Thomas Maldonado, MD
Dr Thomas Maldonado discusses Abdominal Aortic Aneurysms in an interview at NYU Medical Center. This program is part of FORA.tv's NYU Medical Center Wellness Series.
Dr. Thomas Maldonado, M.D. is a Vascular Surgeon at NYU Medical Center. He is now an Assistant Professor of Surgery at NYU, specializing in vascular and endovascular surgery. He is also Chief of Vascular Surgery at Bellevue Hospital. He is well published in the basic science and clinical literature and has won numerous awards in the General and Vascular Surgery national societies.
Dr. Maldonado has a particular interest in endovascular surgery, including carotid and abdominal aortic endograft stent procedures, as well as minimally invasive treatment of varicose veins and is currently the Course Director for the NYU Endovascular Surgery Training Symposium attended monthly by Latin American Vascular Surgeons. He is bilingual, and speaks Spanish fluently.
Dr. Thomas Maldonado
Dr. Thomas Maldonado is an Assistant Professor of Surgery at NYU specializing in vascular and endovascular surgery and Chief of Vascular Surgery at Bellevue Hospital. He is the course director for the NYU Endovascular Surgery Training Symposium attended monthly by Latin American vascular surgeons.
Dr. Maldonado has clinical interests in endovascular surgery, including carotid and abdominal aortic endograft stent procedures, and in minimally invasive treatment of varicose veins.
Dr. Maldonado is well published in basic science and clinical literature and has won numerous awards from general surgery and vascular surgery national societies.
Dr. Thomas Maldonado you are vascular surgeon at NYU Medical Center. What is NYU known for inyour particular area in terms of leadership and research and practice?NYU is a unique institution; it consists of Tisch Hospital, Bellevue Hospital and the Veterans Hospital.And in the field of vascular surgery, we have really pioneered many of the new techniques forintervening minimally invasive limbs, specifically with Endovascular stent-grafts for aneurysm repairfor Carotid disease and lorostremy disease. My role on faculty here is to promote many of thesetrials, to lead them, to involve with teaching and treat patients clinically.How does your research area intersect with your practice as a physician?Well, the research that's involved really is clinical research. It's clinical trials primarily and what we dois we involve patients with clinical trials. We have a unique ability to involve them because many ofthese devices are not available to all comers, for instance, in the community many patients will haveaneurysms that perhaps are not amendable to endovascular repair by standard devices, but we haveaccess to unique devices and that's something that we are able to offer patients.So what is an Aortic aneurysm?An aneurysm by definition is a ballooning or a bulge if you will of any artery in the body in the orderwhich happens to be the largest part in the body, that blood vessel when it gets larger than two to threecentimeters becomes aneurismal. And that can be quite dangerous. When an aneurysm develops, it cango on to rupture or burst and is a fatal event. The threshold that we watch for really is five centimetersor so. So we look for this growth of an aneurysm with routine surveillance, ultrasounds or CAT scans.The way these these aneurysm is going to present is either with symptoms such as belly pain, backpain, chest pain if it's in the thorax in the chest. But more often than not they are asymptamatic and arefound routinely on the screen when in X-ray or a CAT scan. And so most people don't know they have them.Why are they dangerous?If they do go on to rupture it's often times a fatal event, it's something that could be unpredictable andthe name of the game is to catch them before they rupture.So who is most susceptible to developing an aortic aneurysm?There is certainly high risk categories of people, people who are predisposed to developing would beelderly people age 70, 65, 70. Males have a predisposition certainly. Anyone with a first degreerelative has a higher risk of developing such an aneurysm, someone who has a first degree relative whohas had an abdominal aneurysm also can develop one. High blood pressures start to also lead to beingprone to aneurysm development. These are all high risk categories, but certainly anyone can develop ananeurysm and it's important to be aware of the symptoms and to be aware of the treatment options.How have you seen the medicine and the practice in this area changed since you originally came to NYU?Well, it's really been a revolution. We used to perform this surgery was a large surgery a largeoperation requiring a big incision from top to bottom to repair the abdominal aneurysm, and numerousdays in the ICU and then another five to seven days in the hospital. Recovery was quite lengthy lot ofblood loss. And now it has become essentially an overnight stay, to repair what was once a lethalcondition that required numerous days in the hospital, with minimally invasive approach, we can repairthis in a number of hours with minimum blood loss. Sometimes the patient can even be awake withoutgeneral anesthesia just some local anesthesia and they can return to their normal activity within acouple of days and home the next day. So it's really remarkable what this technology and hasprovided for patient care.Then how does that technology develop, is it a few doctors who brainstorm and do all the research andpractice some trials or is there a sort of a an ecosystem of various industrial organizations, variousuniversities, philanthropists how does work in this kind of an area advance so rapidly as it has here atthe Medical Center and worldwide?I think it's a combination as most success stories, it's the combination of having a fertile ground to workin be that with partners and industry be that be administration.One example would be the industry partners that make the devices. So some of these there are fourFDA approved devices for repair of abdominal aneurysms, Endovascular stent-grafts and these industrypartners are very, very important in the cooperation and in the advancement of these technologies. Sowe here at NYU for instance have numerous relationships with numerous of these partners and insome instances run clinical trials for them, in other instances put training courses for own for them. Ihappened to put a training course on for Latin American batch, there were surgeons and cardiologistswho visit once a month, about 10 of them and we give them live case demonstration, they had activesessions and this is all sponsored in large part by industry. So partnership with industry becomescritical. That's one component. Certainly the the brightest and the best minds being at the right theplace and cross pollinating with the with one another also becomes critical. Support formadministration, philanthropy as you brought up also becomes important. But really sometimes it's justone person having a seminal idea that takes off. Endovascular aortic aneurysm repair first in firstoccurred