This week I had the opportunity to talk with Dr. Peter F. Lawrence, Director of the UCLA Gonda Vascular Center, and get an idea of what’s happening and what new technologies they are using for PAD (peripheral arterial disease). I have had a few posts on the blog in the past relative to how PAD therapy is evolving rapidly and some of the new treatments that are becoming available.
First of all here’s a little bit of information about the center and Dr. Lawrence from the website:
“The mission of the Gonda (Goldschmied) Vascular Center at UCLA is to provide comprehensive, state-of-the-art diagnosis and treatment of vascular disorders, ranging from serious disorders such as critical limb ischemia which can lead to gangrene, aneurysms all over the body, and carotid disease (which can lead to a stroke), as well as deep-vein thrombosis and common venous conditions such as varicose veins, venous ulcers, and spider veins. The staff is deeply committed to providing these services in an environment that not only offers the latest technology but also adheres to the highest standards of professionalism in a patient-friendly setting.
Our board-certified vascular specialists apply medical-and-surgical breakthrough technologies to develop innovative minimally invasive techniques to treat a full range of vascular disease. Consistently named to "Best Doctors in America," Dr. Peter F. Lawrence has pioneered the light-assisted stab-phlebectomy procedure, which provides a clearer picture of varicose veins and thus facilitates a more-effective treatment with little discomfort to the patient.”
I would also like to say thanks to Dr. Lawrence for taking time from a very busy schedule to chat with me and explain a bit on the latest technologies they are using at UCLA. Let’s make one statement here known about legs, they are connected to the heart and have an effect on the blood flow throughout your body and this is one big reason that the Gonda Vascular Center exists--when specialty treatment is needed, cardiologists and internists are the first on the list to send referrals. Dr. Lawrence also told me that through patient awareness, via internet research and other resources, patients are also finding their way to the clinic on their own.
Over 30 million people worldwide have some form of PAD, yet there are many out there who are not aware they have the condition and are not receiving treatment. Diabetics are also far more likely to develop PAD as this all goes back to circulation and blood flow. One of the first indications of PAD can be the feeling of “heavy legs” and fatigue when walking. With diabetes, there are also patients who have foot wounds that do not heal properly due to PAD and this eventually results in tissue loss (gangrene) due to an inadequate flow of blood.
For those patients who are suffering with diabetes, Dr. Lawrence told me they are doing their best at the UCLA center to provide a one stop solution with their Gonda diabetes center right next door. The patient wins here with not having to run all over town to keep several appointments for treatment and consultations.
The facility, he stated, takes advantage of the latest technologies with imaging equipment and software. One example that I thought was really neat was the ability to have a totally “non-invasive” test at their lab instead of the standard “more invasive” angiogram to look for clots. Anyone as a patient I think would much rather have a non-invasive diagnostic procedure over an “invasive” alternative any day -- and it certainly would work in my book. It is amazing, via the modern day technologies we have available, what a big difference can be made in patient experience.
In some instances, the facility is using a duplex ultrasound procedure for an example to find inclusions. Other diagnostics that may be used could be an MRI angiogram or a CT angiogram for a slightly more invasive diagnostic procedure, and again, Dr. Lawrence stated it all depends on the patient and individual level of care needed. In addition, he stated that risk factors with each patient are evaluated, such as if the person smokes, has diabetes, has high cholesterol, what their current lifestyle is and what medications are currently prescribed and taken by the patient. Dr. Lawrence stated there are many treatment options out there today and at the center they do their best to customize and treat the patient for not only today’s issues, but create a long-term education and lifestyle plan to go along with any treatments that may be performed.
Not everyone who arrives at the facility is going to need a procedure, he said. With the new technology in the center, such items as ankle pressure can be evaluated and this is a big time saver for the patient in not having to visit many different facilities. As a matter of fact, Dr. Lawrence stated that only about one out of every 10 patients they see actually do have a procedure, although most do get some treatment, such as medication, treatment with leg compression devices, exercise training, etc. In addition, the center has a staff of nurses, wound care specialists, and nurse practitioners who work closely with the doctors and patients. The facility has its own AAAHC accredited procedure room too, and this of course can save time and lots of money, since many patients have insurance that only pays for part of a procedure—they don’t have to utilize the facilities in the main hospital and scheduling can be much more flexible.
To circle back to when a patient has PAD and does need a procedure, I asked Dr. Lawrence what happens next. He stated that when a procedure requiring the placement of a stent or balloon is done, the patient pretty much makes the commitment that they are married for life to the doctors, nurses and the facility for follow up. Once a device is put in place, we all know that our legs (versus our heart) move around a lot, and thus there’s a chance of one of them kinking with lots of motion, although they rarely move. Dr. Lawrence told me about new closure devices for sealing the site where the artery is punctured, making it easier for the patient, and the closure device allows for many procedures to be done as an outpatient.
