Brian Gruber: Dr. Thomas Maldonado you are vascular surgeon at NYU Medical Center. What is NYU known for in your particular area in terms of leadership and research and practice?
Dr. Thomas Moldanado: 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 for intervening minimally invasive limbs, specifically with Endovascular stent-grafts for aneurysm repair for Carotid disease and lorostremy disease. My role on faculty here is to promote many of these trials, to lead them, to involve with teaching and treat patients clinically.
Brian Gruber: How does your research area intersect with your practice as a physician?
Dr. Thomas Moldanado: Well, the research that's involved really is clinical research. It's clinical trials primarily and what we do is we involve patients with clinical trials. We have a unique ability to involve them because many of these devices are not available to all comers, for instance, in the community many patients will have aneurysms that perhaps are not amendable to endovascular repair by standard devices, but we have access to unique devices and that's something that we are able to offer patients.
Brian Gruber: So what is an Aortic aneurysm?
Dr. Thomas Moldanado: An aneurysm by definition is a ballooning or a bulge if you will of any artery in the body in the order which happens to be the largest part in the body, that blood vessel when it gets larger than two to three centimeters becomes aneurismal. And that can be quite dangerous. When an aneurysm develops, it can go on to rupture or burst and is a fatal event. The threshold that we watch for really is five centimeters or 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, back pain, chest pain if it's in the thorax in the chest. But more often than not they are asymptamatic and are found routinely on the screen when in X-ray or a CAT scan. And so most people don't know they have them.
Brian Gruber: Why are they dangerous?
Dr. Thomas Moldanado: If they do go on to rupture it's often times a fatal event, it's something that could be unpredictable and the name of the game is to catch them before they rupture.
Brian Gruber: So who is most susceptible to developing an aortic aneurysm?
Dr. Thomas Moldanado: There is certainly high risk categories of people, people who are predisposed to developing would be elderly people age 70, 65, 70. Males have a predisposition certainly. Anyone with a first degree relative has a higher risk of developing such an aneurysm, someone who has a first degree relative who has had an abdominal aneurysm also can develop one. High blood pressures start to also lead to being prone to aneurysm development. These are all high risk categories, but certainly anyone can develop an aneurysm and it's important to be aware of the symptoms and to be aware of the treatment options.
Brian Gruber: How have you seen the medicine and the practice in this area changed since you originally came to NYU?
Dr. Thomas Moldanado: Well, it's really been a revolution. We used to perform this surgery was a large surgery a large operation requiring a big incision from top to bottom to repair the abdominal aneurysm, and numerous days in the ICU and then another five to seven days in the hospital. Recovery was quite lengthy lot of blood loss. And now it has become essentially an overnight stay, to repair what was once a lethal condition that required numerous days in the hospital, with minimally invasive approach, we can repair this in a number of hours with minimum blood loss. Sometimes the patient can even be awake without general anesthesia just some local anesthesia and they can return to their normal activity within a couple of days and home the next day. So it's really remarkable what this technology and has provided for patient care.
Brian Gruber: Then how does that technology develop, is it a few doctors who brainstorm and do all the research and practice some trials or is there a sort of a an ecosystem of various industrial organizations, various universities, philanthropists how does work in this kind of an area advance so rapidly as it has here at the Medical Center and worldwide?
Dr. Thomas Moldanado: I think it's a combination as most success stories, it's the combination of having a fertile ground to work in 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 four FDA approved devices for repair of abdominal aneurysms, Endovascular stent-grafts and these industry partners are very, very important in the cooperation and in the advancement of these technologies. So we here at NYU for instance have numerous relationships with numerous of these partners and in some instances run clinical trials for them, in other instances put training courses for own for them. I happened to put a training course on for Latin American batch, there were surgeons and cardiologists who visit once a month, about 10 of them and we give them live case demonstration, they had active sessions and this is all sponsored in large part by industry. So partnership with industry becomes critical. That's one component. Certainly the the brightest and the best minds being at the right the place and cross pollinating with the with one another also becomes critical. Support form administration, philanthropy as you brought up also becomes important. But really sometimes it's just one person having a seminal idea that takes off. Endovascular aortic aneurysm repair first in first occurred 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, they were not operative candidates, they were going to die of this condition and he took a leap faith and developed and indigenous device that was able to exclude the aneurysm and repair them and save their lives and that's what really prompted this whole revolution to take off.
Brian Gruber: How would you characterize, if you could, the distinction between a highly productive medical academic institution that is pushing out these kinds of advances on a regular basis versus one that is not? Are there certain dynamics and certain things that you can point to that offer distinction in that in that manner?
