Limb Loss and Peripheral Vascular Disease with Elizabeth Genovese, M.D.

South Carolina has some of the highest rates of lower extremity limb loss in the country, and many of these cases can be traced back to underdiagnosed or undertreated peripheral vascular or arterial disease, known as PAD. Elizabeth Genovese, M.D., a vascular surgeon at MUSC Health, aims to change that statistic through innovative new technology that can reduce the risk of amputation for patients with PAD.

“I would give anything to catch some patients at an earlier stage (of PAD) when we can actually make a difference so that we don't have to resort to major amputations. So, trying to educate people to really try to be seen by a specialist or to ask your primary care doctor to look into it is the first step.”
– Elizabeth Genovese, M.D.

Topics covered in this show

• Genovese decided to become a vascular surgeon after her first surgery, where she restored blood flow to a woman’s arm and saved her limb. She realized that vascular surgery had the ability to drastically affect a patient’s life and well-being.
• PAD stands for Peripheral Arterial Disease, which typically means the narrowing of the arteries or complete blockages in the arteries that feed the legs and feet. Patients will typically start to notice PAD when they experience pain walking or trouble with wound healing on their feet because of a lack of blood flow to the legs and feet. These symptoms are also normal in diabetic patients.
• One of the biggest risk factors for PAD is smoking and smoking cessation techniques and medication are often employed first when treating patients. Walking programs are also commonly introduced early on in treatment, and some patients can get to a good enough quality of life so that no other interventions are necessary. There are other minimally invasive techniques used for treatment, including using x-rays and catheters to find narrow pathways and open them up with balloons or stents.
• South Carolina has one of the nation's highest rates of lower extremity amputation from conditions like PAD. Rural minorities suffer the most from PAD, and have some of the lowest rates of attempts at saving their legs prior to actual limb loss. PAD rates are highest in South Carolina, Alabama, and Texas.
• Patients who have persistent pain in their legs or wounds that won’t heal on their feet should see their primary care doctor and ask for a referral to a vascular surgeon. Testing for reduced blood flow to the legs and feet is simple and painless, and allows for early intervention before major limb amputation.
• Efforts to increase awareness and access, including mobile testing, will help patients arm themselves with the information they need to advocate for themselves.
• MUSC Health has developed state-of-the art technologies and techniques for treating PAD, including minimally invasive techniques for opening arterial blockages and new X-ray technology to properly locate areas of concern.
• MUSC Health was the first hospital in the state to offer the Tack Endovascular System, a minimal metal implant used to repair dissections following balloon angioplasty in complex below-the-knee arteries.

Read the show transcript below

Erin Spain: [00:00:04] Welcome to Advance MUSC health, I'm your host, Erin Spain. This show's the mission is to help you find ways to preserve and optimize your health and get the care you need to live well. South Carolina has some of the highest rates of lower extremity limb loss in the country, and many of these cases can be traced back to underdiagnosed or undertreated peripheral vascular disease, known as PAD. Dr. Elizabeth Genovese, a vascular surgeon at MUSC Health, aims to change that statistic through innovative new technology that can reduce the risk of amputation for patients with PAD. Welcome to the show.

Elizabeth Genovese: [00:00:46] Thank you very much for having me.

Erin Spain: [00:00:48] What first inspired you to dedicate your career to vascular health?

Elizabeth Genovese: [00:00:52] You know, I always knew I wanted to be a surgeon. I grew up with two parents who were veterinarians, and I was around medicine and surgery my whole life, and I fell in love with vascular surgery during my medical school rotation. And I remember my very first surgery. I fell in love with it, where someone suddenly didn't have blood flow to their arm because a piece of clot had flicked off from their heart and gone to their arm and the patient couldn't move her arm. She couldn't feel it, and we took her to the operating room and we pulled the clot out and she had a pulse in her wrist. And she was like, "Oh, it feels so much better." And I was like, I have the ability to change someone's life so drastically. And our limbs - you can't put a price on your limbs and the functionality of your limbs, and I just fell in love with it. It's a wonderful way to impact a patient's life.

Erin Spain: [00:01:40] Describe PAD to me. What is it? How does it affect the extremities, especially the lower legs and feet?

Elizabeth Genovese: [00:01:48] PAD stands for peripheral vascular or periferal arterial disease. So, what we are talking about today is going to be blockages in the arteries that feed the legs and the feet. We need that in order to feed our muscles so that we can walk and do work, and we need it to heal wounds should we stop our toe or get an ingrown toenail. So, patients who have peripheral vascular disease or peripheral arterial disease, known as PAD, they tend to have blockages, and these blockages come in the form of narrowing of their arteries that feed their legs or their feet, or complete blockages or occlusions. This can manifest for different patients in a couple of different ways. One of the ways that people will notice that they have problems with the blood flow to their legs is that their legs might start to hurt when they use their muscles. So typically, what someone will tell me is that, well, you know, I never really had any problems walking, but I started to notice as I go through the grocery store, my calf tends to cramp when I walk and I have to stop and let it rest to let the blood flow come back. Or I can't even get to my mailbox anymore because the burning or the cramping in my calf or my thighs is so bad. That's what we clotication. So, hurting when walking because we don't have enough good blood flow to the foot. The other level of blockages to the legs, or PAD, is when the blood flow is so bad that people's feet hurt all the time because there's not enough blood flow. Or even worse, there's wounds that happen in the feet that just can't heal because there's not enough blood and oxygen and nutrients getting to the foot.

