Health Topics

Treatment Options and Research

Andrew Schorr:

All right, so now that brings us to the UCSF Heart and Vascular Center story, I guess, and that is you have a multidisciplinary team there. So you're a vascular surgeon. You have cardiovascular specialists of all types who all work together to try to determine what's right for Mrs. Smith or Mr. Jones and their individual situations over time. Tell us about the benefit of that, and also you're a research institution, and I know as we said at the outset you led a multicenter trial about the research and how that could apply to somebody with this condition.

Dr. Conte:

Sure. We just mentioned that for many patients with PAD simply making the diagnosis, monitoring, and instituting appropriate medical therapy is really all that's required. So many patients with PAD, diabetic or not, need to just be put on the right program of modifying their risk factors, using appropriate targets for their sugar and for their cholesterol (which by the way are now being increasingly made lower, and the drugs are very effective), and appropriate foot care and shoes. That's really what we do for a large percentage of patients.

One of the misconceptions that unfortunately is out there is that if I have a blocked artery in my leg that it has to be reopened, and really that's not the case. We don't treat patients based on their arteries. We treat them based on their symptoms and the severity of how it affects their overall level of function.

There are many, many treatment options now that are out there that involve less invasive approaches using catheters such as balloons and stents and lasers and other devices that can clean out plaque, and these can be applied. In the right patient, they can be effective at improving leg function, but I would say that there are more procedures than there is evidence to support where and how they should be used and how effective and durable they are.

That's why it's really important to have a multidisciplinary team where we have specialists who are experienced, competent, and have good judgment and are able to offer a variety of these approaches, but the best decision we feel is made by a combined team approach and also by taking into account not just the immediate outcome, but the best chance at preserving the leg for the patient's life requires careful selection of the procedure and timing.

The most effective and durable treatment when a patient's blockages are severe enough to warrant doing something, in general the most effective treatment is surgery to perform a bypass around the blocked artery. This tends to be the longest lasting and provide the greatest amount of increased circulation in the foot; however, it is an operation that does have some risk up front, and even bypass surgery done with a patient's veins, which is the best material to use, can fail over time. Use of balloons and stents and other procedures offer a less-invasive approach, but it has a much higher rate of failure; as many as fifty-percent of these may fail within the first one to two years.

So the point is that all of these procedures have some failure rate over time, and therefore one of the key areas of research is to avoid or reduce the scar tissue that can build up that can result in re-narrowing of the vessels, the problem that we call restenosis, and that is something that we here and at many other places we are researching to develop new drugs that can be either applied to stents or balloons or to the veins themselves to reduce the scar tissue that forms after the procedure and enable a higher percentage of these to stay open for five to ten years or longer as long as the patients need them.

By the way, patients with cardiovascular disease are living longer in general, and so maintaining the long-term outcome of these procedures becomes even more important. Needing a repeat procedure is often a harder thing for the patient to go through. So preventing the scar tissue, the restenosis, is a number one scientific problem that we are working on here at UCSF.

The second area is that there are patients who just don't have good options to work with because the disease is so severe in their leg that they're essentially running out of arteries. They can't be reopened with catheters, and there's nothing left to bypass to, or they don't have a vein available to use for a bypass in the leg.

So in those cases the avenues that are being developed are to try to encourage the body to develop its own alternative blood vessels in a more rapid fashion. All of us will develop what's called collateral vessels in our legs if we develop blockages, but they may not be adequate. Researchers here and at other places have been exploring a variety of ways to encourage this so-called angiogenesis process and its companion process, which is arteriogenesis, which is the development of larger vessels to reroute blood flow around the leg.

This area of research is a little bit earlier I think in its timeline to reaching clinical fruition but is a very active area of research.

Finally, the last area which affects the PAD patient is to somehow create better materials to use for bypasses when patients don't have veins. The currently available artificial grafts do not really work very effectively when we have to do these operations to the smaller vessels down the leg and down into the ankle and foot area, and so there is continued to be a need for developing alternative materials to work with, and that's a final area of important research here.

Andrew Schorr:

Dr. Conte, as I listen to this as a lay person I'm impressed with the fact that if somebody in my family has diabetes I'm going to insist that they get evaluated to see how their circulation is to their extremities and their legs, and if there is some indication there or if they're having any symptoms but even before that that we get it dealt with early. I'm also impressed with the fact that at the UCSF Heart and Vascular Center your team approach may be very right on target for someone not only today but with your research and your variety of procedures and how they're developing over time. So it makes a lot of sense to me, and I know you have a concern personally about how in diabetics this condition is underdiagnosed, so I hope wherever people are listening they get checked for it and get the appropriate care.

Dr. Conte:

Yes, I think I would like to leave off with that message that this is a disease whose complications can often be prevented by early recognition and the appropriate use of aggressive strategies in a timely fashion. Many patients do not require aggressive or invasive procedures, but when they do cross that threshold then picking the right procedure and doing it early is the best way to avoid the endpoints that we don't want to see.

Andrew Schorr:

Dr. Michael Conte, thank you so much for being with us, Chief of Vascular Surgery at the UCSF Heart and Vascular Center, and for our listeners if you want to get more information about Dr. Conte, the whole group there related to PAD and treatment for diabetes and many other conditions, just call the UCSF Physician Referral Line, and that is 888-689-UCSF (888-689-8273). I'm Andrew Schorr. You've been listening to Patient Power brought to you by UCSF Medical Center.

Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That's how you'll get care that's most appropriate for you.