Medically Speaking #3

Well, welcome to Medically Speaking. Excited to be with you again today. Again, as a reintroduction, I'm Matt Logan. I'm CEO of Self Regional Healthcare. And today I'm excited to have two special guests with me. We have Dr. Anastasia Zim and we have Dr. Jeff Lanford. And today we're going to be talking about our vascular surgery program and vascular disease in general and see if we can maybe learn a few things about what we offer here in the community. And so we'll just start with introductions. So Anas, tell us a little bit about yourself and your background. Hi, I'm Anas Azeem. I'm a vascular surgeon at Self Regional Hospital. I did most of my training in cardiac general and vascular surgery at Cleveland, and I have been with the vascular surgery program at Self Regional Hospital for the past three and a half years. Awesome. And he's a very modest doctor's name. He is a phenomenal surgeon, and there's some amazing things. Thank you. Dr. Lanford, tell us a little bit about your background. Sure. I'm Jeff Lanford. I'm from Spartanburg, South Carolina. Went to Walford to college. I went to MUSC. I've been here 28 years. Trained out west and knew I didn't want to stay there and came back to the good south in South Carolina. So very fortunate to have, as you mentioned, Anas as a partner. I mean, just a phenomenal surgeon that brings a lot of new technique, new ideas to the Lakelands area. And Matt, I mean, we've just been blessed with a great vascular program for many years as you know going all the way back to the late 70s when Bill Holloway started the service he was the first vascular trained surgeon in the state of South Carolina we had the first accredited vascular lab in the southeast so we have a lot of first and a lot of positive things going for our vascular program through the years and it's just nice to have a NOS to help us carry those home forward. Yeah, absolutely. Absolutely. Well, thank you for that. So let's just talk a little bit about vascular disease in general. Like what is vascular disease for someone that may not know about what that means and what you guys do? Just maybe tell me a little bit of NOS about vascular disease in general and some of the types of procedures that you guys do to help folks who are having trouble? Vascular surgery represents a pretty large area of surgery involving diseases of the blood vessels. And as some of us know, blood vessels are everywhere in the body. They can either be carrying blood to an organ from the heart or back from the organ to the heart. And those blood vessels can either become clogged or they can become weak. So when they become clogged, there is a reduction of the blood flow to that organ, and that can provide some symptoms that are problematic to the patient. And depending on which organ we're talking about, those symptoms can range from stroke or mini strokes if the clogged blood vessels affect the neck arteries that go to the brain. They can result in problems for patients walking up to losing their legs for blood vessels in the lower extremities, the legs. They can also cause problems eating for blood vessels involving the gut. And they can cause problems with blood pressure and kidney function for arteries going to the kidneys. So there are a variety of problems that can arise from blood vessels that are clogged. The other common problem that we deal with related to the blood vessels are when the blood vessels become weak. And when that happens, patients develop a characteristic problem called an aneurysm, where the blood vessel becomes larger than normal, and the risk is development of rupture of that blood vessel, which can sometimes be either limb-threatening or life-threatening, or if it happens depending on the area of the body that develops, and that's the other common problem that we deal with, which is aneurysms. The other half of the circulation, which are the veins, and we do treat diseases of the veins as well, ranging from, again, clogging of the veins because of blood clots, which is commonly known as deep venous thrombosis. We deal with those problems as well. So those are primarily the majority of cases that vascular surgeons often deal with. In addition to clogging of blood vessels or treating weakness of blood vessels, we do also take care of patients who have dialysis access needs. Patients who have terminal function of their kidneys or on the verge of requiring to be on dialysis, they require creation of access that allows them to be placed on dialysis machines. And they get referred commonly to our practice to, for us to create those dialysis access for patients to allow them to start dialysis as well. Awesome. Yeah. Thanks. That's a great description. I, in my head as a simple ER doctor, I kind of think of it as like, you know, you've got the artery side and what can happen on the arteries, right? They can get either clogged or they can get weak walls. They get weak walls, they can bust and they can have aneurysms. That's an aneurysm is and it can bust and cause you to die if you get a blood a clog like a cholesterol plaque in an artery in your neck it can give you a stroke if it's in your leg and make your leg go cold you lose your leg so those are the like the things you guys do that are amazing is you guys fix those things which is awesome and um you know i i really appreciate uh you know working with you guys when i'm like in the emergency department something like that comes in to have you guys available to come help. And, you know, you guys save lives. You just flat out do. Let me ask Jeff you this question. So risk factors for developing, I guess, on