Talking Tall Rounds®: PAD Outcomes in Minorities

Podcast Transcript

Announcer:
Welcome to the Talking Tall Rounds series brought to you by the Sydell and Arnold Miller Family Heart Vascular and Thoracic Institute at Cleveland Clinic.

Lee Kirksey MD, MBA:
Good morning to everyone and welcome to this week's installment of the Heart, Vascular and Thoracic Institute's Tall Rounds. This week we're focusing on peripheral arterial disease, or PAD as it's known, and its impact on minority communities. This is apropos for Peripheral Arterial Disease Month of September. I have no disclosures for this discussion today.

Lee Kirksey MD, MBA:
Peripheral arterial disease sits at the intersectionality of social determinants of health. That is low health literacy within the patient population and issues of insurance and healthcare system access. Within the healthcare system there are issues such as cultural competency and implicit bias.

Lee Kirksey MD, MBA:
When we look at team-based care, we understand that these patients have a need for high intensity care. However, they're frequently admitted to smaller institutions that don't have the resources.

Lee Kirksey MD, MBA:
Finally, there are public policy issues. We've been working on the Amputation Reduction and Compassion Act as it moves its way through congressional legislation process.

Lee Kirksey MD, MBA:
It's impossible to discuss peripheral arterial disease without reflecting upon COVID which has really shined a spotlight on this issue of disparities within minority populations and in poor white Americans. Peripheral arterial disease sits at the heart of this.

Lee Kirksey MD, MBA:
We understand that Native Americans, Black Americans, Hispanic Americans, and poor white Americans are disproportionately impacted by peripheral arterial disease. They're underdiagnosed, undertreated, and as such suffer worse outcomes.

Lee Kirksey MD, MBA:
These are data from Phil Goodney in the Dartmouth Group which describe amputation rates from a CMS data set. One can see here that the Native American population has a four times higher rate of amputation relative to white Americans. Black Americans, a twice higher rate of amputation. Quite significant. Even Hispanics, even though they have a lower atherosclerotic burden, higher rates of amputation.

Lee Kirksey MD, MBA:
Despite the fact that amputations overall are on a decline, we see that within the diabetic population amputations of a total minor and major significance continue to increase. This supports the need for team-based care and prevention.

Lee Kirksey MD, MBA:
Hispanic and Black patients present with more advanced CLTI. We can see this publication from Jihad Mustapha describing more progressive disease in emergency department visits. From a VA system study, we see that African-American and Hispanic patients present with more significant CLTI at a more delayed state.

Lee Kirksey MD, MBA:
It's not just for amputation reduction that it's important to identify peripheral arterial disease. When we look at these patients, their five year mortality is higher than many of the common cancers. Quite important that we identify peripheral arterial disease and reduce their cerebrovascular and their cardiovascular event rates. This is really the potential to help this patient population.

Lee Kirksey MD, MBA:
Despite the fact that I'm speaking about peripheral arterial disease and its disproportionate impact on minorities, we also understand that this is a socioeconomic disease. As we look across the geography of the United States, we understand that the most impoverished areas of the United States are the areas where the highest rates of amputation occur. Oftentimes in poor rural whites.

Lee Kirksey MD, MBA:
When one looks at the area deprivation index, or ADI, which is a risk stratification for socioeconomic burden, looking at the Northeast Ohio market, we can see that the Cleveland Clinic is surrounded by a densely impoverished area. Within that area are the racial demographics of poor white Americans, Black Americans and Hispanic Americans disproportionately vulnerable to peripheral arterial disease, cerebrovascular, and cardiovascular disease morbidity. These data suggests that within common county lines one can see over the census tract a 30-year discrepancy in life expectancy largely due to cardiovascular disease.

Lee Kirksey MD, MBA:
This is an illustration that I've used with within the COVID pandemic. Many times we speak the words that we're all in the same storm. However, we're all in the same storm with different vessels, and there's a different adaptive reserve for many communities that surround our Cleveland Clinic facility.

Lee Kirksey MD, MBA:
PAD has a PR problem. We have low awareness of what the disease is, what it does, how to prevent it, how to appropriately treat it, and finally the low use of the ankle-brachial index in high risk patients.

Lee Kirksey MD, MBA:
It is with this challenging problem that we require a functional limb preservation team which is who we present to you this morning to discuss the issues around the management of peripheral arterial disease.

Tamas Kovacs, MD:
The care teams that were involved in the following case were podiatry vascular surgery, interventional and general cardiology, the infectious disease and the nephrology team. The case I'm presenting today is a 61 year old male with hypertension, type I diabetes, gastric cancer, end stage renal disease of hemodialysis with a chronic limb treating ischemia with a Y5 score of 3-2-2, clinical stage four, presenting with a gangrenous first and second toe.

