya Acosta  00:23

This is the healthy lifestyle solutions podcast, and I'm your host, Maya Acosta. If you're willing to go with me, together, we can discover how simple lifestyle choices can help improve our quality of life, and increase our longevity in a good way.

Maya Acosta  00:40

Let's get started. All right. Welcome back to another episode of the healthy lifestyle solutions podcast. I'm your host, Maya Acosta. And this is Dr. Is and today we have another episode of Doctor in the house where Dr. Riz joins me on a Monday to answer some questions. And today, Dr. Riz, we're going to learn more about what you do as a vascular surgeon. Are you ready?

Dr. Riz  01:05

Okay, I'm ready. Okay, I hope I answer these questions correctly.

Maya Acosta  01:09

What is the most common procedure that you do? Yeah,

Dr. Riz  01:12

I mean, the vascular surgery does comprise a variety of different types of procedures all over the body. But I, I particularly focus on lower extremity revascularization. lower extremity means the legs and revascularisation means improving the blood flow. And so the probably about, I'm gonna say about 70 to 75%, of what I do, has to do with fixing the arteries, and restoring the blood flow to the legs, there's a spectrum of diseases that affect the legs that require that, you know, probably early, the early on, symptoms are just when people are having some pain when they're walking. And that's called claudication. And that's because as they walk, the blockages restrict the blood flow enough that they're not delivering enough blood flow, to supply the muscles, and we can go in and open up blood vessels and improve the blood flow. And then on the far end of that spectrum, is that that somebody has some sort of wound on their foot or, or gangrene. And, you know, you know, something as simple simple as a small opening to as, as, you know, challenging as open wounds, exposed bone infection, dead tissue, and, and for those people, again, they probably have more advanced problems, and I have to go in and try to fix disease at multiple levels, in order to restore blood flow, and try to save their limb. You know, they might end up losing a toe or something like that. But the idea is to stop the damage there and improve the blood flow enough to where they can keep their leg. And the way we and the way, you know, I go about doing that. Our there's two particular kind of approaches that I take as a vascular surgeon. One is actually operating, where we do bypass operations. And there's a variety of bypass operations that we can do. And then the other thing I do is what we call minimally invasive or percutaneous procedures, where we do a puncture in the groin, and we go, we take catheters and wires and balloons and stents and different devices, and we go in and directly work on the plaque that's blocking the arteries and try to open up the arteries. Okay. And in the in today, you know, if you go back 25 years, or 30 years ago, to where I started in medicine, the vast majority of the procedures that were done was surgical. And then now if you fast forward three decades, with all the developments in technology, I would say the vast majority of the procedure we do are percutaneous, or puncture based.

Maya Acosta  03:58

Okay, that's a lot of information you just gave us. So I'm going to go back and ask a couple of questions about that. So basically, the most common procedure that you do, is has to do with arteries, lower extremity arteries.

Dr. Riz  04:16

Yep. And so yeah, that was a long answer. And but So the most common procedure I do today is percutaneous revascularization of the legs.

04:25

Okay, so before we move forward on that before we talk about that, because you gave us two examples. One is actual surgery and bypass. So I'm hoping that we could paint a picture for our listeners to understand what that means a bypass in the leg. And then the other one is kind of what you call it non invasive, minimally invasive, minimally invasive before we even go there. So can you give us an idea of who deals with these lower extremity complications? We talk is there, you know, is it more common in men than women? Is it common in younger people than older? Can you kind of in this time, give us a profile of that patient who deals with these situations.

