Arun Kumarasamy, MBA, a renowned specialist in interventional radiology based in Frankfurt am Main, enjoys an outstanding reputation within the medical community. With a focus on minimally invasive, image-guided catheter-based procedures, he has specialized in particular in the treatment of vascular diseases, including peripheral arterial disease (PAD). His expertise in interventional radiology, a relatively new field of medicine, has contributed to this speciality gaining increasing prominence.
As Head of the Center of Excellence for the Diagnosis, Treatment and Prevention of Vascular Diseases at Sachsenhausen Hospital in Frankfurt, Kumarasamy is regarded as an experienced specialist in diseases of the vascular system, particularly in interventional angiology, where he is a pioneer in the treatment of peripheral arterial disease. Interventional radiology has gained in importance in recent years, particularly in the gentle and effective treatment of vascular diseases. This discipline utilizes advanced imaging techniques not only for diagnostic but also for therapeutic purposes.
Dr Kumarasamy began his career as a junior doctor in radiology and specialized in catheter-based, minimally invasive therapeutic procedures for vascular diseases. Since 2017, Arun Kumarasamy has been Head of Interventional Radiology at Sachsenhausen Hospital. In addition to his expertise in radiology, he obtained an MBA in International Hospital and Healthcare Management from the Frankfurt School of Finance. This academic qualification underscores his comprehensive knowledge of healthcare management and is reflected in the clinic’s well-organized structure, characterized by short waiting times and excellent patient care.
The department enjoys an international reputation, particularly for the treatment of peripheral arterial occlusive disease, commonly known as intermittent claudication, which the clinic treats to the highest standard. Arun Kumarasamy specializes in minimally invasive catheter-based procedures, including rotational atherectomy, balloon angioplasty and stent implantation to widen narrowed or blocked blood vessels. His precision and expertise are particularly evident in cases of acute arterial occlusion, where rapid diagnosis and treatment are crucial. Around 4 to 20 per cent of people in Germany suffer from peripheral arterial disease (PAD). The prevalence increases with age and is more frequently diagnosed in people over 65. To find out more about this topic, the editorial team at Leading Medicine Guide spoke to Arun Kumarasamy.
Peripheral arterial disease (PAD), commonly known as “intermittent claudication”, is a vascular condition that primarily affects the arteries in the legs. This condition leads to a narrowing or blockage of the arteries, thereby impairing blood flow to the legs. The colloquial name “intermittent claudication” stems from a common symptom: pain in the legs, which causes sufferers to have to stop and rest briefly every now and then while walking, much like looking at shop windows, in order to relieve the pain. When blood flow is impaired due to arterial narrowing, the muscles do not receive enough oxygen, which leads to pain.
Peripheral arterial disease (PAD) is caused by a narrowing or blockage of the arteries, which is usually due to atherosclerosis.
Atherosclerosis is a build-up of fat, cholesterol and other substances on the artery walls, leading to hardening and narrowing. “The first symptoms that sufferers often notice are pain or cramps in the calf muscles while walking, which are described as sharp or pressing. This pain, also known as ‘intermittent claudication’, occurs due to reduced blood flow, which does not supply the muscles with sufficient oxygen. The pain usually disappears at rest and reoccurs when the person starts walking or moving again. However, if the blockages worsen, pain may also occur at rest. The so-called ‘hydrostatic pressure’ plays an important role here. The water column is a measure of the pressure the blood must overcome to flow through the arteries. The higher the water column, the greater the pressure and the more difficult it is for the blood to fight against the resistance of the narrowed or blocked arteries. “The next stage is reached when minor wounds simply no longer heal or start to get bigger,” explains Arun Kumarasamy at the start of our conversation.
The causes of peripheral arterial disease can vary. “The main cause actually lies in genetic predisposition. People inherit the condition. The remaining 20–30%, which arise from atherosclerosis, thrombosis, embolisms and risk factors such as smoking, diabetes, high blood pressure and high cholesterol levels, are the areas where we can make a difference. This means that a smoker can make an effort to give up smoking; one can manage blood sugar, cholesterol and lipid levels and lead a generally healthy lifestyle, which naturally includes exercise,” clarifies Arun Kumarasamy, adding: “The timeframe in which arteries in humans narrow or even become blocked varies greatly. For example, there is also acute limb ischemia, which is caused very suddenly by a blood clot blocking the arteries. Then there is chronic limb ischemia, where the narrowing has developed over a longer period of time. This can take a few years or even decades. During this time, the body compensates for the developing narrowing by creating bypass circuits. Consequently, this only leads to short-term symptoms that the patient barely notices.”
