By Roberto Hugo González
At the second meeting under the umbrella of the South Texas CLI and Limb Salvage Club meeting, an event defined by its commitment to advancing medical knowledge and practice in the field of vascular health, Dr. Pedro Mego, MD, FACC, FSCAI, RPVI, ABVM, took center stage. This gathering brought together experts and enthusiasts alike, all driven by a shared goal: to combat the often overlooked yet critical issue of Peripheral Artery Disease (PAD) and Chronic Venous Diseases.
Dr. Mego’s presentation was not just a dissemination of information; it was a passionate plea for change. With a focus on PAD and its cardiovascular implications, he emphasized the necessity of early detection through regular screenings. His words were a loud call to increase access to affordable diagnostic tests, treatments, and more importantly, to debunk the persistent myths surrounding PAD – for instance, the misconception that it merely leads to a toe amputation, which often can be avoided.
The presentation took an emotional turn as the master of ceremonies Gary Rodriguez recounted the story of Dave Brown, a beloved sports broadcaster from Channel 5. Brown’s journey with PAD began unnoticeably, with a sore on the bottom of his foot, a condition easily overlooked in his profession. However, this sore, initially benign, spiraled into a chronic, bleeding wound. Despite his’ best efforts with patches, creams, and bandages, the condition worsened over the years, ultimately leading to the amputation of his foot. This tragic outcome, it was suggested during this gathering, could have been prevented; it is a statement that resonated deeply with the audience.
Dr. Mego’s message was clear: amputation should not be the primary or only solution in treating PAD. The event, distinguished by the presence of U.S. Congressman Henry Cuellar, served as a motivation for medical professionals, doctors, nurses, surgeons, and caretakers to explore alternative treatments. The story of Dave Brown was a powerful example of the dire need for heightened awareness and proactive intervention in PAD cases.
Dr. Mego earned his Medical Degree at the Universidad Nacional Mayor de San Marcos School of Medicine in Peru. He completed his Residency in Internal Medicine at New York Medical College at Metropolitan Hospital Center, New York, NY. He continued with a Cardiology Fellowship at Montreal Heart Institute and the University of Arkansas for Medical Sciences, then he completed an Interventional Cardiology Fellowship at University of Arkansas for Medical Sciences. Additionally, he is certified as an Endovascular Specialist by the American Board of Vascular Medicine.
His Professional Affiliations: Fellow of the American College of Cardiology (FACC), Fellow of the Society for Cardiovascular Angiography & Interventions, and Diplomate, American Board of Vascular Medicine (ABVM).
But Dr. Mego’s impact extends far beyond his academic and professional achievements. His work in vascular interventions has saved countless limbs and, by extension, lives. He has restored circulatory function and improved the quality of life for many patients. His contributions include numerous publications, research studies, and presentations at both national and international conferences.
Dr. Mego’s dedication to combating PAD and other vascular diseases is not confined to the hospital or the lab. He is deeply committed to community education and outreach. Regularly organizing and participating in public health fairs, educational seminars, and free screening events, Dr. Mego has become a community example — a doctor who not only treats but also teaches and touches lives.
Dr. Pedro Mego began his presentation emphasizing the importance of this event in raising awareness about Peripheral Artery Disease (PAD), a serious condition impacting the Rio Grande Valley.
Dr. Mego introduced a case study of a 57-year-old male patient from the Valley, afflicted with diabetes, hypertension, hyperlipidemia, and obesity. He terms this combination of conditions as “The Valley Syndrome,” prevalent in the area. The patient suffers from claudication pain, cold feet, night cramps, and an ingrown toenail leading to toe discoloration, and toe ulcer.
PAD is explained as a condition where blood vessels carrying blood from the heart to the legs are impaired. The accumulation of fat tissue, inflammatory markers, and platelets in arterial walls leads to reduced blood flow. Dr. Mego highlights that PAD is a manifestation of atherosclerosis, a systemic disease affecting various body parts, leading to different risks like stroke, heart attacks, and in the legs, potential amputation.
The prevalence of PAD is alarmingly high, with over 200 million people worldwide and 8.5 million Americans affected. Dr. Mego stresses the increase in PAD cases due to aging and the diabetes and obesity epidemic. He presents startling statistics on amputations, particularly in Texas, indicating a severe health concern.
Highlighting regional disparities in treatment, Dr. Mego shared that a place like Provo, Utah, has significantly lower amputation rates, compared with McAllen, Texas that has been between the highest rates in the nation. Expressing his frustration over this gap, he recounts his journey since 2005 in focusing on arterial treatments in the legs. Dr. Mego concluded this part by mentioning his increased commitment to addressing PAD, particularly considering its correlation with age, lifestyle factors, and ethnicity, a topic he revisited in his presentation.
As Dr. Mego continued, he asked, who is at Risk for PAD? Peripheral Artery Disease primarily affects those over 65 years old. However, individuals under 50 with diabetes are also at a heightened risk. Other risk factors include a history of heart attack, stroke, or abnormalities in pulse examination. Interestingly, 20 to 50% of PAD patients may not exhibit any symptoms, which complicates diagnosis and treatment.
Dr. Mego, emphasizes the importance of recognizing PAD, even in asymptomatic patients. Classic symptoms include claudication (calf pain during physical activity that subsides with rest), and critical ischemia (CLI), characterized by pain at rest (including pain at bedtime), non-healing ulcers or tissue loss. However, many patients may not present these typical symptoms.
The prognosis for PAD patients, particularly those with critical limb ischemia, is grim. Within five years, 15 to 30% of patients with claudication, a symptom of PAD, may die. “For patients with critical limb ischemia, the outlook is even more terrible, with a 50% chance of survival and limb retention, and a 25% mortality rate, at one year”, he said. He pointed out that this mortality rate is higher than many types of cancer, including colon, breast, and prostate cancer.