the artery side, kind of clogged arteries. What's the risk of developing atherosclerosis in an artery? And also, what are the risk factors for developing aneurysms? Sure, Matt. So, you know, one of the things about where we live is we love to eat and i'll be the first to raise my hand on that growing growing up here but you know our diet has a large part of um playing a role and especially atherosclerotic disease um greasy fat diet that you know bacon and burgers and red meat and all those things you know you and i are nodding our heads that we grew up on and love to eat and if you're like my my grandmother everything was cooked with fat back you know the green beans so i mean it's just it's a lifestyle and a culture here that that we're fighting a little bit and and we live in what's called the stroke belt i mean this is an area of the country that's known for atherosclerotic disease that leads to strokes and heart attacks so so diet is plays a large part sedentary lifestyle um you know going home after work you're tired you want to sit down you want to watch the news you just want to take it easy and just rest for the next day but you know it's so important to stay active uh at least some period of time during the week two or three times well i mean you know just walking and we got a lot of great places here in greenwood lander track um so many nice places uptown to walk you know that that's so important so i'd say nutrition uh exercise and lifestyle and then again unfortunately smoking plays a large role in uh in atherosclerotic disease and and really smoking plays a large role in aneurysm formation We know that the contents of tobacco and nicotine affect the vessel wall and weaken it and lead to predisposition for aneurysm development. So, again, all of those things, when you combine them together in kind of a soup and mix them up, it's a setup for vascular disease, and that's why we see so much of it here. And then you combine that. I tell people all the time, you combine those things with other medical conditions such as diabetes, it just is set up for disaster because you take a diabetic who's a smoker, then it leads to kidney failure. And as Anas pointed out, we're putting dialysis access into them or we're trying to save a limb because the combination of diabetes and smoking together is just a, you're just asking for a matter of time before you begin to, you know, you lose a toe, you lose part of your foot, you lose a leg. And those things just don't have to be. So those are kind of the high points that we see. Hypertension and leading to kidney disease. You know, just so many things in this particular area that we're a little more prone to, that we just need to educate the public. Sure. So, like, if I'm a patient in a community that has diabetes and high blood pressure and I smoke cigarettes, for example, I'm not that person, but if I was, what would be some symptoms that I should be looking out for to think, well, am I developing some type of vascular disease? Sure. I'll take that one. nice man and so you know the big one i say is is of the legs you know i tell people all the time who are diabetics you know if you you go out to the mailbox in the evening you come home and go out to the mailbox in the evening it's all on flat land and you do it not relatively okay maybe a little bit of discomfort in the legs but then you go to visit someone who lives on the incline or a hill and you start going up that hill and then you really notice it and the analogy i draw to them it's kind of like a car i mean you you know the blood vessels the arteries are your fuel line in in your car and the and the motor to the car is your calf muscle and if you're sitting here like we are and you're idling at the red light everything's fine i mean you're getting enough gas to the engine and the motor's running good but then if you get to be an old antique car kind of like i am compared to a nice you know your your your fuel line gets a little bit narrow and so um you you start to take off or accelerate from the red light and the next thing you know is you're sputtering and backfiring because your calf muscle is hurting and and that's what we call claudication and that's kind of a tip-off sign that things are starting to begin to develop that can lead to further problems down the road and um so for me you know claudication is an early sign and and one i point to tell people that hey you know talk with your primary care physician come to one of our and we may discuss this later come to one of our screenings you know that you see advertised uh just catch it early because there's so much we can do with lifestyle modification it doesn't we call ourselves vascular surgeons but everything doesn't necessarily require surgery. I mean, if we intervene early, we can, you know, medically treat or less invasive means to get you back out there in minimal downtime. I was going to ask that too. You know, so if someone does have some claudication-type symptoms or other vascular disease, like what are some treatments that are non-surgical? I know you guys are, you know, you try to do surgery when you have to do it, but you don't want to do it on everybody. So what are some of those decision points on when you treat someone medically versus surgically? And how do you make that decision? Well, as Jeff alluded to, not everybody who comes to see us is going to get a surgery or an intervention. As a matter of fact, there is well close to half of the people that we see are treated medically, either with medications alone plus medications and surveillance, which basically keeping an eye on their disease process, making