Dr. Riz  05:13

So my patients are typically older. If you go back, you know, three decades ago, when I first started, the average age of my patients was in their late 60s And maybe 70s. And now fast forward, you know, 2025 30 years, the age has come a little bit younger, because we're dealing with more aggressive disease at a younger age. And so it's not unusual now for patients to present, sometimes in their late 50s, and even early 60s. So from an age standpoint, you know, late 50s 60s, and early 70s, is probably what I see the most of it's, there's no preponderance for men over women, it's about the same. There is some thought that men tend to get more peripheral arterial disease or peripheral vascular disease early on. But the studies now show that once women go through menopause, they typically catch up in the extent of disease. And, and that's only one factor that causes the disease. So all of the other factors, you know, contribute to it. So we don't see a preponderance of men over women at this at the point where I treat them. And then so that's, you know, you know, age is one factor, I think men and women get an equal pretty much equally. And, and then the the other things that are major risk factors and characteristics of my patients are those with a lot of chronic diseases. I don't have patients who present without other major problems. And, and those, the probably the number one presenting issue is diabetes, probably a close second is hypertension. And then lipid disorders are high cholesterol is also the other thing. And then, and then along with that is obesity. So those are really the four major risk factors that we see that lead to this disease. And so the patients who present to me who those who walk in my door have some, at least one of those problems, if not a combination, and it's not unusual to see somebody with all of those problems.

Maya Acosta  07:30

So what happens when the patient? How does the patient even know that they have a blockage and that a procedure is required.

Dr. Riz  07:37

So you know, the blockages are building up silently in all of us throughout the course of our lifetime. Since this is not really a disease of 60 and 70 year olds, it starts when we're younger. And you know, there's I point to the Korean vet war, Korean War vet study that looked at Korean war vets killed in action, and about 80% of them had the beginnings of atherosclerosis or peripheral arterial disease. But they were all new, the average age of those, those young men was 22 years old. So we know this starts at an early age. But what it is it's it's growing slowly, but isn't causing problems until it reaches a certain point many decades down the road. And once it reaches that point, then symptoms start to occur. And we call that when they become hemodynamic. Okay, hemodynamic meaning they affect the blood flow, you can have a blockage up to a certain extent, and the blood flow still, you know, does Okay, and still provides enough blood flow for our bodily functions. But once you reach a certain critical mass, then that begins to affect our function. So that's one thing and then the other thing that happens to with these blockages as as they get worse, blood clots form or the plaque ruptures, and these things typically don't become symptomatic till later on in life. So this, you know, how do we know? I mean, you don't know for the first few decades, because you're not having symptoms. And then when the sudden we suddenly fall over the precipice, so to speak, we we fall over the edge or the cliff, and suddenly we begin to have problems. So a

Maya Acosta  09:16

patient comes to you and they say, Doctor, my legs are hurting, I'm bruising, what did I can't walk I'm what what are the symptoms? What are they telling you that then you go in you and you say, or are they have they been referred to you by the primary care physician? How does that work?

Dr. Riz  09:33

Yeah, typically my patients are referred by the primary care physician because patients don't just come into the door to me, they're typically going to go talk to their primary care doctor or maybe they've gone into the emergency room and then they get referred to me. But yeah, one of the one of the early presenting symptoms is pain. Pain is an early symptom. One of the of the disease but not all pain, like not all leg pain is due to circulation disorders, like pain can be due to arthritis it can be due to nerve Problems in it can be dysregulation disorders. And so then it's up to me and my other colleagues who deal with these problems, to discern what kind of issue it is, is it vascular problem? Is it a neurologic problem? Is it a musculoskeletal problem. So there's, there's very specific patterns of pain that are more likely vascular. And so like I said, when people are walking, and they require more blood flow to their muscles to walk, then they might experience pain in their calves, or fatigue or tiredness in their thighs. And that's what's called claudication. In more advanced cases, someone might have pain at rest, that's typically pain down in the feet. And that's because the, the blood vessels are smaller, and they're kind of the endpoints. And so if you have blockages up high, not as much blood as reaching the feet, and so people will begin to experience pain at rest in their feet. So those are some of the early examples claudication of which is that pain when walking is an early symptom of somebody, rest pain is a late symptom was somewhat of a more advanced disease. And so that's, that's how people might present. And then and, and then also, again, I talked about wounds. And that's a particularly ominous presentation, because then at that point, patients very often behind the eight ball, so to speak, where, you know, if we cannot fix them, they are at risk for losing their limb. Okay. Unfortunately, the later on you present, the more advanced the problem is, and the harder it is to fix. Okay. All right. I think that, you know, I think that it's particularly telling that somewhere between five and 10% of my patients, there's nothing I can do for them, and they end up essentially, eventually end up with an amputation,

Maya Acosta  11:55

do you want to talk about what happens when there's a recommendation made to the patient's family, and then the family does not necessarily want to follow through with the procedure?

