Dr. David Greuner – Dr. Radio

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Dr. Greuner featured on Dr. Radio

 

 

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Participants:

Dr. Nieca Goldberg

Dr. David Greuner

Carol

Dr. Nieca Goldberg:

Welcome back to Beyond the Heart. I’m your host, Dr. Nieca Goldberg, and in this segment, we’ll be speaking about exercise and overdoing it with Dr. David Greuner, who’s managing director and cofounder of New York City Surgical Associates. He’s also a double board-certified surgeon who specializes in minimally invasive surgery and cardiovascular and general surgery. Welcome to the show, David.

 

Dr. David Greuner:

Hi, Nieca. How are you?

 

Dr. Nieca Goldberg:

I’m great. A lot of doctors tell patients to exercise, but you don’t just talk the talk. You practice what you preach. Tell our listeners about some of your fitness interests.

 

Dr. David Greuner:

I was always an athlete. I was an NCAA runner and a swimmer in college. During residency, I put on, I guess, the freshman 15. I had to get rid of that. It was a little bit tough for me, getting back into the swing of things, but now I deal with sports that aren’t really that taxing on your body, but tend to give you a really good workout. I have a lot of bikes. I cycle a lot, and I swim a lot. I found it’s really good for non-impact, especially with our aging bodies.

 

Dr. Nieca Goldberg:

Are you involved in extreme fitness? Or are you just doing regular?

 

Dr. David Greuner:

I do triathlons, and I do some Olympic distance triathlons, which I think a lot of people would regard as extreme. I do some, not really fitness, but I do heli skiing, heli snowboarding, things like that.

 

Dr. Nieca Goldberg:

Wow.

 

Dr. David Greuner:

That’s a lot of fun, too.

 

Dr. Nieca Goldberg:

You don’t still do it, do you?

 

Dr. David Greuner:

Yeah. I still do it.

 

Dr. Nieca Goldberg:

You still do it? Wow. How do you encourage your patients to keep moving? Do you do cardiac surgery?

 

Dr. David Greuner:

No. I mostly do endovascular surgery now.

 

Dr. Nieca Goldberg:

Endovascular surgery, but a lot of your patients are incapable of extreme exercise.

 

Dr. David Greuner:

Most of our patients are on the younger end of things, because our practice deals specifically with minimally invasive surgery. We have two patient populations in general. One is the massive weight loss patient, which develops a lot of the cardiovascular issues that result. In your body, when you lose fat, especially a massive amount of fat, you also rearrange the vasculature inside of your body, because you have fat pads that separate blood vessels. On a massive weight loss patient, we deal with a lot of patients that lose those fat pads and now they produce anatomic obstructions such as May-Thurner syndrome and nutcracker syndrome.

 

Dr. Nieca Goldberg:

What are those?

 

Dr. David Greuner:

Similar to when you have anorexia and your kidney drops because of the loss of the fat pads. May-Thurner syndrome is a problem with iliac vein obstruction, which is a vein draining your leg. It’s the main one. The highway draining leg. Normally, your iliac artery, or the artery supplying blood to the legs sits right next to that vein, and there’s a fat pad separating it, because arterial pressure is much, much higher than venous, about 20 times as high. If you lose that fat pad inside of you, the artery now compresses the vein because it will always win, because it’s 20 times as dense.

 

Dr. Nieca Goldberg:

Higher pressure.

 

Dr. David Greuner:

Yep, and it will squash the vein. What these people is a lot of leg numbness, leg pain, and especially after a massive amount of weight loss or congenital reasons, they will have an inability to work out, etc. I know this, and I got really passionate about it because it happened to me. I was training for a marathon, and I got down to a very, very low body fat and I actually started to get a huge amount of leg pain as a result. It’s kind of like lumbar disc pain. It’s a little bit heartbreaking, because every time you’re increasing your cardiac output or making your heart beat faster due to exercise, it makes the problem much, much worse. I tell people it’s like a shower that you had in college that worked fine most of the time, it’s just when you take a really long shower, it flooded the whole thing. That’s what happens. Most of the time, you’re okay, but when you tend to exercise a huge amount and you over-deliver blood to your extremities or your legs, it becomes a huge issue.