sure that it doesn't get to that tipping point where their limb or life is at risk, where we have to do an intervention. So the majority of time, we sit down with the patient and try to understand how those symptoms that they develop is affecting their daily activities. And most of the time, if their symptoms are simple and are tolerable and not really interfering with their daily activity and not, in a sense, disabling to what they do day in, day out, a lot of times we can treat them with medications and we keep an eye on the disease process periodically. However, if we see certain signs that suggest that the disease process is really severe at the beginning of the presentation, for example, in the situation where patients have clogged arteries to the legs and they start seeing wounds or ulcers already developed in their leg, that's already a limb-threatening situation. They are at a point where their limb is at risk for amputation. And at that point, we've got to have an intervention done, you know, or at least a concentration for an intervention in order to save their limb. Same situation for patients with aneurysms. Not every aneurysm requires therapy. Most of the aneurysms are not giving symptoms when they are discovered. But the biggest determinant of whether we need to intervene or not on an aneurysm is the size of the aneurysm. And certainly, if the aneurysm is causing a problem, that is an indication for us to intervene sooner than later. But if the aneurysm itself is not causing any symptoms, then the biggest determinant of intervention becomes the size of the aneurysm because that's what dictates the risk of bursting or bursting of an aneurysm. Same for many other disease processes, clogged veins or clogged arteries to the gut or clogged arteries to the brain. It has to do with findings on the diagnostic imaging that we do, ultrasound, for example, or a CAT scan, in addition to the presentation of the patient, how this kind of a problem affecting the daily activity of the patient. And based on that, we present the patients with different treatment options with our recommendations being to intervene if the symptoms seem to be severe enough to be life or limb threatening, or with plan to medical management and surveillance if the symptoms are not that severe. I got you. You know, one of the things that crossed my mind earlier today, I was kind of thinking about us talking today is, you know, for a lot of things like, say, breast cancer, there's common, very clear screening guidelines for prostate cancer for men, et cetera. What are some of the guidelines about screening for vascular disease and what are options for that for folks in general? So there are screening guidelines for aortic aneurysms. Aortic aneurysms is that's when the main pipe crossing the transmitting the blood from the heart to the legs gets dilated, become like a bubble in the middle of that pipe. And the risk with that is that it could rupture and that can be a lot of times very, very life threatening. So, there are guidelines in terms that has to do with the age of the patient and whether the patient is a male or a female or whether the patient has a family history of that disease process, other family members that has the same problem, or whether that patient is a smoker or not and how long they have been smoking. If they meet certain guidelines, then they become eligible for screening for an abdominal aortic aneurysm, even if they don't have any symptoms, because we know that the majority of aneurysms are not having any symptoms when they're first diagnosed. Same thing for the lower extremities. There are no specific guidelines dictating when to screen people for lower extremity clogged arteries. But there are commonly agreed upon findings or risk factors, some of which Jeff alluded to, that would make somebody higher risk for this disease process. If that is combined with some of the symptoms that would be suspicious for clogged arteries, then screening for clogged arteries would be advised. And by screening, we mean mostly an ultrasound assessment, ultrasound test, which is an non-invasive test that is done in the office to try to look at the aorta and look at, to measure the size of the aorta and look for an aneurysm or do an ultrasound of the leg to try to assess the amount of blood flow going down to the leg and see how, try to quantify the degree of blockage and the degree of blood flow going down to the legs and toes. Mm-hmm. Okay. Okay. Kind of dovetailing on something that I said, you know, with the aneurysms, especially for folks Medicare age, that wellness initial examination. I mean, there are certain factors, like if you were a smoker and you're a male and, you know, that's covered as part of the wellness visit. So it's something you might want to ask your primary care physician about. You know, in the time I've been in practice here, I think of one family in particular that one brother got screened and we wound up fixing all three brothers' aneurysms. Wow. Just because the one brother got screened and the other two then subsequently went and got screened. And the next thing we knew, we all saved three lives. Yeah, yeah. Frankly. Absolutely. So, you know, discussing it with your primary care physician, they can, you know, tell you whether this meets the criteria for part of that wellness examination. And as a nice point out, too, I mean, these are ultrasounds. I mean, these are not painful. You know, they're quick. They're done in the office. They're real easy to perform. And the nice thing, you know, again, yeah, I'm tooting our horn because I'm proud of it. But, you know, our