Dr. Riz  12:06

Yeah. The field of vascular is a very complex field. And it's, oftentimes, patients present with quite advanced problems. And as we alluded to earlier, all of my patients have multiple chronic conditions, we call these quorum, comorbidities, other other medical problems going on. So these are not typically Well, patients, they've got lots of things going on. And, uh, you know, I think one of the hardest things to deal with, within my profession for both me and for and for my patients and their families is that we talk about amputation. And that's where I think, you know, you may be talking to, I think I probably told you about something recently where someone presented, and their problem was too advanced. There's just there was just nothing that we could do for them. And, and so, we had suggested that the patient undergoing knee amputation, but the family, of course, you know, anytime you present someone with the optional amputation, that's just really way out there for them. I mean, from my standpoint, I see it on a regular basis, but for them, they may have never seen it before and sort of wrap their heads around that is tough. And it's not unusual, from time to time that the family just can't handle that. That thought of it. Yeah, yeah, that concept and the thought of it and just say, No, we don't want to do it. And, you know, we don't suggest a mutation. Just for the sake of amputation, if the patient can manage their leg and their wound and be okay. With that, you know, we will allow that. But if we're suggesting amputation, it's likely because that means that the leg is accelerating towards death, and a dead leg is toxic to the body. And so I think I think what got your attention was how I told you recently, one of the, in one case, the family refused to hand have the amputation done and and then they took their family member home, but then the family member presented emergently, about a week and a half later to the emergency room because they had become toxic in what we call septic from the leg. And so these are, you know, they're, they're tough, it's tough. And then what and that, unfortunately, then made it even tougher for us because now not only do we have to deal with a leg amputation, but we had to deal with a sick patient who had infection in their blood, and their kidneys were failing. And then she also had a bad heart, which is not unusual in my patients. So you know, she was going into heart failure because of these problems. So right now we're talking about trying to do a life saving amputation in the face of other other issues. You know, it's

Maya Acosta  14:55

it's a debit, devastating decision to have to face As a family, I mean the patient already, it's devastating for the patient, but then for family members who will then become the caretakers, it's even more devastating, to see a loved one just falling apart that like that, to have these kinds of conversations for you might be, you know, it's part of your job. For the rest of us, it might be the only time that we deal with a loved one that's facing, you know, a possible amputation. So that's part of the reason why we work on the preventative and not outside your practice. Because once your patients are your patients, that's that's where they're kind of probably at the end of the road. But we're talking about in, you know, in other cases, we want to help to raise awareness and educate so that people don't end up having to make a choice like this. But I wanted to focus on the procedures that you talked about. So you diagnose an individual who has a blockage, and then you said you either do a bypass or you do minimally invasive, so can you kind of paint a picture for us of what the bypass looks like, and what part of the leg is that located typically.

Dr. Riz  16:07

So a bypass just means that we are using a tube to go around the block, which we're basically putting in a new blood vessel. And it can either be a person's own vein, or an artificial vein, or a donor vein. Or it can be a piece of Dacron or plastic, which are artificial arteries. And they're not really so much artificial arteries, because they're not, they're not really functioning as arteries other than they're just a tube. And their whole idea is they're meant to bypass a blockage. And very, you know, everyone's kind of aware of heart bypass operations. And similarly, we do the same bypass operations on leg arteries. And there's, there's a whole host of bypass operations, you know, the legs are very long, and there's lots of arteries in them. So we're, you know, we tailor the bypass to treat whatever blockage it is that we need.

Maya Acosta  17:05

Okay, so that, and that's typically like the fire area, where is that located?

Dr. Riz  17:10

It can be the thigh area, or it can be the lower leg, or it can be the entire leg.

Maya Acosta  17:14

Wow. Okay, and what does recovery look like for something like that?

