Listen to Your Limbs

Dr. Justin D’Addario, vascular and endovascular surgeon at UConn Health, explains the potential health hazards of poor blood flow, and how to recognize problems like peripheral arterial disease, deep vein thrombosis, and aneurysms, and address them before they require drastic measures.

(June 2024, Dr. Justin D’Addario, Carolyn Pennington, Chris DeFrancesco)

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Transcript

Chris: Problems with circulation can turn into major health problems. Today on The Pulse, we learn why listening to your limbs can help save them.

This is a UConn Health Pulse, a podcast to help you get to know UConn Health and its people a little better, and ideally leave you with some health information you’ll find useful.

With Carolyn Pennington, I’m Chris DeFrancesco. When we have disorders of the arteries or veins, the impact on proper blood flow can introduce problems both chronic and acute.

Carolyn: Signs of problems like peripheral artery disease or deep vein thrombosis, they often show up in our legs. Left untreated, they can threaten quality of life or worse. But problems with plaque buildup can happen elsewhere in the body, like with carotid artery disease or aortic aneurysm. These are just some examples of what vascular and endovascular surgeons can help treat. And today we have one with us: Dr. Justin D’Addario from UConn Health’s Division of Vascular and Endovascular Surgery. Thank you for joining us today.

Dr. D’Addario: Thanks for having me, guys.

Carolyn: So what can pain in the arms and legs really be telling us?

Dr. D’Addario: There’s a wide variety of causes of pain in your arms and legs. The most sinister of which that we see is blockages in the arteries. A lot of times, patients come into our office. With exactly that foot pain and cold feet. You obviously can’t see your arteries, and then by the time they see us It’s a little bit of a shock because they find out something that they didn’t know was there and it’s probably been building up for years and years and years.

Carolyn: What are those some things? You know, what are you talking about here? What’s causing it?

Dr. D’Addario: A lot of it has to do with lifestyle, smoking tobacco, and the long things that we think of are the calcium, the hardening of the arteries. Patients feel fine until they don’t. They feel fine in their normal state of health until they have a wound on the foot, either a rest pain in the foot, or, people that are fortunate enough to have an early warning sign, could be cramping in the specifically the calves and thighs.

Chris: And this is a sign of blood not flowing adequately to those parts of the body?

Dr. D’Addario: It is. It’s actually very similar to what we think of colloquially as angina or chest pain. It’s the same process just in the legs. When you don’t have enough blood to the muscle that’s working, it hurts. When it gets so severely reduced, it hurts just by having a foot that needs blood.

Carolyn: So at that point though, when they come to see you, have they already done some major damage?

Dr. D’Addario: It’s varied. The best case scenario is they have some blockages that we could fix either with an open bypass or minimally invasive procedures like stents, or the blockages are so extensive that we have to use novel modalities or more newly approved in the commercial sense treatments that aren’t privy to a lot of non academic institutions. One such device would be the DETOUR procedure we’ve been doing, and we’ve had great success with that.

Carolyn: And we’re one of the only ones doing that?

Dr. D’Addario: We are. So we were actually first in New England to offer the service commercially, and it’s been great to develop, with input from the device manufacturer and their support to not only grow our experience, but grow their company’s experience in rolling out the product and troubleshooting. I actually have a close relationship and share tips, tricks, techniques, a little bit like a post-market surveillance from an institutional sense.

Chris: Is that something that you eventually will be teaching residents and fellows how to do as this becomes more accepted?

Dr. D’Addario: We already are. The reason we adopted it is, as academic physicians, it’s really not just our job to know the right treatment, it’s our job almost to predict a stock market. We don’t want you to miss a treatment because of lack of knowledge or lack of profitability, if I could be frank, at outside institutions. We want to pick what is best for you, dIsseminate it to our trainees, and even other physicians to treat as many patients as possible.

Chris: So what’s happening when you’re doing a DETOUR procedure? What is that treating and how are you dealing with it?

Dr. D’Addario: The problem is a long blockage in the artery of the thigh, and traditionally you had two options. You would do an open bypass, which is a good option but requires anesthesia, or you’d require stent placements. The DETOUR procedure is novel in my eyes. It’s new from what’s come before current technology in that it’s a stent that acts like a bypass. We actually route the stent outside of the blood vessel and get back into it further down in the leg.