vascular lab is the oldest one and really in the southeast, like I said, first accredited. Our techs are phenomenal. I mean, we have accredited technologists who stay up to date. We maintain our certification, which is called iCABL. You know, I always tell people, if you're going for a vascular examination, just ask them. know are you accredited and because that means so much because if you go somewhere that's not accredited you know maybe like one of the local screening examinations and you bring that exam back to us the nice and our first thing we're gonna look at and see if it's from an accredited lab and because that means so much that they make quality standards and certain criteria that we know that They're on the same page of what we need to see. But screening is just so important, and we can get involved early and make a big difference. That's great. Jeff, maybe you can tell me a little bit more. I know the Vascular Lab has a great reputation in the community, and they do a great job. In regards to quality in general for vascular surgery and ultrasound, et cetera, can you just talk to us a little bit about the history of the program? here it's quality outcomes in the past and what we're doing now to kind of look at quality what do we look at yeah so um we participate in the what's called carolina's region of the vascular quality initiative acronym vqi and um there are eight different regions throughout the united states like i said the carolina's region there's a new england region there's a mid-atlantic region and so it's the country is broken up into these eight areas and we submit data for instance like when we do carotid surgery what people want to know you know you think hey i'm coming to you and you're supposed to keep me from having a stroke and of course that's our goal but you know unfortunately stroke is a risk from carotid surgery and we measure what we call our stroke risk from from the surgery that we do and we submit that data to vqi who compares it to other participating facilities in the southeast i mean you know we're in there with duke and emory and chapel hill and musc and um so we're we're in there with some what i call pretty pretty heavy hitters and you know through the years um since as long as i can remember i mean we've always held our own we've always been right up there at the very top um as as higher ratings as we can possibly get and um and we we've held our own very very much so and you know i tell people i mean there's really not a particular reason that they have to leave the area yeah um you know i mean personally i'm finding myself i just you know i don't want to get involved in traffic and headaches and parking and all that yeah you know here it's just a piece of cake yep but again you look at our data we participate in that every year we go to meetings twice a year where we compare our data like i I mean, stroke rate is just one thing. Length of stay, surgical complications, wound infections, I mean, extremely low in all these areas. Our length of stay is some of the shortest really in the nation. I mean, when we do carotid surgery, I would say nine out of ten patients are home by lunchtime the next day, which is just incredible. I mean, when you look at what's going on around the country, a lot of places are still two or three days. A lot of places are still in ICU stay. When I first got here, we were still doing open aneurysm repair, which was a large incision here. Now, thanks to advancements, having a NOS here too, or even more advancements, we're able to do aneurysm surgery through basically little needle sticks in each groin, which is just amazing, and people are going home the next day. So all that data about length of stay and what we're doing and graft patency is collected constantly, and we enjoy participating, not because we're doing stellar, which I like to say, but it helps us by looking at what our peers are doing and seeing if we can learn anything from them. Absolutely. And the nice thing is sometimes they learn some stuff from two old boys down in Greenwood. Exactly. And, you know, this really fits. I'm glad that we're talking today. One of my goals here at Self Regional is for every service line we have to be the care that we can provide to be as good here as you can get anywhere in the country. And when we're comparing ourselves and our quality outcomes to Duke and Emory and MUSC, and the Prisma system and all the other systems down in the southeast, that's a big deal that we have as high-quality ratings as any of the other hospitals in the southeast, and I commend you both. And thank you for providing that service to the community. It's a big deal. You know, Matt, I mean, it would be easy for us to sit here and say, do this. But, I mean, you know, you look at the people who are involved in our vascular program, and they're long-term players. There's not a high turnover. There are people who are in the operating room who have been there for years. I mean, some longer than I've been here. Our vascular techs have been here for years. Our angiography techs have been here for years. And so they take a lot of pride in this program. So the team, I mean, you hear that all the time. Oh, the team, the team. No, this really is. This is the team. This is all those people involved that make us look good. Yeah, and we're blessed. I mean, one of the points that I want to bring up here is just the nature of vascular disease. Vascular disease is one of those diseases that requires longitudinal follow-up. It's not one of those disease processes where you fix the problem and then the patient is done. It just requires this kind