Dr. Riz  17:18

So bypass operations are pretty, pretty invasive procedures, they involve multiple incisions. And they're deep incisions, because we're going down to the arteries. And then we're oftentimes creating tunnels with which to tunnel the new artificial artery. So they're, they're pretty, they're pretty invasive. And so depending on the type of bypass, the recovery can be from four weeks, to a couple of months. Wow. Yeah. Okay. It does require a lot of time off of, you know, for recovery. And these are pretty big operations for elderly people.

Maya Acosta  17:52

Right? Yeah. Again, it's, I have to remember that, that you're dealing with an older population that has these procedures done. Yeah.

Dr. Riz  18:01

As as, as our as the patients get older and sicker. It the operations are harder on them, and they're more prone to more complications.

Maya Acosta  18:10

Okay, so recovery happens for that individual who's had a bypass and then does that mean, then that once you know that they they're functioning a lot better? They're walking improves, they, what kind of improvements do they get as a result of this bypass?

Dr. Riz  18:27

Well, I mean, the bypasses are done for various reasons, right, could be done for pain, you know, claudication. And, or it could be done for gangrene of the foot. And so the recoveries are very different. You know, if it's somebody who gets a fairly short what we call femoral popliteal, bypass for claudication, their recovery might be four weeks, and they resume a very, very normal lifestyle. Okay? If it's someone with half of their foot eaten up by gangrene, and we're doing a bypass from the groin, all the way down to the ankle. Well, the bypass is one thing, but then they may recur, they might need weeks, months, or even years of wound care and treatment in order to try to get that wound to heal up now that we've improved the blood flow,

Maya Acosta  19:10

wow. Okay. Well, I always thought that once you had gangrene, there was no going back.

Dr. Riz  19:16

Well, so if there's gangrene, then you cut out the areas of gangrene and get them to try to heal up. So that's we're trying to, if they get gangrene of a toe, then hopefully all they loses their toe. Yeah. But yeah, gangrene of the toe with blockages is just a the tip of the iceberg. And they're never going to heal that and it probably wouldn't heal higher up. Whereas if you restore the blood flow, then you can arrest the damage at a certain level and try to

19:42

write and I know that I've avoided looking at photos of different cases because I just can't handle that the gangrene on it's just incredible. Okay, what about the minimally invasive, those are a lot more common. Does that involve stenting?

Dr. Riz  19:58

Yeah. So we've transitioned over the last few decades to a more minimally invasive approach. And it's because we've been able to, with the developments of technology, we've been able to treat more and more advanced disease with these newer devices. And so especially complete blockages and also blockages below the knee, which were things that in the past were not amenable to this kind of treatment and even weren't well treated with surgery. And now we have these new tools available to us. So the interesting thing is, and I was discussing this with my colleague the other day is that we're treating sicker patients and patients with more advanced disease today than we treated 30 years ago, and were more successful today than we were 30 years ago. So we're treating more advanced disease, and we're more successful with it. And so we, you know, that's what the modern technologies have afforded us. And then also, I, you know, I always try to make sure I acknowledge that, you know, we stand on the shoulders of giants, these people who developed all these technologies 3040 50 years ago, the surgeries, and then the ones who have developed these technologies, as we've gone along, have provided us with the opportunity to treat patients who are sicker and more advanced, there's a lot of patients that I treat today on a regular basis, who 30 years ago, their primary treatment would have been a amputation, not an attempt to save the leg, but just, I'm sorry, it's already too advanced, you need an amputation. So, you know, I think that we're very fortunate that, you know, we continue to develop and get better at treating this disease. So stenting looks like what these procedures, the beauty of them is that they're done what's called Twilight anesthesia, or what we, we, our technical term for it is conscious sedation, or moderate sedation. And that means that we're giving them certain medications in their IV to make them comfortable, sleepy and even forgetful of the procedure. But they don't have to have that deep general anaesthetic where the breathing tube is put in, and they're put on the ventilator, with the artificial life support of having to breathe for them. That's typically reserved for the major, major operations. And that's also one of the reasons major operations carry more risk is because you have to put somebody to sleep, there's risk to that. Whereas when you're doing something with minimally invasive technique, and conscious sedation, there, you've not eliminated but markedly reduced the anesthetic risk. Oh,

