Pioneering Advancements in Vascular Health

Dr. Corinn Cross (Host): Advancing health, Personalizing care. At Memorial Hermann, this is our mission. This podcast shares the science and stories behind those. Welcome. I'm Dr. Corey Cross. Today we'll be discussing advancements in vascular surgery and the innovative cardiovascular program at Memorial Hermann. Joining us this afternoon is Dr. Rana Afifi. She’s an associate professor of Vascular Surgery with the Department of Cardiothoracic and Vascular Surgery at UTHealth Houston Heart & Vascular, affiliated with the Memorial Hermann Heart & Vascular program. Dr. Afifi, thank you for joining us today.

Dr. Rana Afifi: Thank you for having me, Dr. Cross.

Host: Dr. Afifi. Tell us what is vascular surgery?

Dr. Afifi: Vascular surgery is a specialty that focuses on the diseases of the blood vessels, both arteries and veins. It has elements of surgery in them where we can do surgery. It everything. Medical management. So a lot of the patients would require, sometimes just with optimizing their medical management. Some of the patients might require interventions. Those interventions can be open surgeries, where we do cut downs and either open the blood vessels or replace some of the blood vessels. And some patients would require interventions that are minimally invasive, such as endovascular interventions. And so the specialty of vascular surgery includes all of that.

Host: So is the difference then between vascular surgery and endovascular surgery the minimalistic approach or is there another differentiation?

Dr. Afifi: No, it's usually the minimalistic approach. So most, departments would have vascular and endovascular specialty, because endovascular is the word endo, as inside. So that kind of makes it minimal that we go from the inside of the blood vessels. Eventually the specialty itself manages the diseases of the blood vessels. And the way for us to approach that, in order to fix that, might be an open surgery approach or a minimal approach, which is the endovascular techniques.

Host: Got it. Thank you. So then what is peripheral artery disease?

Dr. Afifi: Peripheral artery disease is, usually we refer to atherosclerotic disease, meaning, buildup of plaques. And, it's simpler for what's known as a buildup of calcifications and plaques in the blood vessels that cause them to narrow. Peripheral arterial disease kind of talks about any of the blood vessels that are not in the major or big blood vessels in the periphery. That can be in the upper extremity or lower extremity. Even though the majority of what people kind of mean when they mention peripheral arterial disease, they're mostly talking about the arteries in the lower extremities.

And so peripheral arterial disease is atherosclerosis and slowly progressive narrowing of the blood vessels in the limbs and mostly focusing on the legs. It's more common to affect the lower extremities.

Host: Right. Those are the extremities that have the biggest issues with that. So what are the risk factors for peripheral artery disease and are some of these modifiable?

Dr. Afifi: So when we're talking about risk factors for any atherosclerosis disease, those are the same risk factors that we talk about in also heart disease, coronary artery disease because it affects the same blood vessels and there's more than 50% overlap of people who have one might have the other. Some of the risk factors that exist, of course, are things such as hypertension, diabetes, high cholesterol levels. So those are kind of comorbidities. And then we can talk about things such as increased weight and smoking.

The things that are mostly modifiable are the things that we can control, such as smoking cessation, because that's one of the biggest risk factors. But there are other things that we can try to control and improve. So, physical activity is kind of a negative risk factor, meaning that if you are doing more physical activity, it's protective and it can be helpful. So that's another modifiable aspect that we can influence. So stopping smoking and doing more activity can be helpful in preventing or at least decreasing the progression of a peripheral arterial disease.

And of course, controlling all the risk factors that we've mentioned. So even though those are things that when they exist, like hypertension and high cholesterol, diabetes and increased weight, those are things that the person would have, and not necessarily be able to completely eliminate them, but a better control of them would definitely help in control of the disease.

Host: And I have a question for you. So I've been hearing a lot about calcium scores. So, sometimes people say they have high cholesterol and then they go and they get their calcium score done. Does calcium score have anything to do with peripheral artery disease? Is it a sort of a benchmark?

Dr. Afifi: Yeah, it's not utilized as it's utilized in the coronaries. We don't use that in there because most of the things that we try to influence, there's a little bit of a difference in how we manage the presence of a narrowing or a disease in the blood vessels when we're talking about arteries in the legs versus in the heart. So, an existence of a significant narrowing in blood vessels in the heart, even though they're not causing symptoms or we're not feeling the symptoms. There are certain indications for treatment for that because we want to prevent the biggest issue, which is a heart attack.

And the damage might not be something that you can reverse, right? So you want to try to completely avoid that. When we're talking about peripheral arterial disease and narrowing in the blood vessels and the legs, we are not as aggressive for many reasons. One of them is that some of the ways for us to intervene, they're temporary solutions, meaning that those are solutions that we have. We can't reverse the issue or the problem and we can't fix it to the point where there is no damage.

