Vascular surgery

Mahmoud Malas: “I can say without any
reservation that, as far as vascular surgery
is concerned, we clearly are on the cutting
edge of everything we do."

Bringing research to the operating table

For a patient with a carotid artery blockage, danger lies not only in the blockage itself, but in the risks associated with repairing it. It’s a textbook catch-22: If you don’t remove the plaque build-up from the arterial walls, the patient faces a serious risk of stroke. If you do remove it, but something goes wrong in the process, the patient still faces a serious risk of stroke.

To repair and remove a carotid artery blockage is a major and delicate endeavor. As with any surgery, carotid endarterectomy, has several risks associated with anesthesia, along with bleeding and infection. But the procedure-specific risks are just as dangerous, including nerve damage, heart attack and stroke. The minimally invasive approach, carotid stenting, is done without an incision under local anesthesia. A filter is placed beyond the blockage to capture any debris and reduce the risk of stroke. Sometimes, says vascular surgeon Mahmoud Malas, the obstructed artery is so tight and riddled with plaque that it is impossible to fit even the smallest wire or instrument into the vessel. If, during the course of the procedure, even the tiniest bit of plaque dislodged into the bloodstream, it could flow directly to the brain, causing a stroke.

During the last 10 years, however, an Argentina-based surgeon developed a technique—“It’s really a genius idea,” Malas says—that allows vascular surgeons to actually reverse the flow of blood away from the brain, alleviating the risk of stroke altogether. It’s the cutting edge of vascular surgery, Malas says. It’s also the focus of one of 10 clinical vascular surgery trials he’s currently conducting at Johns Hopkins Bayview Medical Center.

Until five or six years ago, there was little vascular research being conducted at Bayview. But, since joining the hospital’s faculty in 2005, Malas, with the help of research associate Umair Qazi, has been able to open and secure funding for multiple clinical trials.

Bringing Bayview to this point has been a labor fraught with myriad challenges. In the beginning, Malas explains, the hospital had no clinical infrastructure for vascular research. Add to that a paucity of vascular surgery patients, and the institution’s means for clinical research were almost nonexistent. But gradually, with the support of Surgery leaders like Department Director Julie Freischlag, Malas and Qazi have developed a thriving vascular research program. Today, Bayview has 143 patients enrolled in 10 vascular surgery clinical trials—several of which are national and five of which focus on carotid artery disease, putting the hospital at the forefront of vascular research and care. Much of that success, Malas says, can be attributed to the willingness of the patients who participate.

“The beautiful thing about Bayview is the gratitude of its patients and their eagerness to participate in research,” Malas says. “Without them, we wouldn’t be able to do any of this.” As is true in most surgical specialties, vascular patients increasingly expect minimally invasive options, which is another focal point of Malas’ research. He’s also looking at postsurgical outcomes and the use of stents in carotid artery repair, and has trials involving aortic aneurysm treatments.

“We can provide the traditional approach very well,” Malas says. But we also have the newest technology in vascular surgery. And we’re really working to find what’s best for our patients long term, so that they face less risk, recover faster, experience smaller incisions and go home sooner.”

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