Peripheral arterial disease (PAD) is diagnosed through a series of diagnostic procedures aimed at identifying circulatory disorders in the legs.
The doctor often begins with a thorough medical history, during which the patient’s medical history and existing symptoms are recorded. “It is important to speak at length with the patient to find out what symptoms they are experiencing and what their living circumstances are like. The consultation is also so important because some patients do not experience specific pain symptoms despite the condition being at a more advanced stage. They simply notice, for example, that they can no longer walk long distances. A physical examination follows, during which the doctor looks for abnormalities such as pain when walking, or changes to the skin or muscles in the legs,” emphasises Kumarasamy.
To obtain precise information about blood flow in the legs, non-invasive methods such as Doppler and duplex sonography can be used. These ultrasound procedures make it possible to visualize blood flow in the arteries of the legs and identify narrowings or blockages. In addition, measuring blood pressure at various points on the legs and comparing it with that in the arm can provide indications of circulatory disorders. In some cases, an angiogram may be performed. This involves injecting a contrast agent into the arteries, and X-rays are used to visualize any narrowing or blockages in the blood vessels. In addition, stress tests may be carried out, during which the patient walks or runs under medical supervision to observe and assess symptoms during physical exertion. The choice of diagnostic procedures is made on an individual basis, based on the patient’s symptoms and the recommendations of the treating doctor, to enable an accurate diagnosis.
In interventional radiology, various techniques are used to treat peripheral arterial disease (PAD), including specific procedures such as atherectomy and targeted treatments in the lower leg and foot.
“There are two treatment approaches – the endovascular, or catheter-based, approach, and the surgical approach using a bypass. In principle, we try to resolve the narrowing using the catheter-based option. If that is not sufficient, surgical measures can be taken. Of course, there is also a conservative approach if the patient has difficulty walking long distances. Walking training often helps here to promote collateral circulation. In principle, I must say – we do not cure, we merely improve quality of life by alleviating the symptoms. We can reconstruct blood vessels, but we cannot stop the aging process with this,” says Arun Kumarasamy on the initial treatment options.
Minimally invasive procedures play a significant role in the treatment of peripheral arterial disease (PAD) compared to conventional surgical procedures. They offer various potential benefits, particularly in terms of recovery time and long-term outcomes.
Compared to conventional open surgery, minimally invasive procedures are less invasive and gentler on the body. They require only small incisions or punctures in the skin, rather than large cuts, to access the arteries. This significantly reduces the risk of complications such as anesthetic risks, infections, blood loss and post-operative pain. The recovery time following minimally invasive procedures is generally shorter than with traditional surgical procedures. Patients can often be mobilized more quickly and have a shorter hospital stay. This helps them return to their normal activities sooner.
“With the endovascular procedures performed here, we can insert a catheter through a 2mm puncture site and then reopen blocked vessels, carrying out the treatment through this small access point. In addition to all the advantages mentioned above, the aesthetic outcome is ultimately much better, and follow-up complications do not usually occur frequently. In theory, some of these procedures could also be performed on an outpatient basis in the near future, although this varies from person to person,” explains Arun Kumarasamy. By improving blood flow in the affected arteries, symptoms such as pain when walking are alleviated, and the risk of more serious complications such as tissue loss or amputations is reduced. However, the choice between minimally invasive procedures and conventional surgery depends on various factors, including the severity of the condition, the location of the arterial narrowing and the patient’s individual health characteristics.
“We place great emphasis on interdisciplinary collaboration. The days of ‘silo thinking’ are over. You have to work with colleagues from other specialist areas, thereby also improving the overall quality of care and strategy for the patient. You have to see it as a whole, like a gearwheel turning, where you need well-functioning units working together,” comments Kumarasamy.
Atherotripsy is a relatively new technology that can be used in the treatment of peripheral arterial disease (PAD).
