Top Docs Q&A: Lawrence Garcia

This post is part of our Top Docs Q&A series where we ask a physician who was selected as one of our Top Docs questions about their field, life as a doctor, and practicing in the Greater Boston area.

Name: Lawrence Garcia

Hospital Affiliation: St. Elizabeth’s Medical Center

Title: Chief of Interventional Cardiology and Vascular Medicine

Field: Cardiology

Specialty: Interventional Cardiology

Peripheral artery disease (PAD) is a common condition in which a buildup of plaque in the arteries restricts blood flow to one’s head, organs, or limbs, according to the NIH. In recognition of PAD Awareness Month, we spoke with Lawrence Garcia, an interventional cardiologist who recently co-led a clinical trial on the use of a minimally invasive procedure to treat the disease.

Why did you choose to specialize in interventional cardiology?

A benefit of being an interventional cardiologist is that you can open up and re-vascularize territories through catheter-based interventions. In the past all we had was surgical re-vascularization, whether it be bypass for the coronary circulation or abdominal procedures or leg bypasses for the abdominal aorta and the lower extremity arteries. Being able to do that seemed a more attractive and a less morbid procedure, which allows you to effectively treat a lot more patients with the least amount of risk.

What do you like most about the field?

The ability to re-vascularize territories in short fashion without having to do surgery is what’s probably most attractive to the field. More importantly, it allows you to provide the science as a backdrop of what we do and why we do it. You can talk more intelligently to your patients and provide important insight as to why they should choose certain therapies.

In the time you’ve been practicing, how have you seen the field change?

In training, I saw a huge shift away from standard medical therapy for patients with acute coronary syndromes and heart attacks to the catheter-based therapies. It was intriguing to be a part of that whirlwind change and see it progress over the years. I’ve seen it all. I’ve seen what’s old become new again, and I’ve seen what’s old again is out.  Trials are so useful because they’re the first insights into the scientific evidence so you can say to a patient, “This device will work, so it’s the best choice for you.”

What are the latest advancements in the field?

Beyond stents and atherectomy, there are two new devices. One is a medicated stent with very good data, which came out about four to five years ago. More recently have been the drug-coated balloon trials. The same drugs that we have in the heart to prevent restenosis are now being used in a balloon. The angioplasty dilates the artery and leaves little pockets of the drug. You take the balloon out and the artery can heal itself.

What is your hope for the future of interventional cardiology?

I look forward to a one-and-done done approach for those with PAD or coronary disease. In addition to genomic and proteonomic-tailored therapy through pharma, that’s the future of treating coronary artery disease. The same thing has to happen for vascular disease. Beyond getting better data sets and comparator trials, the future will be drug delivery through balloon or other technology as well as pharma genomic and proteonomic directed therapies so patients can have individualized therapy that lasts a lifetime.

You co-led Definitive LE, a clinical trial on using directional atherectomy, a catheter-based technology that removes plaque from clogged veins, to treat PAD. What prompted it?

There is a lack of data on PAD therapies. Along with industry, [my co-investigators James Mckinsey , Thomas Zeller, and I] put together a trial to formally assess the outcomes of atherectomy for patients with claudication, which is crampy legs when you walk, and critical limb ischemia. We wanted to examine the genomic and proteonomic expressions of genes in the atheroma to determine if diabetics and non-diabetics had any differences. We also pre-specified that diabetics would do equally as well as non-diabetics. That’s something no other trial has done.

What did you find?

The trial provided the first scientific proof in a large-scale study of the outcomes of atherectomy. In the claudicant group, the primary finding was that the overall patency at 12 months was 78 percent. The diabetic patient and the non-diabetic patient were the same at the end of 12 months. For critical limb patients, we had an amputation-free survival rate of 95 percent at the end of 12 months. Below the knee, what nobody has ever shown, are patency rates of around 90 percent. We do exceedingly well with atherectomy as a first-line therapy for patients with claudication and critical limb ischemia.

What does this mean for patients?

When you have a problem with a leg artery where you can’t walk well or you produce an ulcer, atherectomy with the secondary therapy being angioplasty works very well and gives you a very durable outcome. Should that device fail over 12 months, your doctor has every opportunity to treat you with whatever he feels he can because he hasn’t burned a bridge with any other device by using an upfront atherectomy approach. That’s huge when it comes to cost containment and ability to re-treat patients.

What’s next for research?

Definitive was a 3-part study. The first was Definitive Calcium. We did Definitive LE, which was the [second and] largest of these trials. The third part tries to marry the atherectomy with drug-coated balloons, the latest advancement. There was a pilot study called Definitive AR which looked at atherectomy followed by an adjunctive balloon angioplasty with a medicated balloon to see if that provided incremental benefit to patients with claudication or calcific disease. That trial should be presented this year.

Final thoughts?

This trial is the first step to providing scientific guidance for this type of therapy and giving physicians some help as to how best to treat their patients. We’re at a critical mass. You have a ton of devices which are FDA-approved, but none have compared themselves to another. Let’s start testing these devices against each other and see where the truth lies. That would be the next great thing for our patients and for us scientifically.