Carolyn: Why is that better?

Dr. D’Addario: That’s better because you avoid the common mechanisms of failure with stents. When you have a stent placed, we know that some stents do better than others, and even though it’s minimally invasive, it might not give you the best long-term result. So this procedure gives you the risk profile of a minimally invasive procedure with what we believe and have good data to this point, the outcome profile of an open bypass. I think the short of it is it’s the best of both worlds.

Chris: So someone has that problem and didn’t know about the DETOUR or the DETOUR was an option for that person, or any intervention, they just didn’t get the intervention. Eventually, what happens to that person’s leg or foot or that person’s overall well being, if this problem is not addressed?

Dr. D’Addario: The most dreadful outcome of unaddressed peripheral arterial disease is amputation. I can’t stress that enough. I counsel my patients and set expectations. We ride a fine line as vascular surgeons and endovascular surgeons of trying to save as many legs as possible while decreasing the risk to someone’s overall health at the same time. And there are some people, I tell them, if you don’t want surgery, that’s fine, but we have to come to terms with this process being chronic, irreversible, and can ultimately lead to you losing a leg.

Carolyn: Are there medications to offer them or what are the other options?

Dr. D’Addario: So the best option is smoking cessation. I say it once, twice, again and again and again. That being said, I don’t belabor the point. When you’re at the time that you’re thinking about lack of blood flow and amputations, smoking cessation is great, but we need a fix as well. Ideally, we’re on an aspirin, a high- intensity statin. This decreases not only our cardiac risk profile, in terms of these patients having a heart attack long term, but also helps stabilize plaques everywhere in the body, meaning you’re more likely to have a better outcome for your legs as well.

Chris: When you get to the point of Identifying a patient who is on the path toward possibly losing a limb. How long is that window of opportunity open for you to be able to intervene and prevent that outcome?

Dr. D’Addario: It’s highly varied, I must say, and it depends on the patient’s age and their lifestyle . If someone comes to me with a wound on their foot, their risk of limb loss is about 20 percent a year, if we were to do nothing. So that’s someone, I typically tell them, we don’t have to do this today, tomorrow, or even the next month or two, as long as we don’t have any signs of infection, but we should not delay this for anything other than a good reason.

Carolyn: Varicose veins: we are heading into the summer season, and so just wondering about varicose veins. I’m sure you get a lot of people coming in for cosmetic, and I know they can be very painful too, so it’s good to get them taken care of.

Dr. D’Addario: Yeah, we take care of a lot of patients with varicose veins. Now the fun part about varicose veins is that if you have these large, tender, painful varicosities, heaviness and leg swelling, we could potentially make your leg feel better in a one hour procedure in the office for people with more advanced leaking veins and leg swellings — sometimes we have wounds and we can get good results in healing that wound — so, it’s kind of the low-risk approach to help a lot of folks, people that want better looking legs, people want legs that feel better, and people that may be a little more advanced in age and need to heal a wound.

Carolyn: The old insurance question. Can you get it paid for? I mean what’s the cutoff line or, how do you get paid for it?

Dr. D’Addario: It’s payer by payer. You come see me or one of my colleagues. We do an evaluation, get an ultrasound of your veins. And then we recommend, and rightfully so, to wear compression stockings.

You follow up in a couple of months. If the compression stockings haven’t worked, we submit to insurance. And then unfortunately at that point, we’re at the mercy of the payers. But once we get approved, it’s a pretty easy process to actually go about performing the procedure.

Carolyn: And there are a lot of vein clinics out there. How are you different? Why would someone want to come to UConn health versus one of those many vein clinics out there?

Dr. D’Addario: The difference is actually related to how we get compensated. I don’t have skin in the game, so to speak. So just like with the limb salvage and the doom and gloom of losing legs, I had a need for patients, and my partners had a need for patients, that a small vein center can’t realistically adopt every different treatment modality. When I see a new patient, this is UConn. I’m a state employee. We have contracts. I get that modality. So the difference would be, we don’t “do veins” or “do them well,” we do them every single way you can do them. And that was something we’ve been building over the last six to eight months, to the point where there’s nothing we don’t do.