Erin Spain: [00:03:29] OK, so these everyday activities are what people start to notice, typically, in the beginning. That it's difficult to walk to climb the stairs, things like that. And then there is this more severe form. Just tell me the difference between the treatments for these two different forms of PAD.

Elizabeth Genovese: [00:03:43] There is definitely a group of patients who may not have the pain in their legs at first, and the first way they know it is that their foot hurts all the time or they have a wound that doesn't heal. And that's not abnormal, particularly in diabetic patients. Sometimes they don't hit that first step, which is my legs hurt when I walk and they just go straight to the more severe form. The way we treat it really depends on the patient themselves in the severity of their disease. But if patients are presenting to me with, it hurts when I walk, the first thing we do is we want to say, okay, how can we manage you medically? So, how do we tune you up? So, one of the biggest risk factors for PAD is smoking. So, I spend a lot of time with my patients talking about different types of smoking cessation techniques and I do a lot of motivational interviewing to see what are the factors in the triggers that get people to smoke. Kind of, what their muscle memory is with smoking? And how can we combat that? So, first and foremost, it's making sure people stop smoking and making sure they're on some of the right medications to help this. The other thing that we do if patients are just hurting when they walk, we often like to start patients off with a walking program. So, what this is is that we'll say, okay, I want you to walk and I want your calves to burn. And I want you to keep walking through that, because what that does is that sends signals to the body to say, oh, I need to make little pathways around the blockages. In some people, I would say about 20 to 25 percent of my patients, that is enough to get them to where their quality of life is very good and they don't need any interventions. Then, we have the other people who say, you know what? I can't do what I need to do on a daily basis. It hurts too much. I stopped smoking. I'm doing everything you've asked me, Dr. Genovese, now what do we do? So, then we start thinking about what are the minimally invasive ways that we can treat. So, we try a lot first line to do minimally invasive techniques. And the way we do that is that we put wires and catheters inside the blood vessel, and we do it through just a little poke in the skin. And we use some liquid that lights up under X-ray and shows us where the narrowings are. And we try to balloon open blockages or potentially stent open blockages in order to get blood flow all the way to the foot. The next step, obviously with treatment, if we can't do it successfully that way, is some bigger surgeries. But we have a lot of cool technology and a lot of advances, particularly that are available to us at MUSC that allow us to be very successful with more minimally invasive techniques.

Erin Spain: [00:06:21] Unfortunately, South Carolina has one of the nation's highest rates of lower extremity amputation from conditions like PAD. Now, you tend to see this in the more rural areas of the state. What is going on? Why is this happening and how can it be changed?

Elizabeth Genovese: [00:06:37] It's really a health crisis in the Southeast and particularly South Carolina. We have some of the highest rates of limb loss in the entire United States per capita. And even more upsetting about that is that the patients who are losing their legs, they have some of the lowest rates of attempts at saving their legs prior to actual limb loss. You know, there are times when we try and we balloon arteries open or we do bypasses and we're just still not able to save a leg. But there is a pandemic of patients who don't have great access to health care, who their disease gets too far along and we either don't have the ability to save their legs or they just don't have an aggressive attempt at limb salvage. And it's really too bad because the patients who are most affected by this are rural minorities. And so that is what the data has shown in multiple different studies. And it's really the worst in essentially South Carolina, Texas and Alabama, where kind of the top three states in the entire country.

Erin Spain: [00:07:46] What do you think can be done to get the word out about some of this more advanced technology that could really help folks save their limbs?

Elizabeth Genovese: [00:07:53] If any patient is listening to this or any caretakers listening to this, and something just doesn't feel right about your loved ones or your lower extremities. You know, that pain in your foot just hasn't gone away and it's really bothering you. Or that wound just doesn't look right, and it's just not healing. Ask your primary care doctor for a referral for a vascular surgeon. The best case scenario is that you come and see us and we tell you, you know, you have great blood flow and we just got to tweak your wound care. I would give anything to catch some patients at an earlier stage when we can actually make a difference so that we don't have to resort to major amputations. So, trying to educate people to really try to be seen by a specialist or to ask your primary care doctor to look into it is the first step. But there's a lot of things that, you know, as health care providers, we need to do as far as getting mobile testing out, getting easier access for patients who can't make it all the way to Charleston and improving the referral network. So, it's a complex issue. I think helping patients arm themselves with information so that they can advocate for themselves, and it's absolutely difficult. But at least knowing concerning signs is the first step.

