Melanie Cole, MS (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field.

I'm Melanie Cole. And today, our discussion is focusing on the AHN Vascular Surgery Program. Joining me is Dr. Satish Muluk. He's a vascular surgeon at the AHN Cardiovascular Institute, and he's the Director of Vascular Surgery at the Allegheny Health Network. Dr. Muluk, it's such a pleasure to have you join us today. I'd like you to start by telling us a little bit about the AHN Vascular Surgery Program, the conditions that you treat. Tell us a little bit about it.

Dr. Satish Muluk: Of course. First, thank you for having me. It's a pleasure be here. The AHN Vascular Surgery Program is a very broad-based program that deals with the entire spectrum of vascular surgery problems. And I know most of your listeners know what vascular surgery is, but just to briefly explain, it's anything to do with the surgery upon blood vessels whether it's arteries or veins, sometimes even lymphatics. And we deal with the whole spectrum, ranging from things like carotid artery stenosis, aortic aneurysms, or aortic dissection. We also deal with lower extremity blockages, sometimes called peripheral vascular disease.

And then, there are some rarer conditions of arteries. So for example, blockage in the renal arteries or arteries that supply the bowel, the mesenteric arteries, or even upper extremity conditions. But basically, any place in the body that has a blood vessel is a place that we can intervene if there's pathology, if there's a problem. And then, there's the whole issue of venous disease. Patients who develop varicose veins or DVT or deep venous thrombosis or other pathologies of the venous system, we deal with those as well.

And there's some kind of related conditions we deal with. For example, if people need dialysis access, that's something that we often will help with by surgically creating an arteriovenous fistula so that they can get dialysis. And then, there's a condition called thoracic outlet syndrome where artery, vein, or nerves can be compressed in the thoracic outlet. And we're often called upon to help those patients often by doing surgical decompression of the thoracic outlet.

Melanie Cole, MS: Wow, it's certainly a comprehensive program, really taking care of a wide variety of vascular disorders. So, what's exciting, Dr. Muluk, in your field? How do you see any procedures within your division, current emerging therapies? Tell us about some of the latest or most exciting advances in use right now.

Dr. Satish Muluk: One of the things I always tell my residents is that at least 60% of the cases I do now I did not learn in residency. And that just speaks to how much evolution and ongoing evolution there is in the field of Vascular Surgery. It's changing every day, and new procedures are on the horizon even as we speak. So, it's really exciting. For me, it's been an awesome experience of learning and doing new things. It's never boring. That's for sure.

If you look at one of the exciting things right now, I would say that one of the very exciting things is our ability to deal with more and more complex aortic aneurysms through minimally invasive strategies, through strategies that don't require major incisions and big operations. And that involves a graph that have very sophisticated kind of branches that allow us to deal with the complex aneurysms. Strategies like a laser fenestration where we can make holes in existing grafts and supply blood to vessels that otherwise would be cut off from blood supply. And those technologies are allowing us to do less invasive treatment of aortic aneurysms.

At the same time, we really do pride ourselves at Allegheny Health Network on being able to do open surgery and do it well. There are just still a group of patients, whether it's aortic aneurysms or other vascular conditions, where being able to do open surgery is still the right answer. And we really pride ourselves on doing that at a high level with good a result as we can get in those difficult patients. So, that's one area, aortic aneurysm's definitely evolving because of complex strategies to get minimally invasive solutions.

Another very exciting area is carotid disease. Carotid endarterectomy has been the standard of care for carotid stenosis for many years, gosh, dating back into the 1960s. But over the last I'd say 10 years, we've been at the forefront of using a new strategy called a TCAR or transcarotid artery revascularization. And that allows us to place a stent to treat carotid artery disease by making a small incision at the base of the neck. And that procedure has really helped us do carotid treatment not non-invasively, if there's still an incision involved, but less invasively than traditional carotid endarterectomy and with excellent outcomes. So, those are two important areas.

There's also another area we've been working with recently about lower extremity revascularization. And there are two new really exciting things on the horizon, both of which we've already started working on. One is called the detour bypass. That's for patients who need a femoral popliteal bypass, a very traditional long-standing operation in vascular surgery, usually done by open surgical technique. But this new technology allows us to do that bypass without actually making an incision because we actually puncture from artery into vein in the groin and then track our graft through the femoral vein and then reconnect it back to the artery below the blockage around the level of the knee. So, we're really constructing a femoral popliteal bypass, but doing it entirely by a minimally invasive or percutaneous technique.

And then, there's even a more recent strategy of what we call deep vein arterialization, where some patients have such terrible blockages that there's really no artery to plug into down near their foot. And we can't restore blood flow in many of those patients in the past. We just have undergone amputation below the knee or above the knee even. But now, we can revascularize to one of the veins in the legs. This is actually remarkable. You would think that delivering arterial blood flow into a vein in the foot doesn't do any good for the patient, but we can break up some of the valves in those veins and actually force the arterial blood to get down into the tissues through the venous pathway. So, this is called a deep vein arterialization. And there's new technologies that are allowing us to do that. So, as you can see, really exciting stuff in multiple spheres of multiple subsets of vascular surgical procedures.