Carolyn: Do you ever get people coming in thinking, “Oh, it’s just a varicose vein or a clot or whatever,” and then you find that it’s really something more serious, and thank goodness they came in when they did?

Dr. D’Addario: That’s actually not terribly uncommon. As a specialist, we would love to live in a world where the answer just lands in our lap, but the reality is we’re specialists because these are hard-to-delineate problems. So I routinely have people sent to me for a swollen leg, and sure enough, the veins are fine, but the arteries are bad. And that happens in reverse, too. Sometimes I get someone with bad arteries, and it’s really a vein problem.

So it’s really important to have a high level of alertness, not just in your own care, but in discussion with your PCP and seeking out a specialized care if you have a concern.

Chris: What are some other examples of things that you see as a vascular and endovascular surgeon? And how do you handle those?

Dr. D’Addario: We see problems with arteries and veins everywhere in the body outside of the heart and in the brain. So, blockages in the legs, we discussed, we could treat blockages in the arteries in the abdomen, the kidneys, the arteries going to the intestines, the artery coming off your heart. Less frequently is that a blockage we’re treating, but that could have an aneurysm, a dilation, where if that ruptures, it’s very fatal.

You could have blockages in the arteries of the neck going to your brain. That’s not an uncommon problem either. And we fix all of those. We’re one of the few specialties that not only knows patients as individuals, can treat patients with open surgery, which may be the best, but can treat them with minimally invasive surgery well, depending on their clinical picture, their preferences, and their risk profile.

Carolyn: And maybe just a word about deep vein thrombosis too, because isn’t that the one you get if you’re on like a long airline flight and you should get up and walk around?

Dr. D’Addario: That’s a little bit different of the leaking valves or varicose veins, though they are related. When you have a blood clot, right when you get the blood clot in a vein, it can cause an embolism to go to your lungs. That can be life-threatening. That is not something we treat in the office, but it’s something we treat nonetheless. To go on the point that we have every tool set that you can imagine, we actually treat those as well, typically in the hospital, after a patient comes to the ER with a massively swollen leg and a blood clot. And they’re safe procedures as well. It’s just very scary for patients. Everyone hears blood clot and they’re in distress, but we have good results and all those procedures are minimally invasive as well.

Chris: Before we say goodbye, anything that you can impart on our listeners that they should be watching for to know, “OK, this could be peripheral artery disease. This could be deep vein thrombosis. This could be some other problem.” What should people look for to know that they need to come in and see someone with your specialty?

Dr. D’Addario: When we see a wound on the foot that doesn’t heal, cramping in the calves when you walk or swollen legs, that’s the easiest telltale sign that you should have it looked at. And my perspective is, when I get presented with these questions, patients, if there’s nothing wrong, they often feel silly. And I say, “No, it’s nothing to feel silly about.” We have two options. This could be nothing, or it could be life- and limb-threatening. so we should err on the side of getting it checked out.

For the other diseases, if you’ve had a stroke in the past, you should have had someone look at your carotids with an ultrasound at least once, that’s usually how that problem is identified. And then your PCP should do screening depending on your age and risk factors for aneurysms in the stomach.

Carolyn: Other than not smoking, any other tips for avoiding clots and some of these issues, and I know each is probably different, but any general advice for prevention?

Dr. D’Addario: General advice for prevention is, if you have evidence of hardening of the arteries in your heart or elsewhere, stop smoking, like I said. I can’t stress that enough. It’s the strongest risk factor aside from age. But also take a baby aspirin and a statin. And the reason that’s important, and when I see a lot in my clinic, is, patients say, “My lipid profile is great. My blood fat is fine.” And that’s not really the point. The point is that the statins stabilize those plaques. It prevents those blockages from fracturing and sending debris or blocking off acutely. So really, those three are primary prevention.

Carolyn: Alright, thank you.

Chris: Dr. Justin D’Addario is a vascular and endovascular surgeon at UConn Health. That is our time for today. For Dr. D’Addario and Carolyn Pennington, I’m Chris DeFrancesco.

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