Maya Acosta  22:33

nice, very nice being that stenting is the most common procedure that you do a month, how long does something like that take to do a procedure,

Dr. Riz  22:42

it varies, it varies in length. Again, there is no one blockage or one problem we're treating peripheral arterial disease is complex, it's multi level. And, you know, I could be treating somebody with just a blockage in their thigh. Or I could be treating somebody with a blockage in their pelvis, in their groin, in their thigh, and two blockages in their lower leg below the knee. And those each carry different treatments and length of treatment. So, you know, one procedure might take half an hour and another one might take three hours.

Maya Acosta  23:21

Okay, so, okay, it's Sunday. So you have cancellations? Why?

Dr. Riz  23:26

Yeah, you know, we do have a lot of cancellations. And it's kind of an unfortunate thing. And it's multifactorial. The scheduling procedures is not is not a, it's not a minor thing, too, you have to schedule the surgeon, the operating room, the anesthesiologist, so there's a whole lot of moving parts that are, are there and then you have to get the patient, you know, so there's a lot of moving parts that need to be coordinated in order to get a procedure done. And so things can go wrong at different levels. Unfortunately, there's a high level of non compliance that exists. And, you know, it's but but that, but why does that happen? I mean, there's, it can be as simple as often sometimes patients can't get a ride, you know. And, you know, we're talking about an elderly population who themselves may not drive, they oftentimes rely on their family to get them in and that may or may not, that can that can fall through there. It's also you know, there's preoperative instructions, and it's not uncommon for a patient to have eaten breakfast or or had a you know, some coffee with dairy in it. When they were instructed not to, but they didn't understand it. So that can happen.

Maya Acosta  24:46

That's the most common thing I hear you say is the person ate something in the morning and so the procedure had to be canceled. That's the one thing I hear you say not so much. They couldn't get a ride I hear you say two things the person ate, and therefore the procedure has to be canceled. And they, the patient decided they just are not in the mood to have the procedure. So they're going to put it off. And most of yours are not necessarily elective procedures for the sake of having a procedure, they're usually very important to have done.

Dr. Riz  25:22

Right, right. Yeah. So the probably is the number one reason is someone ate before the procedure. And the reason we ask people not to eat before the procedure for eight hours is because we need them to have an empty stomach. When people get anesthesia, whether it's a general anaesthetic or, or the Twilight anesthesia that I talked about, their gag reflex, their gag reflex, is is inhibited. And so fluid can wash back up or reflux from their stomach. And one of the risks there is that if it goes into the lungs, they can get what's called an aspiration pneumonia. And, and so there's, you know, there, it's very easy to prevent that from happening if they don't eat. Well, that's

Maya Acosta  26:03

news to me. I hope everyone's listening out there because that that's the first time I ever have heard of that. But then I don't go and have, you know, personal procedures. So, so when the doctor or the surgeon schedules the patient and says, Hey, make sure you don't have anything to eat. That's like a big one for us to make a note of for our loved ones who were caretaking. Okay, Mom, you're not supposed to have any breakfast on the day because of these complications. And then usually the person sometimes I've heard you say the person tries to lie. Yeah, they didn't have like coffee or something.

Dr. Riz  26:41

And that's because they don't understand the negative consequences of a complication related to eating. So yeah, I mean, it's, again, something as simple as not eating can prevent that particular complication. And if they've eaten, then it it's not, it's not prudent to proceed, unless it's just a dire emergency. And so that is probably one of the more common reasons that the procedures get canceled. And he knows that, like, there are many, many reasons that a procedure might get canceled. But

Maya Acosta  27:13

the main reason I wanted to emphasize this is because I always I think I can educator, I think like a teacher, I think, well, if we get this information out, and we tell people on a regular basis, hey, by the way, if you have an appointment scheduled for this kind of procedure, and you're asked not to eat anything, try really, really hard not to, because not only will that cause you to not have the procedure done that day, but now everyone who the team that has been lined up and set up for your procedure. Now that spot was taken and cannot be filled in sometimes you have medication that is cracked, open and ready. I don't know the details, but you tell me certain things like that. And so that's wasted time and wasted money for everyone. And then to schedule that patient to come in at another time in the future with a tight schedule that you have is pretty tricky, especially if that part of that individual is in great need of having the procedure done in the first place. Probably don't want to ruin it because you had breakfast that morning.