Tamas Kovacs, MD:
Initially, he underwent SFA and popliteal intervention and then hallux amputation. However, his hallux amputation wound never healed. Therefore, angiographic intervention was planned to improve blood flow. Angiography findings, however, demonstrated very poor arterial runoff to the foot. As a result of his end stage renal disease and diabetes. He continued to have a non-healing wound. Since there were no options to restore direct inline arterial flow to the foot in any angiosomes, the patient underwent a planned staged deep vein arterialization. During stage one, a right below-the-knee arterial popliteal artery to posterior tibial bypass with a reverse saphenous vein graft was performed with a sequential vein bypass off the arterial bypass with the posterior tibial vein.

Tamas Kovacs, MD:
This was followed by a stage two arterialization with a balloon angioplasty of the posterior tibial vein. Patient subsequently underwent a TMA and his wound started to heal. However, despite aggressive podiatric wound care and diligence surveillance, incomplete wound healing was observed. Venous duplex demonstrated stenosis of the arteria posterior tibial vein. Therefore, the patient was scheduled to undergo intervention. During the right peripheral angiogram, a high grade stenosis at the venous bypass to the recipient posterior tibial vein was seen. A percutaneous transluminal angioplasty of the posterior tibial vein with a five millimeter balloon was performed. At the vein bypass to the native vein recipient vein. Completion angiogram demonstrated brisk flow through that the arterial bypass, the venous bypass into the posterior tibial vein. The patient had the palpable pulse and a strong Doppler signal into the foot at the completion of the case. Subsequently, he underwent TMA revision and debridement with now the wound is healing with the palpable PT pulse at the ankle of the arterialized vein.

Ammar Saati, MD:
Hi everyone. I'm Ammar Saati, MD, I'm one of the vascular medicine fellows. I'm going to talk to you today about a lifelong disease of peripheral artery. Our gentleman here is a 67 year old African-American male patient with previous history of hypertension, 30 pack year history of smoking, peripheral artery disease, stroke, PPH, COPD, and cervical radiculopathy. His story started in 2009 when he started to complain of bilateral thigh pain every time he walks. It progressed year after year until 2012 when his pain started to become so severe that he walks 10 steps and he has to stop from that severe pain. He came to our clinic in 2012, had a PVR where it showed mild-moderate disease in both of his right and lower left extremities at rest and also with exercise. Subsequently had an angiogram showing a right superficial femoral artery that requires stents in the proximal and mid distal and angioplasty of the right popliteal and left popliteal artery.

Ammar Saati, MD:
This is a successful artery canalization and stenting after the stent. You can see good flow afterwards. The patient had significant improvement of his symptoms after this procedure. Unfortunate, he was started on aspirin 81 milligrams, and one month of Prasugrel, atorvastatin 40 milligrams, and to continue his antihypertensive medication of amlodipine and lisinopril. Unfortunately in 2013, the patient developed a right-sided weakness having a stroke on the MRI with a lacunar infarct. He was started than on clopidogrel 75 milligrams, along with his antihypertensive medication and aspirin. Between 2013 and 2017, he had multiple admissions to the hospital for TIA versus recrudescence of his old infarct and was under workup for his seizure. He had PT, physical therapy, occupational therapy, speech therapy follow-up in the outpatient. Cardiology and Neurology follow up for a possible cardioembolic disease. Also for the seizure workup and TIAs.

Ammar Saati, MD:
It wasn't until 2021 when he started to notice claudication coming back again in his right lower extremity. This time, every time he walks 50 steps he started to complain of this pain. It doesn't hinder him or make him stop walking, but he goes on a slow pace. There's no resting pain, no swelling, no discoloration. He has some shortness of breath with it and underwent echocardiogram, nuclear stress test that was deemed to be nonischemic and was attributed to his ongoing smoking and COPD. These were his medications on his presentation to our clinic, atorvastatin 80 milligrams, carvedilol, clopidogrel, and aspirin.

Ammar Saati, MD:
He had another PVR which shows a right lower extremity of mild disease with post exercise progressing to a moderate disease. Therefore, an ultrasound of the arterial was done for him. Pre-stent loss of flow and pulse wave form and stent indicating an occlusion. Post-stent parvus tardus waveform. At that time in the clinic, we asked him to quit smoking and referred him to the smoking cessation clinic, continue aspirin. We stopped the clopidogrel and started him on antithrombotic rivaroxaban 2.5 milligrams twice a day. We switched his atorvastatin to rosuvastatin with his LDL being 117. In the next clinic, if he didn't achieve a goal, we wanted to add either ezetimibe or evolocumab. We offered cilostazole, but was deferred to the next visit along with the procedure or interventions and supervised exercise therapy, especially with him undergoing a C-spine surgery.