 

Dr. Nieca Goldberg:

Let me ask you a personal question. Did you make the diagnosis yourself?

 

Dr. David Greuner:

I actually did, yeah.

 

Dr. Nieca Goldberg:

Okay. Then, you didn’t treat yourself. What did you do? What happens when you make the diagnosis?

 

Dr. David Greuner:

One of the surgeons treated me, actually. I had also had another back injury. I had a spinal fusion from an injury I had tele skiing, believe it or not. That happened a few years ago, and then I had this problem with both legs, but it was much worse on my left side because I had a lot of scar tissue from my spinal fusion. Normally, you would tell these people just to gain a little bit of weight back, and that will separate the blood vessels and they’ll be okay, but because they did a diagnostic angiogram on me on the left side, because of the scar tissue. It was not going to get better. One of my doctors went ahead and put a stent in me, and I’m a lot better now. Back to running and biking and all that stuff.

 

Dr. Nieca Goldberg:

That’s great. And no pain?

 

Dr. David Greuner:

No pain at all.

 

Dr. Nieca Goldberg:

Yeah. It’s challenging, because we all encourage people to exercise, but we have to make sure—diet and exercise to lose weight and exercise for cardio health and all this stuff, but I think it’s very important in our explanations or our counseling to patients that we also factor in some injury prevention.

 

Dr. David Greuner:

Absolutely, especially as we get older. Our bodies, whether we like it or not, become more frail and more sensitive to injury as a result of a variety of things, as I’m sure you know. You have to take things that aren’t quite as risk-heavy as you get older, as much as I hate to admit that.

 

Dr. Nieca Goldberg:

How do you counsel your people? How do you counsel your patients?

 

Dr. David Greuner:

I take a very personal interest in this stuff, because it’s a personal hobby of mine, nutritional analysis and helping people with their exercise programs. I take the whole patient into consideration. Their body weight, whether they have musculoskeletal issues, whether they have posture issues, what goal they’re trying to achieve versus cardiovascular fitness versus weight loss. I try to come up with a plan for them. It’s just something I do just because I like it, and it’s resulted actually in a huge building of this practice, because these types of people refer more people, and it’s led to quite a following.

 

Dr. Nieca Goldberg:

Yeah. What are some of the common complaints or concerns your patients share when it comes to the idea of exercise?

 

Dr. David Greuner:

A lot of people, not specifically exercise related, but in terms of weight loss, I think a huge, huge problem in America today is the idea of portion control, because the market is flooded with all these low-fat, low-calorie options, but nobody really talks about portion control. Globally, the group of people I think, there’s a huge misconception about the amount of calories in what amount of food. If I could come up with one that’s basically playing the weight loss, people that want weight loss in this country, they just don’t understand the caloric intakes that they need to have. The other difference with exercise and diet is, I don’t think exercise should be really used as a weight loss technique. I tend to separate the two. Weight loss is probably 80% diet and 20% exercise.

 

Dr. Nieca Goldberg:

The exercise really helps to maintain the weight loss. It doesn’t help initially with the weight loss.

 

Dr. David Greuner:

It helps them maintain a healthy lifestyle, but me, I tend to gain weight when I exercise a lot, because my metabolism is going crazy. I try to separate those two, and I try to educate people about caloric intake and portions and basically, tell them to look at exercise as a functional enhancement activity versus an actual weight loss activity. Usually, when people diet first, they get into healthy feeling. They get down to a weight that’s manageable with activity. Then, I actually gradually increase their activity to a point where it’s doable for them on a long-term basis.

 

Dr. Nieca Goldberg:

Yeah. It’s really about maintaining the improved lifestyle changes, because often people fall off the wagon there. We’re going to welcome Carol from California. Hi, Carol.

 

Carol:

Good morning. Thanks for taking my call.

 

Dr. Nieca Goldberg:

It’s our pleasure.

 

Carol:

I was struck by the comment that your speaker was saying about—

 

Dr. Nieca Goldberg:

Dr. Greuner, yeah.

