In a recent episode of “What’s Up, Doc?”, we had the privilege of hosting Dr. Shawn Skillern, a vascular surgeon from Ventura, California. The interview provided valuable insights into peripheral arterial disease (PAD), varicose veins, and the importance of walking as medicine. This blog post summarizes the key points from this informative session.
Why Saving Legs Matters
When asked about his passion for saving legs, Dr. Skillern explained that PAD treatment often provides the most immediate and noticeable benefit to patients compared to other vascular procedures:
“People who have bad PAD or even moderate PAD, their lifestyle is often limited from it,” Dr. Skillern noted. Unlike preventative procedures such as aortic aneurysm repairs, PAD treatments can improve a patient’s quality of life “right away…it happens later that night.”
Varicose Veins: Treatment Options and Considerations
Dr. Skillern discussed modern varicose vein treatments, emphasizing their safety and convenience:
Most procedures can be done in-office in 30-45 minutes
Treatment typically involves closing down the vein with either a glue-like substance or different types of heat energy
Risks are relatively low (less than 1 in 100 or 1 in 200 chance of developing a blood clot)
Some treatments carry a small risk of nerve injury, which is often reversible
PAD Symptoms vs. Other Conditions
Several patients asked about leg pain and whether their symptoms indicated PAD. Dr. Skillern provided these insights:
Muscle twitching and fasciculations are not typically manifestations of PAD
Heat-like feelings are more likely nerve-related than vascular
PAD symptoms are very reproducible when walking and usually affect muscle groups below the blockage
Pain experienced during rest or sleep in the thighs is unlikely to be PAD
One patient described feeling pain at the exact same spot during walks: “I have patients that will tell me, ‘I’m walking and it’s the same darn house. Every time I pass it, that’s when I feel the cramping or the pain in my legs.’”
The Power of Walking as Medicine
Dr. Skillern strongly advocated for walking as the primary treatment for many PAD patients:
How to Walk Effectively for PAD:
Walk 5-6 times per week
Build up to 45 minutes to an hour (can be split into multiple sessions)
Walk at a pace that triggers claudication (pain)
Continue walking through the pain
Rest only when the pain becomes significant, then resume walking
“I want you to walk until you get the pain and then I want you to keep walking. I want you to keep walking until you start getting really mad at me,” Dr. Skillern advised.
Walking not only helps develop collateral blood vessels but also teaches muscles to work more efficiently with less blood flow.
When to Treat vs. When to Wait
Dr. Skillern emphasized that not all PAD requires immediate intervention. For patients with mild to moderate symptoms, he recommends:
Optimizing risk factors first (blood pressure, diabetes management)
Implementing a structured walking program
Regular monitoring with ultrasound
“It’s surprising how many patients will come back after three months and they thought things were really, really bad. And they’re like, ‘you know what? I’m doing better,’” he noted.
Medication and PAD Management
Several questions focused on medications for PAD management:
Statins
Dr. Skillern strongly recommends statins for PAD patients, even those with normal cholesterol levels: “The role for statins in people with peripheral arterial disease is primarily to help reduce the risk of plaque progression.”
Anticoagulants
For patients with clotting disorders like Factor V Leiden, Dr. Skillern recommends newer anticoagulants like Eliquis (apixaban) or Xarelto (rivaroxaban) over warfarin, which requires regular INR monitoring.
Stents, Bypasses and Interventional Approaches
Dr. Skillern discussed when invasive treatments become necessary:
For patients with lifestyle-limiting claudication despite optimizing risk factors
When patients experience tissue loss, non-healing ulcers, or rest pain
He typically begins with endovascular approaches before considering bypass surgery
Aorto-bifemoral bypasses can last 10+ years with 80-95% patency rates (some lasting 25-31 years)
Stents that repeatedly occlude may indicate the need to evaluate other factors like smoking or kidney failure
On when not to treat blockages, Dr. Skillern said: “Why expose yourself to a big open procedure when you can actually walk and it’s not limiting your lifestyle?”
FAQs from PAD Patients
Is 49 too young to have PAD?
“No, not too young,” Dr. Skillern said, though he noted that symptoms described by the 49-year-old questioner were more likely related to varicose vein disease than PAD.
What about swelling after a bypass?
For a patient six weeks post-femoral-popliteal bypass with swelling below the knee, Dr. Skillern advised: “The swelling is still very normal… it could take up to six months for the swelling to get better.” He recommended compression stockings and possibly another ultrasound to rule out complications.
Can PAD occur in arms?
While PAD can affect upper extremities, Dr. Skillern noted it rarely causes significant symptoms because “we all have actually a lot of collaterals to begin with in the upper extremities.”
What about feet changing color during walking?
For a patient whose feet become pale or gray during walking, Dr. Skillern said this isn’t necessarily concerning as long as color returns after rest. However, he recommended arterial ultrasound and pressure measurements for a complete evaluation.
Can calcium supplements worsen PAD?
Dr. Skillern is not aware of any studies showing a link between calcium supplementation and calcification in blood vessels. He emphasized that treating conditions like osteoporosis is important to prevent falls and other complications.
What diagnostic tests might be needed?
For patients with unclear diagnoses, Dr. Skillern mentioned several testing options:
Toe pressure measurements when ABI readings are artificially elevated
Checking for triphasic or biphasic flow in tibial vessels
Venous reflux studies for suspected varicose vein disease
The Smoking Connection
Dr. Skillern emphasized the devastating impact of smoking on PAD treatment outcomes:
All interventions tend to fail more quickly in smokers
Patients with kidney failure who smoke have particularly challenging outcomes
Quitting smoking provides almost immediate benefits to vascular health
Life Expectancy with PAD
Many patients worry about their prognosis after a PAD diagnosis. Dr. Skillern reassured: “You can certainly slow the progression significantly. I don’t know if I would actually go so far as to say that it’s reversible, but you can get to the point where you don’t have any symptoms and that you may never be affected by it.”
Closing Thoughts
As our session with Dr. Skillern demonstrated, PAD management involves a multi-faceted approach. While walking therapy remains foundational, understanding when interventions are necessary, optimizing medications, and addressing risk factors are all crucial components of effective treatment. For those dealing with PAD, the most important takeaway might be Dr. Skillern’s emphasis on patient empowerment through lifestyle modifications and consistent exercise.
If you have questions about peripheral artery disease, call the Global PAD Association’s Leg Saver Hotline at 1-833-PAD-LEGS or go to PADhelp.org
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