of a long-term follow-up. whether the patient gets an intervention or not. Sometimes the patient never gets an intervention in their lifetime. Still, they require very close observation of the disease process. Sometimes they get an intervention, but they still need long-term longitudinal follow-up over many, many years. And one of the quality measures that we hold ourselves to is how close we follow people up and how really rigorous are we in terms of our longitudinal follow-up of these patients, whether they had an intervention or not, because I think the nature of vascular disease requires that kind of a rigorous observation of patients over many, many years. I got you. So as I'm thinking about the future of vascular surgery and our community, I'm excited about the hybrid room that we're going to be working on really probably in this coming year once we get all the COE and all that stuff approved. Tell us a little bit about what that will allow us to do and how that's going to really kind of take our program up a notch. So hybrid room is a technology that got introduced into many centers around early 2010. time frame and it combines the high quality imaging capability of fixed fluoroscopy in addition to the surgical availability of open surgical intervention what that means in simple we have two kinds of vascular interventions available to us nowadays surgical intervention we have where we have to make cuts in the skin through which we get to the area that has the diseased vessel to fix. The other intervention or the other modality of treatment is called endovascular therapy, which does not require any cuts in the skin, but we go through the skin with thin wires and catheters and to try to treat a problem in a blood vessel that may not be immediately at the site where we access the blood vessel. It may be really a remote site from where we access the vessel. Now, hybrid room allows us to combine both modalities and be able to offer them for the same patient at the same time. Because currently, endovascular therapy is done in an endovascular suite, while open surgical interventions are done within the surgical OR, which are located in two different places. When we combine the two in one place, that allows us to be able to do more at the same time for the same patients. Good. I know these are areas that you are highly trained in, and we're excited to be able to start bringing some of those procedures here to Self Regional. Well, no, this is great. Is there anything else that you guys want to touch on today, just for those that may be watching that you all would like to know about uh vascular surgery in general or the program here or really anything um you know i think we're just in a great place right now matt with with the program i mean it's it's thriving it's still you know doing busy um you know i i think our practice is a lot like that hybrid room you know um we got a nice who's the new technology and yeah and the and the all the new tricks and techniques and things that that come with a hybrid room and the imaging and and we still have a little bit of the the opera old operating room that can and i think the nice thing about our practice is we complement each other yeah you know i like to think i can still bring something to the game and Anas can also show me some some new tricks so it's um it's it's a great practice I mean we I think we genuinely enjoy working and picking each other's mind I mean that's what we were doing before we came out here we were picking each other's brain about cases that we had earlier in the day and and it's nice to be able to have a partner like that and bounce things off and have the team like we do and you know i remember when i got here in 94 um dr holloway came up to me and he said mr self wants to meet you and i said okay and so we met at 5 30 in the morning down here in the greenwood building up at the top and and uh you know mr self took a lot of pride as you well know yeah and and what our service lines were and um Vascular has been, I think, a good quality service line through the years. I think he would be proud, and I think we want to continue that tradition. We just appreciate the support of the hospital tremendously. Well, thank you, Jeff. I say it's an important service line. It's important to the community. I think a lot of people don't maybe know what vascular surgery is because they don't need it, but when you need it, you flat need it. it's time. And you know, over the years, my own family members have been helped by you guys and really appreciate it. And you know, you think about, we've talked about a lot about the artery side, but on the vein side, you know, blood clots, I mean, everybody's heard about blood clots and pulmonary embolisms where people suddenly pass away. And on the vein side, let's just talk about that for a second. What are some of the interventions that we do? Of course we use blood thinners, But outside of blood thinners, if someone needs something done, we can talk about that for just a second too. Yeah, veins are opposite the arteries. They basically carry the blood from the leg or from any organ back to the heart. And commonly, the problems happen in those veins in two different groups of veins in the leg, either the deep veins and the superficial veins. So the deep veins, those are the ones that are directly connected to the heart, and those are the ones that can have a blood clot that can break off and get to the heart. and there are several interventions that we do to prevent that. We could put IVC filters that interrupt the pathway from the leg up to the heart in patients who cannot tolerate