 

Carol:

Dr. Greuner, thank you. My husband has unexplained swelling in his lower leg. The swelling will become so bad that the outer skin will split and the leg will bleed, and it’s very frustrating to try to control this problem. He had an ultrasound to check for clots. He had all the usual blood tests. Didn’t show an infection, but I’m wondering if an ultrasound was the definitive route for something like May-Thurner syndrome.

 

Dr. David Greuner:

No, it’s not, actually. The problem with ultrasound is, they’re only reliable at examining the leg from the groin down. The vast majority of May-Thurner syndrome or even some DVTs will happen higher, like between the belly button and the groin. In that area, you can’t really see it reliably. It’s like looking through a foggy window with ultrasound, because all abdominal organs are on top of everything.

 

Carol:

He’s had this problem for years, and no one has come up with an answer for what it would be. I just recently heard of May-Thurner syndrome and started researching it. What type of specialist should he see to pursue this problem? He’s seen all kinds of specialists. He’s neuropathic. Not diabetic, but neuropathic. He’s got an idiopathic neuropathy. Can’t feel his feet or his legs up higher than his knees. Lost feeling in his fingers. He’s not exactly well. He’s got this autoimmune thing, but no one has suggested referring him for this specific thing, but it’s dangerous. It causes infections, and then he has surgeries to take off another part of his foot. I need to know who do I ask to be referred to?

 

Dr. David Greuner:

There’s really only a few practices in the country that specialize in this kind of thing, and there’s actually the University of Washington close to you. I believe there’s a specialist, Dr. Meisner. He’s quite good. It has to be a vascular surgeon or an interventional radiologist that specializes specifically in venous disease, because most—

 

Carol:

Okay. I’m looking for a vascular surgeon or an interventional radiologist. They can take a look at this and try to figure out what would be causing this intense swelling that actually causes the skin to split?

 

Dr. David Greuner:

Correct.

 

Carol:

Thank you.

 

Dr. Nieca Goldberg:

David, can you please explain what the May-Thurner syndrome is again?

 

Dr. David Greuner:

May-Thurner syndrome is just usually congenital, but it can be acquired, meaning happening as an adult through a large amount of weight loss. It’s basically the artery that’s normally running parallel to the vein now changing its orientation and becoming more perpendicular and basically squashing the vein and obstructing it.

 

Dr. Nieca Goldberg:

That could lead to leg swelling, because your blood isn’t going back to the heart, right, David?

 

Dr. David Greuner:

A hundred percent, yes.

 

Dr. Nieca Goldberg:

Also, obviously, you mentioned it causes symptoms of numbness, pain, and feeling uncomfortable. Thanks for calling in Carol, and asking your question. I want to welcome our other listeners to join our conversation, and they can give us a call to speak with Dr. David Greuner, who’s managing director and cofounder of New York City Surgical Associates. He’s a double board-certified surgeon that specializes in minimally invasive surgery and cardiovascular and general surgery. The numbers are 877-NYU-DOCS. It’s 877-698-3627. Or you can email us at docs@siruisXM.com. David, a couple of people brought up this issue of leg swelling, and a lot of people, they go online when their legs are swollen and all of the sudden, they think that they have heart failure or a DVT. Give us some ways when you should consider your leg swelling serious and you need to seek urgent care versus maybe you just need to elevate your legs.

 

Dr. David Greuner:

Most of these problems are not emergent, and they’re basically subjective in nature. What I tell patients, May-Thurner, as you actually screen everybody, is extremely prevalent. It’s probably present in about 40% of women, and it’s mostly due to the different hip to shoulder ratios and the different angles of the blood vessels. Males don’t tend to get it as often, and they tend to get it at very specific sites. It’s very specific presentation. It’s more present on the right leg on males. On the women, it usually happens on the left leg. Probably a 10:1 incidence in terms of women’s preponderance. May-Thurner basically, if you screened everybody and you wouldn’t need to treat everybody, because most people are asymptomatic, and there’s two presentations where it becomes an issue. One is if you have, May-Thurner can result in a clot because the blood is not flowing that well. Once you have a clot as well as a May-Thurner lesion—

 

Dr. Nieca Goldberg:

That’s a DVT, right?