Melanie Cole, MS: Wow. What an exciting time in your field. And Dr. Muluk, I can hear your passion and excitement for all of these technologies. Absolutely fascinating. One of the important things in your field is the multidisciplinary management, working with other providers in this interdisciplinary way for your patients. Tell us what that looks like for your team at the Vascular Surgery Program at AHN.

Dr. Satish Muluk: We really work closely with other specialties here at Allegheny Health Network. I think there's actually a long tradition at AHN of doing that, not just within Vascular Surgery, really across the board. Let me give you some examples.

When we do complex aortic aneurysm treatment, we work very closely with our cardiac surgeons. Because many of those patients have aneurysms that extend up into the chest or into the aortic arch or sometimes into the ascending aorta. And working with the cardiac surgeons basically allows us to do more very effectively, safely, jointly, that's been a tremendous experience. When we do lower extremity procedures, like I mentioned, you know, those bypasses or deep vein arterialization, we work very closely with our foot and ankle surgeons, sometimes orthopedic surgeons, sometimes foot and ankle specialists. And that's been a really great collaboration, because they can help us a lot with dealing with issues in the foot like whether it's infection or complex bony operations that have to be done to treat wounds down there. And then, we work on the improvement of the arterial blood flow and they work on the actual soft tissue problems in the foot itself. Another kind of collaboration that's worked very well.

We also have a lot of patients that present with chronic wounds. That's one of the areas that vascular surgeons deal with, but not alone. We have a wound center that's actually run by our Vascular Medicine colleague that allows us to have optimal wound care done by the wound center. And then, the vascular surgeon's responsibility is figure out a way to deliver good blood flow to that extremity to allow the wound to heal. And both are very important. You need oxygen to allow wounds to heal, but you also need optimal local wound care to have those wounds healed. So, those are just three examples of the kind of collaboration we do with the colleagues here at AHN.

Melanie Cole, MS: And Dr. Muluk, speak about the geographic scope of the AHN Vascular Surgery Team. With care close to home, multiple locations so that patients don't have to travel and even speak about televisits or how that has helped with this Vascular Surgery Program.

Dr. Satish Muluk: Yeah, you hit upon a key topic for us, because we want to deliver the appropriate care in a way that's as convenient as possible for the patients. Some of them have transportation difficulty and nobody likes to travel unnecessary long distances to get their care, right? So if you just look at our hospitals, of course, Allegheny General Hospital, our quaternary care flagship hospital, if you will, is located on the north side of Pittsburgh. But we also have Forbes Hospital, which is located out east in Monroeville. We have West Bend Hospital, which is located in the Bloomfield area. And we have vascular surgeons at all three of those hospitals, by the way. And we also have vascular surgeons up at Wexford Hospital up north. And although we don't have Vascular Surgery presence regularly, we are able to go out and see patients at Canonsburg Hospital and at Allegheny Valley Hospital as well. And that's just the hospitals.

We also have outpatient clinics that are in the vicinity of every one of these hospitals so the patients don't necessarily need to come to the hospital building itself. For example, we have a facility down in Peters Township and then one out further east from Monroeville, near the Westmorland area. And that's just the Pittsburgh metropolitan area. We also have two vascular surgeons in our group up at St. Vincent Hospital in Erie. And they're extremely busy, and that has a whole different catchment area up there.

The point is that we want to be able to see patients and deliver care over a wide geography to make it easier for the patients to get that care without traveling a long distance.

Melanie Cole, MS: Well, that certainly is a patient-centered program. And all of the highlights that you've given us here today, Dr. Muluk, really are so exciting. I'd like you to speak as a summary, what your vision for this program, how will this care model that you've discussed here today improve the way patients receive their care, their journey and patient outcomes and change the way that they receive care for related conditions. Because as you mentioned, many times when there's vascular disorders, there are other comorbid conditions. You mentioned wounds that usually goes with diabetes, that sort of thing. So, tell us about how this program brings all of that together and what your vision is for the future.

Dr. Satish Muluk: At the heart of our mission is to deliver the right care with the right use of resources, and not just, you know, deliver that care and deliver it with the proper amount of resources, but also be very vigilant about our outcomes. And we do pride ourselves on that. We monitor outcomes very closely. That's not just lip service. We actually enter a lot of our case data into the vascular quality initiative, which is a national database that allows us to look at our results and benchmark our results against other centers that are similar to ours.

And by doing that, we seek continuous quality improvement is the term I'd use that we deliver what we think is the best care. But then, because we look at our results, we want to continually improve ourselves as well. It's not enough just to think that one is delivering good care, the responsible surgeons are the ones who really look at their data and then change your practice accordingly

Melanie Cole, MS: And the outcomes speak for themselves. And Dr. Muluk, thank you so much. I so appreciate your passion and compassion. I can just hear it in your voice and really thank you for sharing your incredible expertise with us today. And to learn more or to refer a patient to Dr. Muluk, please call 844-MD-REFER, or you can visit ahn.org. Thank you so much for listening to this edition of AHN MedTalks with the Allegheny Health Network. I'm Melanie Cole. Thanks so much for joining us today.