in 1991 in Argentina by a fellow named Juan Parodi and this person really decided to try,intervene on patients who had no surgical options due to their high risk, I am being more tidy, theywere not operative candidates, they were going to die of this condition and he took a leap faith anddeveloped and indigenous device that was able to exclude the aneurysm and repair them and save theirlives and that's what really prompted this whole revolution to take off.How would you characterize, if you could, the distinction between a highly productive medicalacademic institution that is pushing out these kinds of advances on a regular basis versus one that isnot? Are there certain dynamics and certain things that you can point to that offer distinction in that in that manner?Yes, I think it's the infrastructure, the University well it happened to be a world renowned universityhere at NYU that has multiple sub-specialties and departments that are very academically prolific andpioneers in each of their respective fields. We have a tremendous amount of cross pollination betweenthese departments. We have strong support by our administration, the deans and the faculty. And Ithink that being at New York University in Manhattan, in one of the capitals of the world, is a magnetfor patients and I think that this is really also enable us to to grow our vision and to really develop alot of these technologies. It's why industry comes to us, we are constantly being quoted by industry andI think that's what all the rest of this were success.So, an industry quotes you how do you work out the conflict between the commercial and profitorientation of those industrial partners and the research, academic and medical orientation of those atmedical centers such as NYU?Because the principal investigators for these clinical trials are all the physicians and clinicians at themajor Universities, so we are the ones directing the clinical trials, we are the ones designing the clinicaltrial and we are the one's troubleshooting and and keeping it as safe. So while certainly as is anytrue in any industry there is money to be made by by industry patient safety and patient youknow, well being come first and I think that is why these industry partners are being so successful,because they recognize that.Is the United States a leader in this area and whether it is or not or are there other world leaders thatare emerging in another parts of the world?Absolutely, I think the United States is a leader. However I will tell you that elsewhere in the world, inEurope, in South America as I mentioned, some of the real thinkers, movers and shakers are all overthe world. And one of the nice things about New York is that we are able to attract these people here.We have conferences that we host. And the feat Symposium French Meet is one of our facultymembers here in Manhattan, is one of the largest vascular surgery conferences world wide annually.We have been sponsored as a part of NYU and this is something that that allows us to really interactwith all the other leaders in the world.Yeah. So how is an aortic aneurysm diagnosed?It's usually an incidence of finding, something found by chance on a CAT scan performed for otherreasons, on Ultrasound performed for other reasons, someone has some belly pain, from gallstones,they do an Ultrasound and find the one behold the large aneurysm. When it's occurs or is discoveredbecause of symptoms, it's clearly more worrisome. This could be symptoms of abdominal chest orback pain. Some aneurysms which have a little clot inside can spill some of the clot downstream andwhat we call embolization occurs. This can lead to pain or black toes or the blue toe syndrome isactually the name the proper name. And these symptoms are worrisome because they are ominous inthat it can lead the next step from here is rupture. And as I mentioned if someone were to rupture ananeurysm at home, certainly the mortality for that is upwards of 80 percent. Someone who makes it tothe door in the emergency room with a ruptured aneurysm has a 50-50 chance of success or or being saved.So this all speaks to importance of good careful screening and of staying half a step ahead of thisdisease process and intervening when appropriate. Screening for this disease really occurs for thepatient population 65 or 70 and above. Now Medicare has allowed for reimbursement of one initialscreening for all new Medicare recipients aged 65. So someone who turns 65 tomorrow can come andyet an Ultrasound test for free, covered by Medicare, for the purpose of screening for abdominalaneurysm. This is a very important new legislation that allows us to detect aneurysms earlier.Can the condition be treated?The condition can be treated. Traditionally the first treatment in 1950 was an open big operation, whereof the aneurysm was excluded or essentially repaired by sowing a prosthetic tube made of polyester, ADacron graft, from one part of the order down below to the more distant part normally order. As Imentioned this a quiet a large operation with a lot more I believe mortality, but life saving, nowadays,we have minimally invasive ways as I described with small incisions or even per containers in the grointhat accomplish the same thing much more clinically with much lower less recovery time, and with the same results.So what is that the Chief of Vascular Surgery at the Bellevue Hospital does on a daily basis?What I do want to do on a daily basis, it depends on the day. But for the most part I'd see patients inthe office. I operate quite a bit. Endovascular is one of my specialties, both for aneurysms, for clotteddisease, for blockages in legs, claudication and peripheral arterial disease. I do a lot of varicose veinprocedures and surgery. A lot of that also is minimally invasive, with very small little punctures, needlepunctures, the varicose veins and then I do a whole lot of teaching. We have one of the leadingfellowship programs here in the United States for vascular surgery. It's a two year program. We alsohave quite a successful general surgery residency program, and we do a lot of teaching for those as wellas the medical students and the students. And at Bellevue Hospital, which is as you may know thelargest and oldest public hospital in the country, public city hospital; we I spent quite a bit of timethere administratively as a Director of Vascular Surgery there and take care of most of the New YorkCity indigent and less advantaged population.One final question, what do you love most about what you do?I think what I love most about what I do and what I really allows me to come to work everyday, eagerenthusiastic to really to be part of such an exciting time in vascular surgery. The technology is justsurging ahead. It's having incredible impact on patient care, it's the bottom line is its helping people,make it through their life with safely and with as minimal complications with surgery, that's whatvascular surgery has become. It has become a minimally invasive field; that is quite rewarding.Dr. Maldonado thanks very much for your time.Thank you.