He also explained, that beyond mortality, PAD significantly impacts patients’ quality of life and economic stability. It can transform a family’s breadwinner into a disabled individual, creating immense personal and family strain. The economic burden includes diagnostic and treatment costs, hospitalization, long-term care, and loss of productivity.
To diagnose PAD, Dr. Mego reinforced the importance to examine the patient’s feet regularly by patient’s primary care physician and by family members, especially if it is diabetic (checking for skin temperature, changes in color, sensitivity, pulses strength and more importantly the presence of sores or ulcers). Regarding tests, The Ankle-Brachial Index (ABI), it is a simple test that can be performed at the PCP office, and it can provide the diagnosis of PAD. The main noninvasive test is the Lower Extremities arterial dopplers that usually provides enough information to decide further treatment options.
Dr. Mego highlighted the multifaceted approach to treating Peripheral Arterial Disease. The primary focus is on lifestyle modification and medication: quitting smoking, controlling diabetes, managing high cholesterol, and maintaining blood pressure levels. Regular exercise is also emphasized. However, for patients with critical limb ischemia, these measures might be insufficient.
Angiogram and Revascularization
In such cases, a vital procedure called an angiogram is recommended. This minimally invasive technique involves inserting a needle usually into the groin or ankle and advancing a catheter to the affected leg. Iodine contrast is used to visualize and assess the severity of arterial blockages. He also mentioned that CO2 can be used as contrast instead in patients with kidney dysfunction. The angiogram facilitates revascularization – a process of clearing blockages within the arteries. He said, “This can be a game-changer for patients with critical ischemia, improving blood flow and aiding in wound healing, thus preventing amputation.”
Use of Balloons, Stents, and Other Devices
For revascularization, small balloons, small metallic pieces known as stents or other devices may be used to remove cholesterol build-up in the arteries, enhancing blood circulation to the foot.
If percutaneous revascularization is unsuccessful (percutaneous is the medical term for the route that penetrates the skin with a needle, allowing the uses of small catheters for the angiogram), traditional bypass surgery is considered. Current guidelines recommend exploring vascularization options before considering amputation. However, it’s noted that about 50% of patients undergoing amputation in the U.S. do not have a pre-amputation angiogram.
Case Study: a 57-Year-Old Male Patient
Dr. Mego finished the initial case of the 57-year-old male patient with arterial issues. The patient had several blockages. Using a percutaneous approach, the blockages were cleared from the thigh to the foot, ensuring adequate blood flow and allowing wound healing.
He stated that this patient’s prognosis could have been terrible, potentially leading to amputation. However, thanks to advanced medical technology and expertise, the patient recovered and returned to work within a few months.
Hispanic Population and PAD
Dr. Mego touched upon the prevalence of PAD and related amputations among the Hispanic population in Texas, noting a higher incidence compared to national averages. This increase correlates with higher rates of diabetes in the region. The Rio Grande Valley, for example, has a significantly high diabetes prevalence of 30.7%, contributing to the higher rate of PAD and amputations.
“Interestingly”, Dr. Mego said, “there was a noted decrease in diabetes and amputations during the 2008 financial crisis, attributed to reduced obesity and diabetes rates due to lifestyle changes during that period. This points to the impact of socioeconomic factors on health trends.”
Dr. Mego, in his insightful presentation at the McAllen Chamber of Commerce, highlighted the alarming prevalence of amputation in the Rio Grande Valley, primarily attributed to uncontrolled and untreated diabetes. This issue is further exacerbated by other challenges, such as late presentation for medical care, especially among the Mexican Texan population. Limited access to healthcare, a tendency for non-compliance, and infrequent doctor visits contribute significantly to this problem.
Cultural Factors and Dietary Habits
A notable cultural aspect that Dr. Mego emphasized was the community’s inclination to rely more on neighbors’ advice than on professional medical decisions. This cultural trait, combined with poor dietary habits, particularly the excessive consumption of ‘Vitamin T’ (tortillas, tacos, tamales, tres leches, etc.), plays a crucial role in escalating diabetes and obesity rates in the region.
On a positive note, Dr. Mego mentioned the advancements in medical infrastructure in recent years. Where once only a few local hospitals were equipped to perform lower extremity angiograms, a critical diagnostic tool for vascular health, now almost all local hospitals and new outpatient centers offer this service. This increased accessibility is a significant step towards better vascular health management in the community.
A Multidisciplinary Approach
Dr. Mego stressed the systemic nature of Peripheral Artery Disease (PAD) and its high correlation with cardiovascular events and mortality. He advocated for early diagnosis and treatment for better outcomes, emphasizing the necessity of a multidisciplinary approach. This approach would involve not only primary care physicians but also specialists such as wound care, podiatrists, diabetes specialists, and endovascular experts like himself, to effectively manage and ideally prevent limb amputation.
Dr. Mego pointed out that the intersection of diabetes and the obesity epidemic is significantly influenced by cultural and socioeconomic factors. Populations at the highest risk for amputation include males, diabetics, and low-income Hispanic individuals. To combat this, Dr. Mego called for comprehensive educational campaigns, immediate engagement in healthcare, and widespread vascular screening.
Collective Responsibility for Prevention
Dr. Mego emphasized that addressing the high rate of amputation in the Rio Grande Valley is not solely the responsibility of healthcare professionals. “It requires a collective effort from the entire community, including public awareness, education, and proactive healthcare engagement. Early diagnosis, lifestyle changes, and increased access to specialized medical care are crucial in reducing the prevalence of amputations related to diabetes and PAD in the region,” he finalized.