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Chronic Limb-Threatening Ischemia: Recognize It, Treat It, Prevent It · Flourish- A Prisma Health Podcast

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Carl Maronich (Host): Welcome to Flourish, the podcast where we dive
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into health and healing advice with trusted experts from Prisma Health.
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I'm Carl Maronich, and with me today is Dr.
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Moyen Ed, an interventional cardiologist and endovascular
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specialist with Prism Health.
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And we're gonna be talking about chronic limb threatening ischemia.
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We'll explore how to recognize it, treat it, and hopefully how to prevent it.
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Welcome to the podcast.
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Dr Moinuddin Syed: Thank you.
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Thanks for having me, Carl.
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Carl Maronich (Host): Yeah.
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Glad to and appreciate your time.
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And maybe we could start by having you just describe what chronic
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limb threatening ischemia is, I believe it's also referred
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to as critical limb ischemia.
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Dr Moinuddin Syed: That's correct.
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so, chronic limb threatening ischemia is the most severe manifestation of
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peripheral arterial disease, which affects, almost 30% of the population,
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in the us and basically what chronic limb threatening ischemia, it manifests
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in one of three farms where patient's have either gangrenous changes or in the
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toes, which means basically dead toes or ulcers or wounds in the foot, which
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are not healing because of compromised blood circulation down to the foot.
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And some patient's even can present with, what we call ischemic rest
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pain, which means that they have pain in their foot when they are resting.
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usually, that happens because there's not enough bed circulation getting down
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to the foot because of blockages in the artery supplying, blood to the, legs.
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Carl Maronich (Host): those blockages I'm guessing could
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come from a number of things.
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Trauma could cause that or also just other health issues that close, the vessels.
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is that correct?
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Dr Moinuddin Syed: yes and no.
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Usually the blockages, uh, are caused by what we call atherosclerosis,
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which is buildup of block in the arteries, which can happen as.
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People age or from risk factors that can include smoking, diabetes, high
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blood pressure, high cholesterol, and sometimes even family history.
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And when these blockages develop in the, artery supplying blood to the legs, we
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call it peripheral arterial disease, or in the artery supplying blood to
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the brain, we call it carotid disease.
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When it affects the artery supplying the heart, it is
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called coronary artery disease.
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So it's kind of the same disease process, when patient's develop.
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Buildup of plaque that kind of compromises the blood
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circulation to the legs and foot.
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And when it's more severe and blockages it at multiple levels, that can cause
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such bad, compromise and circulation to the foot that the foot can die.
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Essentially.
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That's what gangrene means.
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And sometimes when patient's with trauma, they are.
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Unexpected trauma or from diabetes can develop some ulcers or wounds,
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which usually, and most people should heal if they have good
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blood circulation to the feet.
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But when there's compromised blood circulation, the ulcer
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or the wound doesn't heal, and sometimes when that doesn't heal.
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Progresses, the infection can progress and sometimes people end
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up with what we call amputation.
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And that, believe it or not, is a very serious problem.
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currently, especially here in South Carolina where we have a very high
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burden of amputation And what we call PAD or peripheral arterial disease.
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Carl Maronich (Host): so chronic limb threatening ischemia, or CLTI, it could
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be also called, really can develop from a number of, factors, and overall
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health kind of factors into that.
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If, folks aren't taking care of themselves in a few different ways, maybe you could
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talk a little bit about the risk factors.
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Dr Moinuddin Syed: Yes, absolutely.
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You know, the risk factors are similar to, people who have blockages in the
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heart arteries or people who have heart attacks is risk factors, is the
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same disease process that affects a different vascular bed in the legs.
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And it's something that's.
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Kind of really under-recognized and undertreated because no one looks
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for it or people don't look for it.
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And even if they find it, they don't refer them to their
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specialist to get taken care of.
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So, the risk factors are, as I said, usually it's smoking and diabetes.
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Those are the major risk factors.
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And if you have a combination of those two, actually the
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US Preventive Services task.
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Force, which recommends, screening for peripheral arterial disease
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in patient's more than 50.