So we're kind of doing damage control. So some surgeries might last longer with patency or how long they stay open and help, and others might stay less than that. It depends on the location, the control of the risk factors, the technique that is being used. So there's a lot of data to go over with the surgeon on that. And so we usually keep those options for intervention for when it's really necessary. So people with peripheral arterial disease might have what we call claudication, meaning that they might have pain in their legs when they're walking, but not at rest.

And it's not really preventing them from having a good quality of life, but they can't walk further distance. The management in that population, in most cases, is going to be medical management, walking, exercising rather than doing an intervention. Because at this point, even though we know there's a severe disease in the legs, we still prefer to be able to help with the medical management and the physical activity and reserve our interventions from when there is, threatened symptoms for the limb. And so if the disease is progressing and the patient presents with what we call critical limb ischemia, that have multiple criteria to go there, those are the cases that we are more aggressive into intervention. So having just an imaging that would show that there is a calcium or that there is narrowing is not a sole indicator for intervention. So, this calcium scoring and the imaging that are implemented for the heart are not yet implemented for our lower extremity and are not really used to influence our decision-making.

Host: That makes a lot of sense. Thank you for taking the time to explain that. I appreciate it. So what are the signs and symptoms of peripheral artery disease and do these differ for women?

Dr. Afifi: The traditional or more common symptoms for peripheral arterial disease depends on the level of the disease and the progression of it. Many times, if the disease is in the arteries that are in the legs already in the thighs, so the patients will feel pain in their calves while they're walking. And if it's higher up in the pelvis, so the symptoms will be higher up and include the muscles in the thigh, the level of symptoms, might differ. And as the disease progresses, the symptoms might progress, meaning that the pain might start or be triggered at shorter distances of walking. And when the disease is really progressed and, there is a compromise of the blood supply for the legs, then the patient can complain of pain at rest.Not necessarily while walking or making an effort.

The differences between men and women are at multiple levels. And it's something that is common between a lot of the vascular diseases and cardiac diseases. So similar to the differences in women with heart diseases. We've also found it in women with aortic disease, which is something that I'm more specialized in and interested in, but also with peripheral disease.

So, the differences start with the risk factors. Women have the traditional risk factors that we talked about earlier, which is the smoking and hypertension, hyperlipidemia, the diabetes, and the obesity, but also have other risk factors that are considered non-traditional or are more specific for women. Some of those might be social determinants of health, for example. There are a lot of studies that were showing that low socioeconomic status or factors that are dependent on education level and what we call social determinants of health also influence outcomes in cardiovascular diseases.

And there are studies that showed that women are more influenced, and have more of those social determinants of health risk factors than men, and so that also would influence their outcomes, and that's also been found to be true for peripheral arterial disease. And other risk factors that are related to hormonal therapy and the complications of pregnancy and others, when we're talking about symptoms, there are differences because more women present in an atypical symptoms. So, only about 15%, 20% of them might present with what we just called claudication, meaning pain in the legs while walking.

Sometimes they will not have a lot of symptoms until they have an ulcer that's not healing or something, that is more progressive. Sometimes the patient's symptoms may be masked by other symptoms, such as other reasons for pain such as osteoporosis or arthritis and other diseases. So there are a little bit of differences in the presentations. Also, women are usually older when they present with vascular or cardiac diseases. So those are the main differences, which eventually lead to also differences in outcomes. So, the importance of having different presentation is the fact that it might delay diagnosis; it might mask the disease until it's progressed.

So it would also influence the outcome. If the risk factors are not managed well, and studies have demonstrated that women are less well controlled and managed as far as their diabetes and hypertension and smoking cessation compared to men. So not having well-controlled risk factors also influences your outcome, because the disease is going to be more progressive, and so many of those things are connected together. So having differences in the risk factors and differences in the way they present also influences and leads to differences in outcome.

Host: Yeah, that makes sense. So, obviously then the differences between men and women in the outcomes is a negative for women, they're doing worse in outcomes than for men. And there's a lot of factors in that. You mentioned that early intervention is, of course, what one would strive for as well as modifying those things that can be modified. Besides pain, with activity, what are other signs or symptoms that someone might experience that they would say, wow, I should bring this up to my doctor?

Dr. Afifi: If they're having changes in the color of their toes or feet, or if there is a wound or an ulcer on their foot that's taking longer than what usually would. So if we get injured or we have a rub from the shoe on one of our toes, usually within the next day or two or three, you'll start seeing signs of healing. So if the wound is there for a week or two and it's not healing, it's time to try to go and address it. Because if there is lack of blood supply because of the blood vessels that are narrowed or blocked, then the healing process will be worse. And so it'll be an ulcer that takes it a lot longer than usual to heal.