Jai Khatri, MD:
Good morning, and thank you for the invitation to talk today. The only disclosure I have is that I'm not an endovascular specialist, per se. I'm an interventional cardiologist specializing in complex coronary intervention. I'm going to share with you some of the parallels in the field and why I find this to be such a fascinating arena. Hopefully you'll find this as exciting as I do.

Jai Khatri, MD:
What are the skill sets that we use in complex coronary intervention and how can they be utilized in endovascular intervention? Number one, we spend all day accessing people's regular arteries both conventionally in the wrist or on the back of the hand, in the distal snuff box area. We use ultrasound to do this. It's the same thing to get access to a tibial vessel. We're very experienced using 014 wires, 018 wires, 035 wires. The same stuff that you would use in endovascular intervention. We're very, very comfortable using coaxial microcatheter techniques to deliver equipment and wires, to cross recalcitrant lesions. Lastly, we're very, very comfortable with being sub-intimal in a coronary artery which makes it very, very comfortable being sub-intimal in a peripheral artery. I'll show you some examples of how these skill sets overlap.

Jai Khatri, MD:
In a coronary artery, the goal is ultimately to cross the lesion with a wire, and this can be done by advancing a wire conventionally through the antegrade side or through the retrograde side with a combination of wires, balloons, catheters in both directions. This is a very rapidly evolving field that was originally developed primarily in Japan and has exploded across the world at this point. There are expert centers all over the country and all over the world now that specialize in these techniques. We can utilize some of this to help our patients with peripheral arterial disease as well.

Jai Khatri, MD:
This is an example of a right coronary artery total occlusion case that I did many years ago where we've advanced a guide wire and a catheter through the left coronary system through a septal collateral channel retrograde. I have knuckle wires in both directions, and you can see up here, I have a retrograde wire being advanced through the right coronary artery into the guide catheter to basically perform a loop and deliver stents. This is amazing that this can be done. This was something that was completely impossible when I was a fellow only 15 years ago. Yet we do this three to four a week now at the Cleveland Clinic. It's pretty fascinating how this has evolved over time. It's not without its risk. This is a case that I wish was done early in my career, but I'll have to admit this was not that long ago.

Jai Khatri, MD:
Stiff wires advanced into occluded coronary arteries can sometimes exit, and when the exit they're in the pericardium. Once that happens, you can have a potentially catastrophic event causing cardiac tamponade and cardiogenic shock. This has to be recognized and corrected immediately if this were to happen. This is one of the big differences between coronary total occlusion and endovascular total occlusion because that peripheral bed is a lot more forgiving for these type of events.

Jai Khatri, MD:
This is a case that I'll share with you as a patient who was referred for a critical limb ischemia who has a totaled popliteal artery extending from... right here is the cap, and it extends all the way to the tibioperoneal trunk. There's a long segment, total occlusion. Something that we wouldn't realistically be able to wire antegrade. He's got excellent three vessel runoff distally. What we did with him is we advanced a wire subintimally just to get purchase into the vessel. That's what this picture on the left shows. Then once we have that wire in place, we come in on the retrograde side.

Jai Khatri, MD:
We can see here that there's a nice beak in the TP trunk to access. What we do is we use ultrasound to get into one of the tibial arteries and use this to advance a guide wire up the tibial artery retrograde. Once we have the wire to that beak that I pointed out, we advance a microcatheter to support the wire. Then you have to understand which wire to use where, but the idea here is to use a wire that can form a knuckle like what we see here. You advance the knuckle through the occluded segment. There's no way to wire this or understand exactly the course of the vessel, but the knuckle will find the vessel for you. Now the idea here is to try to advance the knuckle all the way to the antegraded knuckle that we created earlier in the case.

Jai Khatri, MD:
Once you've done that, then we deploy the same techniques that we use in the coronaries to complete the case. We have overlapping knuckle wires. Balloon this space to create a common channel that's subintimal, and then use a very steerable guide wire which you see in the right panel to make the final connection. Once you've made this connection, you can deliver stents. You can see here, we've got the stents deployed in the popliteal artery. We preserve three belts to runoff to the foot and the patient had resolution of his symptoms. Just a nice example of how we use all the same techniques, all the same wires, all the same catheters to achieve a slightly different goal. The idea is here to safely navigate through an occluded segment of an artery.

Jai Khatri, MD:
In conclusion, I would say that contemporary coronary CTO PCI technique are quite applicable for endovascular intervention. I think that peripheral intervention is honestly quite a bit more forgiving. I honestly use this area as a way to understand how to use wires in the coronary. It's a lot safer for me to understand what a wire can and cannot do in the peripheral bed as opposed to the coronary bed. Ultimately one of the limiting steps in both coronary and peripheral is calcification. We'll talk a little bit more about that moving forward. Calcification really limits the efficacy and the effectiveness of all of these treatments, both in the coronaries as well in the peripheral world. Thank you.

Announcer:
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