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If you have both those risk factors.
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So the screening tests, we can get a dwell a little bit deeper into this
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a little later, how to recognize it.
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But, the smoking, the diabetes, high blood pressure, high cholesterol, these
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are the main risk factors, the most important being smoking and diabetes.
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Carl Maronich (Host): Yeah, so as we often talk about in these health
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podcasts, knowing your body, knowing your health, seeing your primary
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care provider pretty regularly to be monitoring these things would be, uh,
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an important factor in this as well.
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Dr Moinuddin Syed: seeing your primary care physician and
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taking those medications, for cholesterol and diabetes and.
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Quitting smoking for patient's who smoked a lot and getting your blood pressure
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under the ideal control, that would definitely reduce the risk of developing
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an even progression of, peripheral arterial disease and, progression
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to CLTI or critical limb ischemia.
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So Those are definitely important components of care.
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Carl Maronich (Host): doctor, how prevalent is CLTI in the United States
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and are there certain populations that should be more concerned?
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Dr Moinuddin Syed: Yes, it's definitely, that's a very good question, Carl.
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So, the burden of PAD is, I would say around 20 to 30% of the adult population,
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especially it's enriched in people who have these risk factors like.
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diabetes and smoking and it can be way higher in these patient's..
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It's usually the lower socioeconomic status and certain ethnicities, which
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can mostly in African Americans and Native Americans and Hispanic population.
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This prevalence is way higher And for unclear reasons, we are not sure they
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have more aggressive and more severe manifestation of PAD, which is the
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chronic limb threatening ischemia, and their burden of disease is way higher
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than in some of these other populations.
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So yes, definitely the African American, native American And
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the Hispanic population, I would say, has an extremely high burden
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of peripheral arterial disease.
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Carl Maronich (Host): so someone who has peripheral arterial disease, is there
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a percentage of those patient's that might, get to the point of amputation?
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Dr Moinuddin Syed: So, a lot of patient's have.
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Peripheral arterial disease, but I would say probably three to 4%
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kind of progressed to the most severe form, which is the CLTI.
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And most patient's will have what we call asymptomatic PAD, where
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they do have plaque, but they don't know that they have PAD.
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And that's where we need to recognize these patient's.
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And uh, would say, probably, 60% of patient's with peripheral arterial
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disease kind of remain asymptomatic, and they never know they have it.
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And for them it's recognizing and preventing progression would be the key.
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And, uh.
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Of those remaining 40%, probably like quite a few of those, 60%
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would be asymptomatic and 40% would develop some symptoms.
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And the most common symptoms would be what we call claudication, where
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patient's develop discomfort or.
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Pain in their thighs or calves or hip when they walk or exert themselves.
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It could even be like tiredness or fatigue in their legs when they walk.
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And then it goes away when they stop and rest And then they resume walking.
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They again develop the symptoms.
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So that's the most common, manifestation of symptomatic PAD.
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a few percentage of most of those patient's will remain
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stable with claudication.
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A few percentage of those.
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Can progress beyond exertional symptoms to having, lifestyle limiting claudication,
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what we call advanced claudication, where, they can't carry out day-to-day
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activities or like going to the grocery store or picking up mail from the mailbox.
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Those kind of activities can also be, difficult for them when they're,
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Disease progresses and compromises blood circulation to the legs.
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I would say those would be probably, you know, of those 40% symptomatic,
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probably 10 or 15% would progress.
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and given the such a huge burden though it sounds like 10 15, That is
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still a very high burden of disease and of Those are 15% probably.
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Two or 3% can again, progress to more advanced stage where they have pain
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at rest or ischemic rest pain, or even when they have these other risk factors
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like diabetes and other things can develop ischemic ulcerations or what
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we call tissue loss, where they have wounds and ulcers in their leg because
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of compromised blood circulation, which never heal unless we open those blockages.
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so You know, either by surgery or balloons and stents, what
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we call endovascular therapy.
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Carl Maronich (Host): if someone is, having some of these initial
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symptoms that you talk about, leg pain or, extreme fatigue kind of.
