Of Life and Limb

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Do you know
anyone with
diabetes?

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."

Dr. Papia works his wire out of the leg and commences a bit of cleanup.

"It's time-consuming, that's for sure," he says. "But when it goes well, it's worth any amount
of time."

TOE TO TOE

"Let's face it: This is not sexy work." Dr. Papia is seated on a couch in his Sunnybrook office, explaining how he got into minimally invasive, below-the-knee angioplasty.

"I think we've found a core group of passionate physicians around it, but it's not the heart, you know? It's toes."

Four years ago, there weren't many vascular surgeons who would do work below the knee. Treatment then was largely focused on bypass surgeries. As coronary technologies evolved, however, smaller balloons and wires used in cardiac procedures began to make angioplasties a more sensible option for the typically older patients in need of below-the-knee revascularization. Plastic surgery also provided a game-changer: Surgeons had identified angiosomes – three-
dimensional, discrete zones of tissue that are fed by an artery and drained by a vein. These regions exist in places like breasts or cheeks, where plastic surgeries are often performed, but they also exist in six places on the foot. That knowledge provided a road map for targeting blood flow to specific areas of the foot. The efficacy of below-the-knee angioplasties spiked.

After training on such procedures in the U.S. – Dr. Papia at the Cleveland Clinic, Dr. Dueck at the Arizona Heart Institute – the former University of Toronto classmates joined Schulich's cardiac cath lab as part of a joint division of cardiac and vascular surgery. The crossover of disciplines bore fruit: As Drs. Papia and Dueck began their work, they were able to take advantage of the expertise and technology available to them through their cardiac colleagues.

"We realized why a third of these kinds of [below-the-knee] procedures were being done by cardiologists worldwide," says Dr. Papia. "They had the right technology and know-how to do this. It just serendipitously fell together really well."

Five years into their time at Schulich, Drs. Papia and Dueck are now performing 200 procedures every year. Their client list is growing. Their program, however, doesn't have the funding to keep up.

LIVING WITH PAIN

"It was like somebody was sticking knives in the back of my calves." Charles Hykawy, a 64-year-old patient of Dr. Papia, is describing what drove him to his family doctor and, eventually, to the Schulich Heart Centre. A diabetic who works a physically demanding job doing home repairs in Pickering, Ont., Hykawy found himself unable to walk more than 50 feet before he was crippled by debilitating pain caused by claudication, a restriction of blood flow to the muscles often caused by peripheral arterial disease.

Seven months after two procedures with Dr. Papia – his left leg, later followed by his right – the claudication is gone.

"I do a lot of walking when I go to the Home Depot," he says. "Before I could only walk partway around the store before I'd have to stop. Now I can walk around and buy all the materials I need and everything, and I don't have a problem; it doesn't hurt anymore."

That ability to restore quality of life is what's at the core of the work Dr. Papia is doing at the Schulich
Heart Centre.

"You have to evaluate what the bar is," he says, referring to the old school of cardiovascular thought that insisted on bypass surgery as the best course of action for patients with peripheral arterial disease. "If the bar is palliating the pain, healing the ulcer and giving patients a better quality of life, then what we're doing is fantastic!"

Hykawy and Korol concur. By performing less-intrusive angioplasties that don't require a hospital stay, Dr. Papia's work is more than a lifesaver – it's also a money saver. The Canadian Diabetes Association (CDA) estimates that diabetic foot ulcers currently cost our health-care system more than $150-million annually. Eighty-five per cent of all leg amputations, says the CDA, are the result of non-healing foot ulcers.

"If you look at the explosion of diabetes worldwide and in Ontario, I think there's a good argument for a project here that's more than a demonstration project. I can't remember the last time I did an amputation, but I do remember the last two patients that I sent for an amputation. And I remember them because that doesn't really happen any more."

"The day [diabetics] develop a foot ulcer is worse
than the diagnosis of most cancers," says
Dr. Giuseppe Papia, shown here in the lab and in
surgery performing the below-the-knee angioplasty.

This content was produced by The Globe and Mail's advertising department, in consultation with Sunnybrook. The Globe's editorial department was not involved in its creation.