Erin Spain: [00:09:03] You have a first of its kind implant that you're using here at MUSC Health to help these patients who have this more severe form of PAD. Tell me about this technology, how it's being used, and how did it come to MUSC Health?

Elizabeth Genovese: [00:09:18] When we are opening up blockages? The first thing that we do is we have to get across the blockage, which isn't always easy. So, we get across the blockage and the first thing we do is we say, okay, that's just gently balloon open the blockage. So, we have a catheter and we inflate a balloon and it kind of opens up a pathway and then the balloon comes down and that comes out. We take a picture and we say, okay, what does it look like? And ideally, we would like to be able to only balloon open blockages. That way, patients aren't left with long segments of stents and things like that, because that takes a lot of maintenance down the road. And so we try to avoid leaving any implants in. So, a vascular surgeon actually developed this and he said, you know, when I am working on the blood vessels open and I see them with with my hands and I see them with my eyes - sometimes when there's injuries to the vessel wall, I just put a stitch to to fix it and to make it all OK. What if I can develop a little TACK, just one little strut that does that same thing without having to leave a big, long stent? So we got the TACK system in just a little bit over a year ago, and it is so successful in patients where we balloon and there's just a little injury that we think typically and traditionally we would have put a stent across. It's like, oh, I'm just going to leave this one little guy behind, and it's going to open that up and allow the patient to not have big, long stents we have to take care of in the future. It doesn't work for everyone and all lesions, but it is a very nice alternative.

Erin Spain: [00:10:51] How often is it being used and what's the reaction been like from patients?

Elizabeth Genovese: [00:10:55] You know, it's interesting about the reaction from patients. I think what patients understand and what they feel is our ability to keep things minimally invasive and to be successful at opening up the blood flow to the legs without having to do a big surgery. And I think it's really a testament to a number of technologies that we have here at MUSC. So, we have a brand new room that we operate in where when we take the X-rays to look at the blood vessel flow, it not only takes pictures for us, but it has the ability to tell us how fast things are flowing. So, imagine you're looking at your Google Maps and you're trying to find out how long it's going to take you to get somewhere, and you notice there's green and then there's yellow and then there's red, and it's telling you traffic's really slow there. Well, we have this new technology now using this system that says, oh, this area is red, this is slow. And it may not by the naked eye look narrowed on the picture, but it's telling us the flow is slowing down there and that we need to pay attention to it. So, that's a really, really cool new feature that we have in our room. And we also have technology that allows us to look with ultrasound directly within the blood vessel to see what the blood vessel looks like. So, how narrowed is it? And we can measure how narrowed it is. We can see is it is more like clot? Is it more like rubbery plaque? Is it calcium? We can tell all of that with this technology. So, I think the imaging really allows us to be super successful. But then also new technology like the TACK system or one of the other new technologies that we have here is the ability for us to when we balloon, we can actually use some ultrasound to help break up the calcium. People traditionally know this for kidney stones, right? They use the ultrasound to break up the kidney stones so people can then pass those kidney stones. Same technology on the balloons.

Erin Spain: [00:12:50] What's it like for you as a vascular surgeon to have this access to this type of new technology, and when new things come along, you're able to bring it in and try it?

Elizabeth Genovese: [00:12:59] I mean, I feel a little bit like a kid in a candy store, but honestly, if I can make their experience easy and painless and if I can do it so that they are able to have a durable intervention without me having to put them through a large surgery, then that's that's everything to me, right? And some of this technology really does allow me to give my patients the best results because typically my patients are older with a lot of medical problems, because that's kind of what contributes them to getting blockages in their legs. And if I can avoid a big surgery, then I'll try anything, particularly some of this technology. We've been using them for a while now and it's shown to be very successful. So, I like that I have this so readily available for my patients.

Erin Spain: [00:13:44] The last question is the question we ask everyone on the podcast. What do you do to optimize your health and live well?

Elizabeth Genovese: [00:13:50] I grew up in the Northeast where it was very cold, and so one of the things that I have done since I've lived here is just really taking advantage of how beautiful this weather is and the ability to be outside every day of the year. Even when it's a little chilly in the middle of the winter, you put on a jacket and you have the ability to go for a walk. So, I just try to stay active and utilize our gorgeous environment to be able to do that.

Erin Spain: [00:14:14] Thank you so much for coming on the show and sharing these insights. Hopefully, some folks will hear of these warning signs and share it with their loved ones. 

Elizabeth Genovese: [00:14:22] Yes, well, thank you for having me.

Erin Spain: [00:14:28] For more information on this podcast, check out advance.MUSChealth.org.