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In a sudden onset, if you will, of extreme fatigue when walking
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and such, they're likely gonna see their primary care provider first.
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And if, they suspect something, would they then refer, to someone like you?
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Or how would the diagnosis process work?
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Dr Moinuddin Syed: so usually they could directly refer to a vascular specialist or
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they can even do some baseline screening tests, in their office or send them to
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refer basic screening tests, which we call, a BI or ankle brachial index, or
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even a vascular ultrasound, to assess the Blood circulation in the legs.
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So This is a pretty basic screening tests or they can just directly refer
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to us And we can order those testing.
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And There are several layers to testing and when patient's have probably
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claudication just they can do the testing But when patient's have like ischemic
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ulcers, wounds or gangrene or dead toe, or someone is considering an amputation,
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then they definitely, before progressing to the amputation stage, they should
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be referred to a vascular specialist.
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Carl Maronich (Host): Yeah.
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And what would some of the treatment options be at various stages of CLTI?
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Dr Moinuddin Syed: when patient's come in with claudication, the first-line
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therapy would be risk factor modification.
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If patient's are smoking, we would.
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Recommend that they quit smoking, get better control of their diabetes, get
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their cholesterol levels into control with medications, and re-prescribe what
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we call supervised exercise therapy or supervised exercise program where they
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walk or exercise through their pain.
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The idea being that the body improves blood circulation by itself to the foot
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so that, they wouldn't need therapy.
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But that's only for patient's who have this claudication which is the least
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severe form of manifestation of PAD.
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And if they continue to have symptoms, then.
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We can offer some more advanced therapies, which could be, surgical bypass.
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And in the past, probably couple of decades, our endovascular therapy
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has advanced so much that has kind of become the first-line treatment
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for patient's with, advanced PAD, which could be like ischemic rest
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pain or patient's with, CLTI.
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Carl Maronich (Host): doctor, in what ways is CLTI life-threatening, and, how does
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it impact, the patient's quality of life?
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And you, touched on some of those, but maybe you could speak, to the
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life-threatening component of CLTI.
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Dr Moinuddin Syed: Yes.
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So it's basically a limb threatening, and when the limbs get threatened,
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there's a life threat too.
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So it's definitely something that has to be recognized.
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I mean.
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Traditionally we think of, blockages in the heart arteries
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that need to be taken care of.
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Otherwise, you know, patient's come in with like a heart attack.
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This is kind of like a limb attack when patient's have a wound or
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ulcer and they definitely need to be referred to a vascular specialist for
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evaluation if they have a wound ulcer or gangrene in their toes before they
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progress to, needing an amputation.
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Because if untreated.
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wound never heals.
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And if they develop an infection, it can progress and be a threat to their
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limb, which would require an amputation.
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And as you can imagine, when someone gets an amputation that could be
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very disabling, they can move around and amputation itself carries a
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very high mortality, I mean, two amputations are okay, But when.
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Patient's start getting below the knee or above the new amputations.
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it's a very morbid procedure.
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And we do know that, the survival of these patient's gets down to
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almost 50% over a year or two.
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So almost sort of four, two patient's can die if they get an amputation.
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And the death may be from like.
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Cardiovascular causes or stroke or those kind of things.
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But still these patient's are extremely sick and need to be cared for with
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appropriate medications and therapy before they progress to needing an amputation.
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Carl Maronich (Host): Dr.
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May, maybe a, a brief moment to talk about, people hear cardiologists and
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they may not think of, extended limbs in their feet and things and, but really
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it's, because of circulation and your expertise in endovascular surgery that
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you're involved in CLTI is, that right?
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Dr Moinuddin Syed: Yes.
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just generally This is a multidisciplinary, care that our
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patient's need when they have PAD, that traditionally they would need
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care from a vascular surgeon or even like I'm a vascular specialist and
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I have specialized training and, endovascular and vascular medicine.
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So, patient's need care from multiple different, specialties, who should be
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coordinating care because sometimes surgery might be a better option when
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they have extremely complex disease.