Dr. Thomas Moldanado: Yes, I think it's the infrastructure, the University well it happened to be a world renowned university here at NYU that has multiple sub-specialties and departments that are very academically prolific and pioneers in each of their respective fields. We have a tremendous amount of cross pollination between these departments. We have strong support by our administration, the deans and the faculty. And I think that being at New York University in Manhattan, in one of the capitals of the world, is a magnet for patients and I think that this is really also enable us to to grow our vision and to really develop a lot of these technologies. It's why industry comes to us, we are constantly being quoted by industry and I think that's what all the rest of this were success.
Brian Gruber: So, an industry quotes you how do you work out the conflict between the commercial and profit orientation of those industrial partners and the research, academic and medical orientation of those at medical centers such as NYU?
Dr. Thomas Moldanado: Because the principal investigators for these clinical trials are all the physicians and clinicians at the major Universities, so we are the ones directing the clinical trials, we are the ones designing the clinical trial and we are the one's troubleshooting and and keeping it as safe. So while certainly as is any true in any industry there is money to be made by by industry patient safety and patient you know, well being come first and I think that is why these industry partners are being so successful, because they recognize that.
Brian Gruber: Is the United States a leader in this area and whether it is or not or are there other world leaders that are emerging in another parts of the world?
Dr. Thomas Moldanado: Absolutely, I think the United States is a leader. However I will tell you that elsewhere in the world, in Europe, in South America as I mentioned, some of the real thinkers, movers and shakers are all over the 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 faculty members 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 interact with all the other leaders in the world.
Brian Gruber: Yeah. So how is an aortic aneurysm diagnosed?
Dr. Thomas Moldanado: It's usually an incidence of finding, something found by chance on a CAT scan performed for other reasons, 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 discovered because of symptoms, it's clearly more worrisome. This could be symptoms of abdominal chest or back pain. Some aneurysms which have a little clot inside can spill some of the clot downstream and what we call embolization occurs. This can lead to pain or black toes or the blue toe syndrome is actually the name the proper name. And these symptoms are worrisome because they are ominous in that it can lead the next step from here is rupture. And as I mentioned if someone were to rupture an aneurysm at home, certainly the mortality for that is upwards of 80 percent. Someone who makes it to the 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 this disease process and intervening when appropriate. Screening for this disease really occurs for the patient population 65 or 70 and above. Now Medicare has allowed for reimbursement of one initial screening for all new Medicare recipients aged 65. So someone who turns 65 tomorrow can come and yet an Ultrasound test for free, covered by Medicare, for the purpose of screening for abdominal aneurysm. This is a very important new legislation that allows us to detect aneurysms earlier.
Brian Gruber: Can the condition be treated?
Dr. Thomas Moldanado: The condition can be treated. Traditionally the first treatment in 1950 was an open big operation, where of the aneurysm was excluded or essentially repaired by sowing a prosthetic tube made of polyester, A Dacron graft, from one part of the order down below to the more distant part normally order. As I mentioned 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 groin that accomplish the same thing much more clinically with much lower less recovery time, and with the same results.
Brian Gruber: So what is that the Chief of Vascular Surgery at the Bellevue Hospital does on a daily basis?
Dr. Thomas Moldanado: What I do want to do on a daily basis, it depends on the day. But for the most part I'd see patients in the office. I operate quite a bit. Endovascular is one of my specialties, both for aneurysms, for clotted disease, for blockages in legs, claudication and peripheral arterial disease. I do a lot of varicose vein procedures and surgery. A lot of that also is minimally invasive, with very small little punctures, needle punctures, the varicose veins and then I do a whole lot of teaching. We have one of the leading fellowship programs here in the United States for vascular surgery. It's a two year program. We also have quite a successful general surgery residency program, and we do a lot of teaching for those as well as the medical students and the students. And at Bellevue Hospital, which is as you may know the largest and oldest public hospital in the country, public city hospital; we I spent quite a bit of time there administratively as a Director of Vascular Surgery there and take care of most of the New York City indigent and less advantaged population.
Brian Gruber: One final question, what do you love most about what you do?
Dr. Thomas Moldanado: I think what I love most about what I do and what I really allows me to come to work everyday, eager enthusiastic to really to be part of such an exciting time in vascular surgery. The technology is just surging 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 what vascular surgery has become. It has become a minimally invasive field; that is quite rewarding.
Brian Gruber: Dr. Maldonado thanks very much for your time.
Dr. Thomas Moldanado: Thank you.
