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Featuring Mahmoud Malas, M.D., Assistant Professor of Sugery, Director of Endovascular Surgery at Johns Hopkins Bayview Medical Center
My name is Mahmoud Malas, I’m the director of the Endovascular Surgery at Johns Hopkins Bayview Medical Center. I’m also the director of the Vascular and Endovascular Clinical Research Center at Johns Hopkins Bayview Medical Center.
Peripheral arterial occlusive disease is treated with medical management, minimally invasive endovascular procedure, and surgical intervention. The patients are first advised to quit smoking and are helped with several smoking cessation measures. Another very important aspect of the medical management is to control the patient’s diabetes and to lower their cholesterol.
Exercise is very important and often is the first line of treatment for peripheral arterial occlusive disease. The patients are asked to walk through their pain and monitor their walking distance, and increase that distance gradually over several months. Often, patients are able to improve their walking distance sometimes up to 50%, especially if they are given a scheduled, monitored exercise program.
The surgical intervention has been the gold-standard treatment of peripheral arterial occlusive disease in patients who have failed exercise programs and conservative management. The surgery involves performing a bypass, and what bypass means is simply going around the blocked artery. To utilize a conduit in this bypass, we make every effort here at Hopkins to use your own vein in your leg and sometimes in your arm to go around the blockage. Often, people use a synthetic graft, call PTFE or dacron to perform the bypass. The advantage of using your own vein is that the survival of that graft, which we call the patency of the graft is actually much better if you use your own vein rather than using a synthetic material.
Over the last decade, the endovascular approach became very popular. Endovascular approach means that we can get inside the blood vessels without performing any surgery. The procedure is done percutaneously, utilizing certain catheters. There are several ways we can treat a blocked vessel without performing surgery. One of which is actually utilizing laser to remove the plaque from the blocked artery. The other approach which is very popular is to perform an angioplasty, which is simply utilizing a balloon to dilate the blood vessels. Sometimes we have to place a stent, which is a metal cylinder that helps to keep the blood vessels dilated.
How do we choose between surgery and minimally invasive approach, or endovascular approach, is dependent on our patient risk factors and also on their lesions. Lesions that are very extensive blockages, very long, that involve long segments of the leg often are treated with a bypass. If the lesions are shorter, limited to a small segment of the vessels, we often perform minimally invasive approach with an angioplasty and stent.
Performing a bypass, the patient will be in the hospital for a period of three to five days. They are able to mobilize on the very first day after the surgery and often are able to walk with help within a day or so. And they are able to go home within five days after the surgery. With the minimally invasive approach, the patients often leave the same day, or the next day after the procedure, and are able to do their daily activities almost the first week after the procedure.
It’s important to understand that peripheral arterial occlusive disease is a progressive disease and is not treated permanently with performing a bypass or performing an angioplasty and stent. We realize this here at Hopkins and we understand that the disease also a marker for coronary artery disease, so we always are very interested in the overall wellness of our patients. We follow them, literally, forever. We see them in the clinic. We work very hard on reducing the risk factors of coronary artery disease and trying to minimize the risk of recurrent symptoms. If we perform a bypass or a stent, the disease can actually be progressive and in the future, a patient might have blockages again. We know from many research that we’ve done that good control of smoking, dyslipidemia, diabetes, exercise program, can actually limit the progression of the disease.
What makes Hopkins different is that we have a comprehensive program for treating patients with PAD. We are very interested in the overall well-being of our patients. We understand the strong association between peripheral arterial occlusive disease and coronary artery disease. We are very interested in making the patients a lot better. But more important, we want the patients to live longer. We have a state-of-the-art facility that involves excellent vascular labs where our patients can get very accurate diagnosis without the invasive procedures.