being on a blood thinner. But even some of the patients come in with blood clots that are severe enough that it's causing a lot of symptoms, and we have now a lot of tools in our box to allow us to remove that clot to provide a relief of the swelling and the pain that comes with those clogged veins. We have devices and we have clot-busting medications that we can use to clear the veins from clots. In terms of the superficial veins, those are the veins that are closer from the skin, who oftentimes are implicated in pain, inflammation, and discomfort, and swelling, and sometimes even severe form with ulceration because they are not really functioning appropriately. And in these situations, we try to close those veins. And in the not very distant past, the only available option was to strip the vein, basically remove the vein out of the body. But now we have more minimally invasive interventions involving percutaneous closure devices that can close the vein while it stays in the body, but then it doesn't really become bothersome as when it is still open. And those do not require more than a 30- to 45-minute procedure under oxidation, and patients can go home the same day. So that technology is available to us as well here, and we have been pretty active in terms of evaluating patients and screening them for that kind of procedure. And sometimes patients do not require any intervention at all. They just require some simple instructions about compression stockings and exercise and losing some weight, and their symptoms eventually improve just with that. I just have to add that I'm really fortunate to work with Jeff and be part of the self-regional family and provide services to the community. I really enjoyed being here with my family, all enjoyed being part of the community. And I really thank Jeff for the past three and a half years. They were really wonderful. He really helped me tremendously with his surgical wisdom throughout some of the difficult cases that we had. So I've been very fortunate. For sure. I just want to say on top of what Anas just said, Matt, about the venous side of things. You know, a lot of times we see folks with what they call venous stasis ulcers or ulcers on the inside part of the ankle. And, you know, we have a pretty aggressive wound clinic. And, you know, combined with our intervention, getting those wounds addressed and taken care of, you know, It's a good working relationship that helps us kind of offer a total care from start to finish and get those wounds healed up in a timely fashion. Also along that same line, switching gears just a little bit, you know, in the past couple of months, you know, we've added podiatry, which has been a huge complement to our vascular line in terms of, especially for diabetic foot ulcers. I mean, for years we could revascularize and get blood flow back there, but we were probably less than optimal in terms of our care from us with the ulcer itself. And now having Kelly Mandahl here and we're adding another podiatrist later this year, I mean, it's just a great compliment to the service and helping us tremendously. Yeah, I'll tell you, just touching on podiatry, I was surprised, I mean, what a need in the community for podiatry services. When Dr. Mandow started, you know, I was like, well, we'll kind of see how it goes. Well, within like a week, she's out, like, booked out like a month, month and a half. Right. So hence the needing to hire another podiatrist to join Kelly. So, yeah, excited about that total package, really. And we think about, you know, all the care that's needed for some of these folks with the conditions they have to be able to provide all of that. That helps our limb salvage program. We were going back to quality earlier in terms of things that we follow, and amputation rate is one of the things that's followed in quality. I hate to say it, there are parts of this state that at one time have led the nation in terms of rates of amputation. Fortunately, not here, but it again goes back to communities that can offer the total care package and and we just you know our medical staff is so good because we have a good working relationship right you know picking up the phone and being able to call it's just invaluable jeff what you just said i think is one of the the neat things about self-regional i think differentiates us from a lot of places is you have that in the camaraderie and you know um i've had that my whole time here as an er doctor most people hate getting calls from the er doctor because it usually means they have to get up and work and do something. Well, Matt, I was going to say that. But I can tell you just from my own experience for the 18 years that I've practiced here, it's not like that here. And the physicians get along with each other and support each other, and the internists have the surgeons back and vice versa. And we really do put that patient in the middle of the whole equation, which is what it's all about. Well, guys, listen, thank you so much for your time today. I appreciate you joining me. And we look forward to continuing to see how the program grows in the future. And, of course, if I can ever do anything for you guys, just let me know. Say, I feel like part of my job is to support the team. And you guys are doing the awesome work, and I want to make sure you guys have what y'all need to continue to do that. So with that, I think we'll call it a wrap today and thank everybody for watching. And you guys, I hope you don't need these two guys for anything. But if you do, you've got good people here to support you. Thank you. Thank you, Matt. Thank you very much. Thank you.