Dr. Michael Jaff

Dr. Michael Jaff is the Director of the Vascular Center at Massachusetts General Hospital in Boston, a large collaborative program encompassing over 100 doctors who diagnose and treat patients with different forms of peripheral artery disease (PAD), a common complication of diabetes that can have serious side effects. He trained at the Kirksville College of Osteopathic Medicine and did his residency at the Cleveland Clinic in Ohio. In an interview with diaTribe, Dr. Jaff discussed the particular importance of peripheral artery disease for diabetes patients. He gave us some tips about simple and easy things that people can do to avoid this disabling complication.

diatribe: Hello, Dr. Jaff. Thank you for speaking with diatribe on this often neglected topic. We're particularly interested with how peripheral artery disease relates to diabetes. Can you give us a quick take on what PAD is?

Dr. Jaff: PAD or peripheral artery disease is the hardening of the arteries of the legs or arms. This is a similar process to artery blockage in the heart (heart attack), the brain (stroke), or the kidneys. This is a very common disorder - some believe it's as common as artery disease in the heart. About 10 to 12 million Americans suffer from this every year and the reason it should be of incredible interest to diatribe readers is that the most serious and the most common condition that leads to peripheral artery disease is diabetes. About 40% of patients with peripheral artery disease have diabetes and as you know, one of the greatest fears of diabetics is limb loss or amputation. Even patients with diabetes and normal leg artery circulation are at risk of amputation. Add to that peripheral artery disease and the risk of losing the limb goes up quite impressively.

diatribe: Are you talking about a build-up of plaque (fatty deposits) inside the blood vessel, like in coronary (heart) artery disease?

Dr. Jaff: Yes, it's the same process. There may be a few subtle differences between the leg artery blockage pathology and the heart artery blockage, but it's generally the same. It's a combination of cholesterol and other deposits that lead to plaque, which then narrows the space in which blood flows.

diatribe: How do you go about diagnosing PAD?

Dr. Jaff: In patients with diabetes, physicians must remember that this is one of the major manifestations of diabetes. Since it's so common, we generally recommend that patients on insulin have an objective test for peripheral artery disease, whether they have any symptoms or not. If they have type 1 diabetes, it's recommended that they get an objective test of their peripheral artery circulation before the age of 50. For type 2s, you can wait until the age of 50 unless there are symptoms or signs. If their circulation is normal, then they should get rechecked every five years.

diatribe: What does the test entail?

Dr. Jaff: The nice thing about peripheral artery disease is that the test is purely non-invasive and completely painless. It's basically two blood pressure cuffs at the same time with one on the arm and one on the ankle to measure differences in blood pressure. The pressures should be the same, but in patients with peripheral artery disease, the leg blood pressure is generally lower than the arm pressure.

diatribe: What's the next step following a diagnosis?

Dr. Jaff: Well, first I would remind the person of the absolutely mandatory importance of foot care. Then we go through the big five: tight control of diabetes, reductions in LDL cholesterol, control of high blood pressure, complete abstinence from cigarette smoking, and the use of platelet blocking medication like aspirin. If a patient actually has a sore on his toe due to poor blood supply, then we do a small surgical procedure to improve their blood flow. The procedures are generally minimally invasive, like a balloon, stent, or surgical bypass.

diatribe: Could you talk a bit more about foot care?

Dr. Jaff: First of all, people with diabetes should not cut their own toenails. Oftentimes, they can't feel their foot and so they cut a toenail too short or they'll nick the skin around the cuticle and that will be enough for gangrene (tissue decay) to set in. We talk about the fact that either they or someone else needs to inspect their feet every evening, specifically between the toes and on the heels, looking for athlete's foot, skin breakdown, calluses, fissures (cracks), things like that. We recommend an emollient skin cream that they rub aggressively on their heels and over the bones of their ankles every day so that the skin won't crack. We remind them that after they bathe, they must take a terrycloth towel and thoroughly dry between the toes. We talk about making sure their shoes are properly fitted, especially if they have insensitive feet. That's pretty much it.

diatribe: What should patients look out for when they're trying to choose specialty footwear?

Dr. Jaff: They need to go to a reputable outfit, known or recommended by their healthcare provider. There's an awful lot of this type of business out there and some of them are not that good. What we do is send patients to orthotists, who actually know how to do foot molds. We don't just leave it up to the patient to decide.

diatribe: Does this disease affect the kind of activities a patient can do?

Dr. Jaff: No, they should definitely go ahead with their routine activities just as long as they're wearing the right kind of shoe, but they should watch for warning signs of PAD. People with diabetes who have any discomfort in their feet or legs should be tested for peripheral artery disease because they may have a blockage and not know it. They might think they pulled a muscle or strained their back or something. Patients should remember that it's particularly important to look for warning signs during activity.

diatribe: What online resources exist to improve education about peripheral artery disease?

Dr. Jaff: There are two great websites. The federal government in their wisdom was actually convinced by a group of us that this was a public health urgency, so they started something called the PAD Coalition. Its website address is www.PADcoalition.org. Another one that is actually done by the National Institutes of Health is www.aboutpad.org. They're great, they're unbiased, there's no commercial sponsorship, and they have a lot of good information for patients.

diatribe: Okay great. Thank you so much for talking with us. If you were to sum up the importance of PAD for diabetes patients in one sentence, what would it be?

Dr. Jaff: I think that patients with diabetes need to think about at least the possibility of PAD, not to be afraid of it but certainly to be aware of it, so that they can get an early diagnosis and effective preventive therapy.