Dr. Riz  28:19

Yeah, those are tough. Those are tough things. So yeah, I mean, first off. Again, putting together surgery is not cheap. We're talking about expensive operating rooms, the time of the anesthesiologist and the surgeon, the operating room staff. And so just to schedule a surgery is probably cost 1000s of dollars, okay, in, in our society. And so if someone doesn't show up for their surgery, or their surgery gets canceled at the last minute, that spot is not going to be filled. And so that's a wasted slot that did cost money. And somebody else who could have used it doesn't get to use it. So that's, that's number one. Then, yeah, you talked about the schedule. I'm typically booked weeks in advance as our most busy surgeons and and so if this patient who got canceled needed this surgery, relatively urgent and and most of my work is not elective surgery, most of my work is something that needs to be done in a timely fashion. Well, then, if I'm booked for weeks, then I'll have to bump somebody else. And that happens regularly where I have to look down the road and go, Okay, who's who can be bumped so that we can put this patient back on the schedule. So it's, or it might take weeks to get that patient back on the schedule, especially if it wasn't something that was urgent.

Maya Acosta  29:42

Yeah. See, I feel like today we had a lot of valuable information and I hope that our listeners found it valuable as well because these kinds of kinds of seeing that side of Doctor risks the surgeon hat and the procedures that he does regularly Um, throughout the month is very important to note, the stenting the diagnosing symptoms that people have improvements that they see after a petite procedure, and also the importance of just being compliant so that things are smoother in the office. And then because you know, time is money and money is time, and when people don't respect that, because either they decided have breakfast or decided that they weren't in the mood for a procedure, well, then that just messes everything up. And, and so, okay, anything else to add? Before we wrap up about that?

Dr. Riz  30:35

You know, I mean, I think that it was, it was good to share what I do on a regular basis. But what I really want to point out is there's, you know, what I treat is very advanced, severe disease and very sick patients. It's not uncommon for the hospital to acknowledge that mine are the sickest patients in the hospital. Well, we call they have the highest acuity. And that means that they have that not only is there a particular illness that I'm treating bad, but they have multiple other problems. And what that brings to mind to me is that I don't want people to, to have these problems. And I'll I joke about it, but there is some truth to the fact that I'm trying to put myself out of business. And But why, why do I bring this up is that I don't want anybody out there to get what I treat. And the best way to do that is to prevent it from happening. When I treat is actually a temporizing measure, I'm just bypassing a blockage, or opening up by blockage and but the disease process that caused it to get there isn't going away, just because I open up an artery or even you know, saving a leg that that patient, my patients are come back to me over and over again, even after I fix something. And so the idea here is that what I'm getting at is that the best way not to be my patient, and you don't want to be my patient. The best way not to be my patient is to prevent the disease. And that's through aggressive lifestyle changes. Yep.

Maya Acosta  32:06

Well, Dr. Reyes, this was very valuable. Let us know what you think about today's topic and go to the show notes. If you're watching the video. Leave us a comment what other things which you'd like to hear Dr. Risk, like really go into detail about especially things that he does to support his patients. So yeah, let us know what you thought about it. And Dr. Risk, thank you again, for sharing all your knowledge.

Dr. Riz  32:29

Thank you very much. You know what I think would be interesting. If you guys out there would send us questions, because someday I'd like to do a q&a.

Maya Acosta  32:37

Oh, yeah. That'd be great. All right. Thanks again for listening. You've been listening to the healthy lifestyle solutions podcast with your host Maya Acosta. If you've enjoyed this content, please share with one friend who can benefit. You can also leave us a five star review at rate this podcast.com forward slash HLS. This helps us to spread our message. As always, thank you for being a listener.