Do you know
Dr. Giuseppe Papia lets the question hang awkwardly in the air. With almost one in 10 Ontarians diagnosed with the condition, the 40-year old vascular surgeon already knows the answer: “Everyone does.”
So he takes it one step further: “Do you know somebody with diabetes who’s had a foot ulcer?” A beat, then: “Do you know that statistically their chance of being alive in two years is less than 50 per cent?”
It’s a grim stat, but a strong motivator for Dr. Papia and his Sunnybrook colleague, Dr. Andrew Dueck. Together they’re perfecting minimally invasive angioplasty techniques to improve the lives of patients with peripheral arterial disease, a narrowing of blood vessels that can lead to lost limbs and even lost lives.
Diabetics with foot ulcers often take a year to get from their family physician to Dr. Papia, which, when you consider their two-year mortality rate, is half a lifetime. And it used to be that when they finally made it to a clinic, the solution was often a life-changer.
“When I was training, and you came in with this problem you just got an amputation,” says Dr. Papia. “Nothing we did below the knee worked.”
Now, using concepts honed in plastic surgery and techniques developed in the cardiac catheterization lab, Drs. Papia and Dueck are restoring blood flow to extremities below the knee. Instead of trying to bypass a blocked artery – procedures which typically result in long, painful recovery periods, especially for slow-healing diabetics – Dr. Papia uses angioplasty procedures that clear blockages with a guided coronary wire, then open up the artery more permanently with a balloon. Once blood flow is restored, patients go home the same day without ever having undergone general anesthesia. The goal is to quickly restore quality of life to patients coming face to face with their own mortality.
“The day [diabetics] develop a foot ulcer is worse than the diagnosis of most cancers,” says Dr. Papia. “Nobody appreciates that. And there’s nowhere for them to go. There’s no limb centre.”
That’s true, officially. But at Sunnybrook’s Schulich Heart Centre, work is going on that may change all that.
BELOW THE KNEE
It’s mid-morning on a frigid winter day, and 74-year-old Moisei (Michael) Korol is flat out on the table in Schulich’s catheterization lab. Dr. Papia leans over him, eyes focused on a monitor that shows the progress of a wire moving through Korol’s femoral artery en route to an arterial blockage above his right knee.
“I want to go to Cuba in two weeks,” Mr. Korol deadpans in a thick Latvian accent.
Dr. Papia’s eyes remain on the screen. “Yeah, that’s probably not a good idea, Michael.”
Like many of Dr. Papia’s diabetic patients, Mr. Korol is a repeat client – even with successful angioplasties, the probability of disease recurrence is high. His first angioplasty, in December 2012, helped restore blood flow to an ulcer that had developed on his left foot; his second visit, for pain in his right leg, cleared arteries that had become blocked below the knee; this visit, his third at the Sunnybrook cath lab, has been precipitated by the development of an ulcer on his right foot.
Well over an hour into the procedure, Dr. Papia is struggling to get the coronary wire down to the first of two blockages in Mr. Korol’s right leg. He tried accessing the arteries from the right hip to no avail. So he tried going in from the left side. No dice. Finally, on the cusp of calling off the procedure, he tries again from the right side, and manages to get his wire to clear the first of two blockages. Moments later, he points to the screen monitoring Mr. Korol’s blood flow.
“Beautiful,” he cries. “Look at that! Much better, it’s just flying down there.”
Once dormant arteries are now flush with blood being pumped into the area surrounding the foot ulcer. The taps, as Dr. Papia’s plumbing metaphor goes, have once again been turned on.
“How are you feeling, Michael?”
“Better,” comes the reply. “The foot feels much easier.”