 

Dr. David Greuner:

Correct, yeah. Then, it becomes really symptomatic. Basically, it is what we call permissive disease, kind of like your generic predisposition to forming cancer. You have to have two issues, usually. Usually, one is a specific vein problem. It doesn’t usually cause a problem on its own, unless you’re really, really active and you’re challenging your circulation all the time. When it becomes a problem is when you have another issue, like I did with my spine surgery and the scar tissue around my veins. Then, it became huge. Or, if you have May-Thurner and then you develop a DVT as a result, then it will become a huge problem.

 

Dr. Nieca Goldberg:

What about people who don’t have May-Thurner but have leg swelling and think they have a DVT?

 

Dr. David Greuner:

Most people, yes, it can be an issue. One of the things I want to stress to people is that, which this patient brought up which was very useful, actually, is ultrasound doesn’t rule out major DVT at all. If you have a blockage of the veins higher up, clearly you will have some flow disturbance in the leg, which will be seen by a very good ultrasound technician, but a lot of them are maybe not that good to pick that up. To really rule out anything, you need to see a specialist. In general, the rule of thumb is, if it’s bothering you significantly, go see somebody about it, because in general, you have a very short timeline to treat clots. Clots are like cement. After about a week, they tend to get really hard and very difficult to remove. You treat them within a week, it’s very easy to get rid of it, typically. In general, time is of the essence.

 

Dr. Nieca Goldberg:

After you were diagnosed with the May-Thurner syndrome and you were treated, how long did it take you to get back to exercising?

 

Dr. David Greuner:

I was back the next day.

 

Dr. Nieca Goldberg:

Really?

 

Dr. David Greuner:

Yes. It’s basically like relieving the kink in a hose. I felt much better coming off the table.

 

Dr. Nieca Goldberg:

Did the experience change and make any—cause you to make any changes in your exercise regimen?

 

Dr. David Greuner:

It got a lot more vigorous after that.

 

Dr. Nieca Goldberg:

Really?

 

Dr. David Greuner:

Yeah. One of the things I wouldn’t recommend is, I went snowboarding. I had a trip planned with the guys in our practice. They’re all into a lot of social stuff together. I went snowboarding, and that wasn’t the smartest thing, because the stent was sitting and swaying to my body.

 

Dr. Nieca Goldberg:

Yeah. When I have patients that get cardiac stents, we hold off a few weeks before they start cardiac rehab.

 

Dr. David Greuner:

Yeah, but that’s a little bit different, because it’s a very, very small vessel. Any risk of thrombosis or anything is a huge problem because it’ll create a—

 

Dr. Nieca Goldberg:

A heart attack.

 

Dr. David Greuner:

A heart attack, yeah. For iliac veins, it’s a different situation. The vessel is about the size of two of your fingers together. It’s a lot higher flow, and you’re relieving a very tight vessel. In general, the congestive leg will have an increase in flow. These people, is it okay if I get a little bit technical in terms of blood delivery or no?

 

Dr. Nieca Goldberg:

As long as you explain it.

 

Dr. David Greuner:

Okay. When your veins are chronically obstructed or they’re narrowed, your arteries compensate, so to speak, over time. Basically, your arteries will deliver blood at a higher pressure to a leg than they normally would deliver in somebody that did not have a vein obstruction. What we see a lot in people with longstanding vein obstructions like May-Thurner is when you relieve the vein obstruction, their leg will get very red and very hot for a few days afterwards, because what happened is, your body hasn’t realized that it can pump at a lower pressure now to the leg. In general, they’re very, very low risk for clot after this procedure because the blood is getting flushed at a very rapid rate throughout the leg, and your body hasn’t figured out that it doesn’t need to push it that hard anymore.

 

Dr. Nieca Goldberg:

One of the things I didn’t ask you yet, and you also believe very strongly in is, how we breathe is very crucial to our health. What do you mean by that?

 

Dr. David Greuner:

How we breathe is—

 

Dr. Nieca Goldberg:

Everyone’s breathing, David.