This method uses sound waves to break up plaque deposits in the arteries, rather than removing them as in conventional procedures. In atherotripsy, a special balloon catheter is inserted into the narrowed or blocked artery. The balloon features integrated lithotripsy elements that generate ultrasound-based sound waves. These sound waves produce short, controlled pulses that break up the plaque deposits without damaging the surrounding healthy tissue. The aim is to break up the blockage. Atherotripsy technology is regarded as a complementary innovation, as it offers a non-invasive method for treating PAD. This is because it breaks up the plaque deposits rather than removing them.
“This procedure has been used in other medical fields for some time, and high-frequency ultrasound has previously been used successfully to break up kidney stones, for example. Vascular calcification can be broken up and shattered in exactly the same way, making the vessel significantly more supple. The effectiveness of atherotripsy technology in the treatment of PAD is the subject of ongoing research and clinical trials. Early results suggest that this method could be promising for treating plaque deposits and restoring blood flow in the affected arteries. This procedure is certainly not suitable for every location, but it is another option for treating calcified vessels that cannot be treated by atherectomy.
In recent years, the treatment of peripheral arterial disease (PAD) has made significant progress, giving new hope to patients with this condition.
“Endovascular procedures have established themselves as effective minimally invasive techniques and have continued to evolve. These techniques reduce the need for extensive surgical procedures and significantly shorten recovery times. In addition, new drugs have been developed that specifically target improved blood flow and can slow the progression of the disease. The focus on personalized treatment approaches tailored to individual needs has improved the effectiveness of therapies. Overall, however, the aim is to follow the motto ‘Leave nothing behind’, which means trying to work without foreign bodies such as stents. Naturally, every effort is also made to avoid amputations. This is because there are still too many amputations in Germany, even though other approaches may be possible. There are regions where more amputations are performed because endovascular treatments have not yet become established there as a standardized treatment regimen. More expertise needs to be brought in here, and better education is required. “A mandatory second opinion prior to a potential amputation is now enshrined in the guidelines for diabetes care practices and definitely makes sense,” explains Dr Kumarasamy.
Further breakthroughs could be on the horizon in the near future. The continuous improvement of interventional techniques will further increase the accuracy and efficiency of PAD treatment.
Furthermore, a greater focus on preventive measures and lifestyle changes could reduce the incidence of PAD and minimize the need for invasive treatments. Continuous developments in medicine, supported by innovative technologies and a deeper understanding of the disease, open up promising prospects for improved treatment and quality of life for people affected by PAD.
“I believe that the treatment of lower leg and foot arteries will continue to take center stage, and new technologies such as bioresorbable stents and the treatment of the smallest vessels, such as those in the foot, will once again be a topic of discussion and come more into focus. Specialization and subspecialisation among doctors will also increase, not only because it is technically necessary, but also because patients are demanding and expecting increasingly specialized expertise,” says Arun Kumarasamy.
The complexity of the procedures and the need to improve blood flow all the way to the toes require careful planning and expertise on the part of doctors. Despite these challenges, the new therapies hold enormous potential, particularly in terms of the quality of life of those affected. The ability to improve blood flow all the way to the toes can definitely help prevent amputations and maintain patients’ mobility and general well-being.
In good hands at Sachsenhausen Hospital in Frankfurt am Main
“Here in Frankfurt am Main, we perform some of the highest number of atherectomies in Germany and have specialized in innovative vascular-opening procedures. We first use a drill to clear a blocked or narrowed vessel, which leads to increased blood flow; we can then insert a balloon, and by drilling the vessel open beforehand, we can minimize the high pressure caused by the balloon. In any case, this method often helps to avoid the need for a stent, i.e. a foreign body. We have a high level of expertise in this area at our hospital and have been able to specialize extensively. In November 2022, I published a new paper on a novel lower-leg catheter that improves patients’ condition even further following treatment (https://pubmed.ncbi.nlm.nih.gov/36363551/). To ensure that others can also benefit from our expertise, we operate as a training center and can pass on this knowledge, including to the industry, where we can evaluate and help develop new products. “Doctors from around the world come to us to take part in training courses and observe, and occasionally I also travel to other clinics, most recently to Bangkok – all of this is motivating, great fun, and means you’re directly involved in the latest developments,” says Arun Kumarasamy, and with these positive outlooks we conclude our interesting conversation.
Dear Mr Kumarasamy, thank you very much for the vital information on peripheral arterial disease!
