Coordinated care of atherosclerosis increases efficiency, reduces risk
|William Pevec, left, chief of the Division of Vascular and Endovascular Surgery, and David Dawson, an associate professor in the division, stand in the UC Davis Vascular Laboratory.|
Even though Lois Taylor felt no pain and was not aware of the problem, her daughter, Frankie Gonzales, saw that her mother's right leg and foot were extremely swollen, and the skin below the knee was cracked and draining fluid.
“Her toes were as black as black could be,” Gonzales said. “It scared me.”
Gonzales was so concerned that she scheduled an appointment for her 89-year-old mother with her primary care doctor, who recognized the problem as potentially the result of restricted blood flow. The physician referred Taylor to David Dawson, a surgeon in the new UC Davis Vascular Center and professor in the Division of Vascular and Endovascular Surgery. He determined that she had very poor arterial circulation and, as a result, had an ulcer that would not heal.
“Without more blood flow to the foot,” Dawson said, “a major amputation was inevitable.”
Minimally invasive procedures
Despite the seriousness of her condition, Taylor insisted that she would not have it treated if hospitalization or major surgery were necessary. After assuring Taylor that he would try to address her problem with a minimally invasive procedure, Dawson scheduled and performed an arteriogram, which confirmed the presence of extensive arterial disease. During the same procedure, he performed angioplasty of Taylor's posterior tibial artery to improve her circulation.
Today, the ulcer is healed and “the swelling has gone down considerably,” Taylor said. She continues living independently in her home, more than a year after the procedure, due in large part to the prompt action from her primary care doctor, Dawson and other members of the UC Davis Vascular Center.
Peripheral Artery Disease
The most important risk factors for peripheral artery disease include:
Other factors include:
Peripheral artery disease may not cause symptoms, but people often are impaired in their ability to walk. The most common peripheral artery disease symptom is intermittent claudication, which is often experienced as pain, aching, or fatigue of the muscles in the buttock, thigh or calf that come on with exercise — typically walking.
Claudication symptoms typically go away after a short rest. Some people with peripheral artery disease may not have the usual IC symptoms, but will nonetheless be limited in their ability to exercise. Severe peripheral artery disease can result in serious complications, including limb loss. Any wound, ulcer, or infection in a limb that does not have a palpable pulse should be regarded as an urgent problem.
Appropriate medical management can reduce risks of serious complications. In addition, drug treatment is available to help some people with claudication walk farther. Patients with critical limb ischemia can often avoid an amputation if blood flow to the limb is improved, but early intervention, especially in patients with diabetes, is the best means to achieve successful limb salvage.
The Vascular Center was established to help patients like Taylor by bringing together different specialties to provide state-of-the-art vascular care.
A major focus of the center is comprehensive and interdisciplinary care for patients with atherosclerosis, the process in which fatty materials, cholesterol and other substances, collectively known as plaque, accumulate in the lining of an artery. Patients refer to it as “hardening of the arteries.”
Plaques can significantly reduce the blood's flow through an artery. If severe enough, this reduced blood flow can lead to pain with walking, limb loss, kidney failure or stroke. When plaques become fragile and rupture, they cause blood clots that can block blood flow or break off and travel to another part of the body, causing a heart attack, limb loss or stroke.
Treatments offered through the UC Davis Vascular Center include medical therapies, surgery and a variety of minimally invasive endovascular therapies, including angioplasty with conventional balloon catheters, specialized cutting balloons and cryoplasty. Plaque removal with rotational or directional atherectomy and stent placement, using bare metal or covered stents, are other techniques used.
The UC Davis experience with these minimally invasive techniques has been positive, with most patients returning home in less than 24 hours.
Because atherosclerosis is a systemic disease, it presents in different ways, and physicians specializing in different disciplines typically have concentrated on one aspect of the illness. This approach can result in fragmented care that is inconvenient for the patient and inefficient in terms of the overall well-being of the patient.
Recognizing the limited reach of a single specialty treating this disease, the Vascular Center is coordinating vascular care among the multiple physicians who typically provide some aspect of care for patients with atherosclerosis. The center facilitates collaboration among vascular surgery, cardiology, interventional radiology, endocrinology and nephrology. The coordination allows the center to increase efficiency and reduce risks to patients while using both established and emerging diagnostic and therapeutic methods.
“This center brings together a number of components that have traditionally been separated,” said John R. Laird, director of the Vascular Center. “The many facets of a patient's vascular disease can be addressed as a systemic disease instead of being treated separately by various units. Through collaboration, we can exponentially improve the care we can provide."
Laird is internationally known for his work on the endovascular treatment of peripheral artery disease and joined UC Davis this summer. He comes from the Washington Hospital Center in Washington, D.C., where he was director of peripheral vascular interventions at the Cardiovascular Research Institute and co-director of the Center for Vascular Care.