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And when patient's have these kind of wounds and ulcers or
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gangrenous changes in to, we.
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Do advanced evaluation with an invasive angiogram, And then we
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classify their disease based on what we call a task classification.
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And when it's extremely severe, some disease may not be amenable
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to, endovascular therapy.
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Then they would require surgical therapy, which would include an open bypass.
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but currently some of our patient's are so sick that they're too sick
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to go through a surgery, And then those patient's will still be
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candidates for endovascular therapy.
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So I would say they require multidisciplinary care with, vascular
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surgery or, interventional cardiologists with specialized training in endovascular
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therapy And the POCAT risks and primary care and endocrinology, infectious
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disease and all these specialties.
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Definitely, and wound care.
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That's another thing, you know, sometimes.
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We restore blood circulation of the foot, but the wound needs to be taken care
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of, making sure it heals completely, And that would prevent an amputation.
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So I would say yes, they do require a multidisciplinary approach.
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Carl Maronich (Host): like with many things in healthcare, it takes a village.
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truly.
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doctor, if, listeners have a loved one who's going through this, how
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can they support, someone who is having these, vascular health issues?
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Dr Moinuddin Syed: my message would be that the burden of
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amputation currently so high that.
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when patient's develop wounds or ulcers that have not been healing for some
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time, And then you're following up with a podiatrist or your doctor and so when
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someone recommends an amputation you have to get them to see a vascular specialist
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before someone gets an amputation.
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Unfortunately, there's a lot of patient's out there who have progressed
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to an amputation without getting their vascular vasculature evaluated and.
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And, seeing a specialist who can potentially salvage their limb
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and prevent an amputation by revascularizing them with either
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endovascular therapy or open surgery.
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So that would be my key message.
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And if you have any symptoms, where you have tiredness.
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Fatigue in your legs when you're walking, then you have to be
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referred to a vascular specialist.
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or if if you develop changes in your feet that you have some ulcers or
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wounds that are not healing, those kind of things, they have to be
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evaluated with the bio avascular specialist and, take it from there.
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Carl Maronich (Host): doctor, as you mentioned earlier, a lot of lifestyle,
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components to staying healthy and, keeping good circulation, and certainly
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one of those is eating healthy.
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And doctor, I know you like to cook, so I'm sure you, mentioned to your
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patient's and give them some healthy options when they're cooking to make
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sure their vascular health is maintained.
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Is that right?
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Dr Moinuddin Syed: Yes, absolutely.
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You the diet obviously currently with the burden of obesity and diabetes
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going hand in hand and calorie restriction is a key component.
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And we have excellent therapy for, even weight loss and those kind
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of things, and eating healthy.
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incorporating more fruits, vegetables, and more Mediterranean diet and less
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saturated fats and fast foods and those kind of things would help a lot go a
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long way, mainly in preventing, uh, diabetes and obesity, which kind of play
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into developing this atherosclerosis, which is the underlying disease process,
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for patient's with PAD and CLTI.
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Carl Maronich (Host): as an accomplished chef, do you offer to go to the homes of
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patient's and cook them healthy meals?
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Dr Moinuddin Syed: I don't usually do that.
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I do advocate that patient's, you know, currently, in our society we
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don't have that every, everyone's busy and, You know, no one has the time
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to, make a meal or we rely more on.
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Fast foods, but definitely trying to, be cognizant of, planning your
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meals and, calorie restriction, eating healthy, those would definitely help
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in, preventing diabetes and obesity.
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That is, uh, underlying risk factors for, PAD and progression to
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chronic limb threatening ischemia.
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Carl Maronich (Host): Well, even if you're not gonna cook us a meal,
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you, you were very helpful today with all this great information, doctor.
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We greatly appreciate it.
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Dr Moinuddin Syed: Thank you so much, Carl for having me.
16:56
Carl Maronich (Host): Yes, And for more information, visit
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prisma health.org/flourish.
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explore our full podcast library.
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For topics of interest to you, I'm Carl Moroni, and This is
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Flourish from Prisma Health.
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Thanks for listening.