Host: Now, I understand that you have many pregnant patients as well, like pregnant patients with heart conditions. Could you share a little bit about this work?

Dr. Afifi: When I got interested in looking into disparities in women, because my specialty and interest was in aortic diseases and specialty and aortic aneurysms, which is ballooning of the main blood vessel and the body at different levels. And sometimes, for different reasons and causes, and there might be a tear inside the inner layer of that blood vessel, which would cause what we call a dissection, an aortic dissection. And during treating one of my patients a few years ago, I had to treat someone who had had an aortic dissection after pregnancy, which triggered my interest to look at it because it's not something that's very common. And the more we got to know about it, that's also we saw that there were little data to know, and that there are disparities around that.

And so when we look at that, maternal mortality cardiovascular diseases is one of the leading causes for maternal mortality during pregnancies, and that can relate to many factors such as heart diseases, valve diseases. But the aorta is also one of those reasons. So that sparked an interest to getting to know more and more about it and create a group that has multiple physicians and multiple staff such as genetic counselors, maternal-fetal medicine coordinators, and of course nurse practitioners and physicians at multiple specialties such as cardiology, maternal-fetal medicine, genetics, vascular surgery, cardiac surgery, and critical care and anesthesia, to kind of come together in order to care for those complicated situations as a group.

So we have been treating and focusing on that for the past couple of years, where we would have what we call a multidisciplinary approach and meetings, discuss women who are pregnant or planning to get pregnant, that have heart disease or heart. That might be a valve problem. That might be a weak muscle of the heart functioning. And it might be someone who has a genetic disease and aortic aneurysm, and kind of set up a plan of care. Discuss what needs to be done during the pregnancy as far as follow-up. How do we want to do the delivery? Is it going to be a C-section or regular delivery? What timing of the pregnancy? Because in certain situations it's not safe to complete the pregnancy because in the third trimester it might be a higher risk.

So we kind of have to discuss with the maternal fetal medicine, everyone, the right timing where we can give the better outcomes for the baby as well as the mother. And then also plan the delivery in an environment where there would be backup in case of any cardiac or vascular complications that would require an immediate surgery from our end as well. So having that multidisciplinary team makes it unique and helps us offer those women all the complete management to try and lower their risk during those difficult, and more complex, pregnancies.

Host: Wow. I mean, as a physician myself, I know that the multidisciplinary approach when you have such complicated patients, that's really the gold standard of care. And for patients it is so comforting to know that all of your physicians are working together as a team because the going back and forth between one doctor and another when you have something that's medically complicated, is just so stressful to the patient when they're already going through so much. So I can only imagine that this has both increased, outcomes for your patients, but also mental health, really helping them through these difficult times.

Dr. Afifi: Yeah, you're completely right about this. The patients themselves feel at ease because they don't have themselves to juggle around between multiple clinics or figure out who might be the best. even if the patients originally had a gynecologist that was not maternal-fetal medicine and was not in our group, communicate together, were around the delivery time. Her original OB/GYN would refer them to our group in order to have that multidisciplinary, because eventually, the best outcome for the patient is everyone's goal.

Host: Is there anything else unique about your personal clinical interests that you'd like to share with us today?

Dr. Afifi: I love vascular surgery, in all aspects of it, and I do take care of vascular surgery that's related to peripheral artery disease, like we discussed, dialysis access and everything. But my passion and love is about aortic diseases. Which is again, aneurysms or dissections, those are complex cases and the outcomes can be catastrophic. So for me, they're a challenge. We have a great center and a team that helps work and treat those patients. We have the ability to take care of those complex cases, in both open and endovascular approaches, which is unique for our center as well the ability to be offering that for patients. And mine specifically is focusing on sex and gender disparity. And so, I'm trying also to focus the research, towards that, to try and understand what is the cause of that disparity. What is the reasons for those different outcomes? To try and understand it better, so we can also try to help improve that. So a lot of my research work is focused on that in the last couple of years.

Host: That's wonderful. I mean, as a woman, I really appreciate that. And the fact that you love what you do and get to do what you love is just what we all strive for. Thank you, Dr. Afifi, for joining us and sharing your expertise with us today.

Dr. Afifi: It is my pleasure. Thank you for having me.

Host: To learn more about vascular surgery, visit the Memorial Hermann website at memorialhermann.org/heart. That's Memorial Hermann with two Ns. That concludes this episode of Advance, the podcast series for Memorial Hermann. If you found this podcast helpful, please share it on your social channels, and be sure to check out the entire podcast library for other topics that might be of interest to you. Thanks for listening to this episode of Advance. I'm your host, Dr. Corey Cross.