Peripheral Artery Disease (PAD) in the Diabetic Population

Podcast Transcript

Announcer:
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Lee Kirksey, MD:
It's PAD Awareness Month and joining us today, we have two of our distinguished colleagues in the Heart, Vascular and Thoracic Institute, Dr. Khatri, who is one of our Interventional Cardiologists and General Cardiologists, and Dr. Botek, one of our Podiatrists from the Orthopedics and Rheumatology Institute, the Director of our Podiatric Program. I'll ask you guys a couple questions. We deal with the diabetic patient and they always want to know how should they care for their feet? Who should be on their team to help them monitor their feet? Because we know that diabetics have about a 25% chance over their lifetime of developing ulceration.

Georgeanne Botek, DPM:
It's important to determine who is at risk. When we say at risk, we mean a person with diabetes who potentially could develop a foot ulcer or could lose their foot in their lifetime. Developing that risk, you can work with your internal medicine doctor or endocrinologist, but also us. We like to see that diabetic patient who's had diabetes for more than seven years. If they have risk factors like hypertension, hyperlipidemia, have pain in their feet, or have even deformity in their feet, we like to have a good assessment and comprehensive assessment of the foot.

Georgeanne Botek, DPM:
It's probably just a small fraction of those patients that we see that we do now see regularly. I mean, like every two to six months. So I have a fair number of patients with diabetes who I see every two to six months, or even more frequently because they have risk factors such as peripheral arterial disease, a lack of blood flow in their feet. Those are the patients that I personally am debriding their toenails. I'm taking care of any callouses and just trying to prevent a skin insult to their feet, prescribing prescription footwear, because we do know that amputations are preventable with comprehensive, multidisciplinary care teams and with podiatry in specific.

Lee Kirksey, MD:
That's very important information. How important is shoe wear?

Georgeanne Botek, DPM:
Shoe wear is critical. Even just keeping shoes on in the house can prevent a problem with the foot. Preventing skin irritation, if we protect the skin, we protect the whole foot, so just preventing a skin problem can prevent amputation. Footwear in the home is just as important as footwear outside of the home.

Lee Kirksey, MD:
That's great. That's great. Dr. Khatri, so you do these great interventions. Patients want to know what's the process? How complex are these procedures? What's the recovery for these procedures, whether you're intervening on the extremities or you're intervening on the heart?

Jaikirshan Khatri, MD:
That's a great question. Most people are obviously very apprehensive about coming in for a procedure on an artery, in the heart or anywhere else. In the legs in particular, we like to get a CT scan if we can, if there's no medical reason not to so that we have a plan in terms of what we need to do. A lot of these cases can be done through the wrist, which is a really safe way to get access to the arterial circulation with very little risk of bleeding complications afterwards. A lot of inflow disease, arteries like the iliac arteries, we can reach those from the wrist and fix those through the wrist. The heart, we can fix through the wrist and that adds a high level of safety to it. If we can't reach it that way, we can go through the legs. Almost all these patients are well enough to be discharged home the same day with a very quick recovery back to normal activity.

Lee Kirksey, MD:
That's so important because sometimes we're intervening upon patients to save their legs. Sometimes we're intervening upon patients who don't have tissue loss who we're intervening for quality of life or improvement in their functionality, and so getting them back on their way, returned to their normal activities, I think, is really important. So you perform a lower extremity intervention on a patient, what's their postoperative regimen? How complex is it in terms of their medication?

Jaikirshan Khatri, MD:
I mean, I think that's critical. I think that there's the whole prevention side of things, modifying the risk factors with statins, which we discussed earlier, but it's critical that patients that have these types of interventions be put on the right type of blood thinners and your doctor may prescribe aspirin in conjunction with a second blood thinner. Typically, we use something called clopidigrel, but there are other options as well, but it's very important that you follow the advice given to you by your interventionalist because there are specific indications for specific drugs and specific interventions.

Lee Kirksey, MD:
Adherence, I think, is really important for patients in understanding what the prescribed regimen is and adhering to that regimen and if there are problems, contacting one's primary physician. Dr. Botek, I think podiatrists, just like vascular surgeons in some instances, it's poorly understood exactly what we do. Some people consider a podiatrist caring for their nails or toenails, but I want to emphasize to patients that you are a surgical expert at managing foot issues. Maybe you can tell patients about some of the procedures that are performed to reconstruct their foot so that they're able to ambulate.

Georgeanne Botek, DPM:
Again, in dealing with someone with diabetes and peripheral arterial disease, our main aim is to prevent a major lower extremity amputation, but our aim is also to prevent any kind of amputation, a toe amputation, a forefoot amputation. I know that this is a great fear for many diabetics, more fearful sometimes than losing their life. There are things that can be done preventively and sometimes that does involve surgery, like straightening a bunion or correcting a hammer toe, and sometimes even simple procedures like a tendon lengthening. While we are surgeons and we probably do perform the majority of foot amputations, our goal is not to get to that point.

Lee Kirksey, MD:
Understood, understood. I think the take home message from cardiovascular experts and podiatric experts, we want to reduce amputations. Prevention is critical and early identification of problems are important to accomplishing that goal, but equally important is reducing the risk of heart attack and stroke. We know that patients that suffer from diabetes and peripheral arterial disease are at increased risk of each of those. Those are usually the cause of death in those patients and so prevention is paramount. We need a team to do this and an interdisciplinary approach is how we care for these patients here at the Cleveland Clinic. Thank you so much for your attention.

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