He stated that interventional procedures can be anywhere from 45 minutes up to three to four hours, again depending on the patient and the procedure. The morning we spoke, he had already completed a couple procedures by 10 am. Patients with non-healing wounds and even gangrene are going to be a longer and more complicated procedure versus a patient with relatively minor issues, by comparison. With an interventional procedure, the mission is to get the blood flow and circulation so patients can avoid amputations and see their former non-healing wounds either heal up or improve dramatically. There’s also the possibility of stem cell treatment with wound care, which is still considered investigational and not yet FDA approved yet, and the link below explains how it works.
Wound care is also located in the same UCLA facility. When describing all the potentials here with treating PAD I mentioned to Dr. Lawrence that it sounds like there are a lot of options, and he agreed with me on that account. So how does the center determine which is going to be the best plan and treatment for the patient I inquired? Just by writing this blog I have enough knowledge to know that digging through and finding the right decision-making data can take some time, as that is done with software today in every business and thus the choice of many medical devices that are available today is somewhat plentiful, too. All of this information certainly can’t be floating around in a complete version inside one’s brain. One example of an investigational product that is in clinical trials, as an example, is a new type of stent that expands and is drug eluting. I posted about the clinical trial recently here at the Medical Quack, covering the randomized 24-month patency data.
That question lead to the next part of our talk, discussing medical registries, and Dr. Lawrence is right in the circle of using research to find out which devices have the best outcomes, what’s working today and how to include clinical trial information, too. One registry in particular he mentioned was an endovascular site that was started back in 1993, when surgeons at UCLA put in the first FDA approved endograft, and they are still following those patients and recording their progress. In having such early roots in this area, there’s a multitude of valuable information here to help in the decision-making processes. This is not the only registry used, as there are several additional references. I asked the doctor how he uses all registries that are available to drill down and find the information he needs and how long does it take, being I have a curious mind in this area.
He stated the VA (Veterans Administration) has a wealth of information to offer on expected outcomes, too. He stated that the time to research can vary, but can be as short as a few minutes up to perhaps an hour to locate the desired information. I asked if there was a simple format to find all the information contained in all various registries out there, and is there an ability to nail down and find the information quickly. He said they have a dashboard that helps and he had just attended a meeting to refine this even further and make the process easier and more accessible for the physicians and those working in the center. In addition, Dr. Lawrence also made reference to the new electronic medical record system that will be coming on board soon at UCLA, and that will be costing several hundred million dollars. When completed, however, they will have everything under one roof.
At present, they have access to shared records all throughout the facility but have individual logins for each area, such as the PACS server for X-rays, one for patient records and perhaps another for wound information. In other words, each area of technology has its own security logins and he’s looking forward to the day that “single sign on” for all is a reality. From a patient’s stand point, it is good to know that information is shared and available throughout the facility as this helps avoid duplicate tests, visits. As in many facilities, technologies have been added and the days of making it simple are in the works with aggregating patient data at all levels. UCLA will be converting to Epic Medical records, which is the same software used by Kaiser Permanente and many other large medical centers. A couple years ago I did an interview with Long Beach Memorial Hospital and their transition and how it all comes together with some pretty massive training and leadership events.
With having information up front, as well as skilled doctors at the facility, only about five to maybe 10% of all patients ever need to return for a second procedure, and as patients, we like that! The center is seeing approximately 125 patients a day for all types of vascular consults, treatments and procedures. To me that sounds like a very busy facility and thus I inquired as to how long would a patient need to wait to be seen? He stated two to three weeks is the standard for non-emergency type consultations, but if it were a more urgent situation, patients can also come directly to the center on the day of the problem, so they rarely need to get admitted through the emergency room.
I also asked about insurance coverage for these procedures and he said that virtually all are covered in the outpatient setting, even if they are interventional procedures. He said that complex by-pass or open vascular surgeries are also covered, but they often have high deductibles or co-pays so it makes sense to practice preventive care and to catch PAD and other issues such as aneurysms early to avoid the big ticket surgery which is both harder on the pocketbook and the patient.
In addition to seeing patients with PAD, the center can also handle aneurysms, carotid artery problems, access for dialysis problems, thoracic outlet syndrome, venous ulcers and other ambulatory procedures. The website has additional information available.
In summary, Dr. Lawrence again reiterated on education and care and the fact that the Gonda Vascular Center puts a lot of effort toward working with patients to help them understand how to take care of their health with the potential of removing some risk elements in their lives, if possible.
The Gonda Vascular Center is certainly setting the pace with using the latest state of the art technology to bring about procedures and cures that were not available only a few years ago with the advent of interventional medicine. Again I appreciate the doctor’s time and hopefully the information he provided today will give everyone an update on some of what is happening in the world of today’s world of medicine, many possibilities for certain.