 

Dr. David Greuner:

True, but our lungs have what’s called, there’s a residual space in the lungs that is present with every breath, and that’s a fixed capacity. It’s basically, the air capacity in your lungs will not change regardless of the breath. In an average human, it’s about 150 milliliters or ccs. If you take a deep breath of let’s say one liter, which is a very, very deep breath in an average person, and 150 ccs of that is not being used for oxygen exchange. You have a total of about 850 ccs. You take a regular breath, which is probably about 400 ccs, so the 150 ccs of non-oxygen exchange stays the same, but now the percentage of air that you inspired actually contributing to oxygen delivery because it doubles by you taking a deeper breath. Is that easy to understand, or no?

 

Dr. Nieca Goldberg:

Yes. You’re telling us to take a deep breath.

 

Dr. David Greuner:

Yep. Take a deep breath, because by taking a deep breath, you’re increasing the oxygen delivery, not just by the deeper breaths, but by an exponential fashion because the air that’s not actually contributing to oxygenation becomes smaller the deeper your breath is.

 

Dr. Nieca Goldberg:

Smaller percentage. A lot of people never think about how they breathe.

 

Dr. David Greuner:

Yeah. This is a trick that athletes have used for years. Any endurance athletes will tell you same, that they’re trained in breathing techniques, such as belly breathing, etc., and it’s all about increasing your oxygen exchange. When you’re performing at a very high level, these little details make a huge impact on the actual performance of an endurance athlete.

 

Dr. Nieca Goldberg:

You have a practice where people, you said it catered to people who may have these vascular injuries because of extreme exercise and because they are participating in extreme exercise or they’ve lost a lot of weight. What are some of the common complaints or concerns your patients share with you when it comes to exercise?

 

Dr. David Greuner:

Very, very often, I’ll see two types of patients. I’ll see patients that will be the patient that called in, where they will have some sort of issue and then they would have a DVT and now, everything is much worse. A sedentary person, if they had two problems, would be having ulcers and things like that on their leg, or tremendous amount of swelling. Then, the other type of patient we’ll see is somebody that’s lost a lot of weight but can’t progress to the next level because they can’t exercise anymore because they’ve made their vascular issue worse. Or we’ll see somebody that never had an issue, has not sustained a huge amount of weight loss and just had a congenital issue, but they only have a problem because they are so taxing on their body. A marathon runner that had May-Thurner syndrome and runs 50 miles a week, they’ll have issues regardless because they’re demanding so much from their body. It’s really three different areas that we see patients in.

 

Dr. Nieca Goldberg:

I think your own injury has really motivated you to do even more for your patients. What would you say to encourage to our listeners out there to improve their health, David?

 

Dr. David Greuner:

Medicine has gone through such a change in the last 10 years. It’s now not all about preventing mortality. People are focusing tremendously on quality of life now and preventing morbidity. This was a path pioneered by some of the younger doctors of the last 10 years that are focusing more, like yourself, on wellness. It’s the next bastion, I guess, in healthcare that people are trying to reach disease before they ever get to those end stages.

 

Dr. Nieca Goldberg:

Yeah. We hope we can help slow down the process of disease through these lifestyle changes.

 

Dr. David Greuner:

Lifestyle changes and small things. This is a little bit off-topic, but for instance, I had another issue after my spinal surgery where I have an issue with arthritis on one of the joints. Typically, the only option with that was a spinal fusion, but now, I’m able to go to a pain management doctor. He does what’s called a nerve ablation. Just a little nerve supplying my joint, he sticks into a needle and burns it every six months or so and I’m back to normal.

 

Dr. Nieca Goldberg:

That’s great. I’m glad that you could keep up with all this, David, and your practice. We’re running out of time. I want to thank you very much for joining us today.

 

Dr. David Greuner:

Thank you so much for the opportunity. I really appreciate it.

 

Dr. Nieca Goldberg:

Thanks.

 

Dr. David Greuner:

All right. Bye-bye.

 

Dr. Nieca Goldberg:

Bye.

 

 

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