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Centennial Sounding Board |
1 Department of Radiology, Emory University Hospital, 1364 Clifton Rd., N.E., Atlanta, GA 30322.
Received September 23, 1999;
accepted after revision September 23, 1999.
Address correspondence to W. J. Casarella.
Introduction
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The most influential pioneer was Charles Dotter, the innovative, fearless, and audacious late chairman of radiology at the University of Oregon. To read his articles on femoral angioplasty [1], fibrinolytic therapy for vascular thrombosis, embolization of visceral and traumatic hemorrhage, and the development of early balloon catheters, to list a few, was to have a glimpse of the future.
In 1973 angiography was primarily a diagnostic technique that had grown rapidly after the work of Seldinger [2]. Its procedures drew a road map of atherosclerotic vessels for the vascular surgeons. These angiograms were critical in diagnosing and staging most tumors from the brain to the lower extremities. Localization of abscesses, thrombi, traumatic organ damage, vasculitis, and various endocrine hyperplasias and adenomas was securely in the domain of the angiographer. The anatomic data were supplemented by selective venous sampling for parathyroid hormone, renin, insulin, norepinephrine, gastrin, and almost anything else that could be secreted by an offending organ or tumor.
The founding of the Society of Cardiovascular Radiology ("Interventional" was added 5 years later) by a group of 12 individuals led by Stanley Baum in a hotel room in New York during the 1973 Association of University Radiologists meeting provided a focal point for communication at the scientific, social, and educational levels. Later, the Society of Cardiovascular & Interventional Radiology published a successful journal, conducted superb annual meetings, and played a role in fostering research. During its inaugural meeting in 1974 at the Ocean Reef Club in Key Largo, FL, the group found that it had a lot to talk (i.e., argue) about. Durable working relationships and lifelong friendships were formed. No one realized that a specialty was being founded. The great stars of that era—Amplatz, Judkins, Dotter, Baum, Athanasoulis, Abrams, Hawkins, Ring, and White, to name only a few—created whirlwinds of excitement around their presentations that resulted in an unstoppable momentum for the burgeoning specialty. The original 12 grew to 4000 today.
Most of the early interventional procedures centered around the treatment of bleeding and hypervascular tumors [3]. The tools available for angioplasty of arterial occlusions limited the procedure to small peripheral vessels, and many results were not as successful as Dotter's work. Treatment of gastrointestinal or traumatic bleeding depended only on the angiographer's skills to catheterize the specific bleeding vessel and to infuse a vasoconstrictive drug or to position a small pledget of Gelfoam (Upjohn, Kalamazoo, MI). Early success indicated great diagnostic sensitivity and considerable improvement in the management of these patients.
While all this was going on here, momentous events were taking place in Zurich, Switzerland. A young German physician, an escapee from East Germany where he had been designated to become a stonemason by the communist regime, was diligently working in the kitchen of his apartment creating a device that would revolutionize interventional radiology and jump-start interventional cardiology.
Andreas Grüentzig's goal was to devise a method for the percutaneous treatment of coronary artery disease. Instead of the rigid tubes devised by Dotter or the cumbersome "caged" balloon of Porstmann and Dotter, Grüentzig needed a soft, flexible catheter with a very small diameter. It would be guided coaxially to the coronary artery through a larger Judkins-type guiding catheter. This was not an easy feat, given the tools available.
Serendipitously, Grüentzig had a physician's assistant whose husband was a plastics chemist. He suggested that a locally heat-treated sleeve of polyvinyl chloride (PVC) adhering to a polyethylene catheter would do the job. The treated PVC segment, under pressure of injected diluted contrast material, would expand to a cylinder, and it would maintain that shape and size under increasing force, allowing high pressure radial forces to dilate a vessel without overstretching or rupturing it. Because it was easier to work with larger catheters, the first new balloon angioplasties were done in the femoral and iliac vessels with dramatic success [4]. American interventionalists flocked to Zurich where Grüentzig gave freely of his time, his expertise, and his catheters—which would later earn him a small fortune—and trained a group of angiographers with the new balloons for use in the peripheral circulation.
In October 1978 Grüentzig performed the first coronary angioplasty on a Munich policeman with stenosis of the left anterior descending artery and an aversion to surgery [5]. The results were remarkable, and the vessel remains patent today, 21 years later. His results were presented at the Council of Cardiovascular Radiology of the American Heart Association in November 1978. The cardiologists had rejected his abstract on coronary angioplasty in dogs, and the radiologists—aware of his success in the peripheral vessels—accepted it. Word of mouth that indeed six human subjects had been treated preceded the presentation that was witnessed in the relatively small radiology meeting room by an uncontainable throng who, although mostly on their feet to start with, responded with a prolonged standing ovation. Percutaneous transluminal coronary angioplasty (PTCA) has become the most common percutaneous endovascular procedure worldwide and has forever changed the field of cardiology and the treatment of coronary vascular disease.
The interventional radiologists used this development to apply Grüentzig-type balloons to every blood vessel in the body as well as to the biliary tree, the genitourinary and gastrointestinal tracts, arteriovenous fistulas—essentially any tubular organ that was susceptible to stenosis.
The vascular radiologists—some of whom thought their discipline was going to be replaced by the hot new diagnostic techniques of CT and sonography—suddenly experienced a magical renaissance. Their hard-earned catheter skills honed on difficult diagnostic cases now became essential to the performance of major minimally invasive vascular therapy.
Grüentzig, a man who came on the scene as a brilliant rocket, moved to Atlanta, where in 4 short years he established PTCA as a valuable cardiovascular technique. He started the famous National Institutes of Health-funded EAST (Emory Angioplasty versus Surgery Trial) that proved the relative equality of angioplasty and surgery in selected groups of patients. Unfortunately, the rocket was prematurely extinguished in 1985 when his private plane crashed in a storm in Forsyth, GA. However, he left an enduring legacy of accomplishment. He surely lit up the present and inspired the future.
This major breakthrough was followed by a series of significant advances: steerable guidewires; new types of balloons—bigger, smaller, stiffer, softer; digital fluoroscopy; new drugs; better trained radiologists and technologists; and most recently, stents and stent-grafts that are revolutionizing the treatment of vascular disease [6].
As this tremendous growth continued through the 1980s and 1990s, many people were attracted to radiology because it is the home of the vascular-interventional subspecialty. More than 100 fellowship programs in vascular and interventional radiology have been accredited by the Accreditation Council for Graduate Medical Education, with 200 trainees being produced per year. After a long political tussle with surgery and medicine, the American Board of Radiology was able to establish an oral examination that leads to a certificate of added qualification (CAQ) in vascular and interventional radiology. To this day, the radiology-accredited fellowships and CAQs are the only recognized training programs and certifications in vascular and interventional radiology. Even the Health Care Financing Administration accepts vascular and interventional radiology as one of the recognized medical specialities that can generate its own Current Procedural Terminology codes and fee schedules.
In 1994 the first CAQs were given. Certified specialists now number more than 2000, and they continue to increase in number.
Is the future as bright as the past? Will vascular and interventional radiology continue to enrich our specialty and increase its stature and recognition as a leader in innovative therapies? That depends on our resolve to continue to improve our skills and to be at the cutting edge of innovation. It is now clear that endovascular therapy threatens the future of the vascular surgeons and provides an opportunity for the cardiologists to jump on the bandwagon. The good news is that we are more experienced and better trained. We need to develop more clinical skills in order to take a more active role in complete patient care.
The future is bright for interventional radiology. We will continue our leadership position in a field that started primarily in Oregon, crystallized around the Society of Cardiovascular & Interventional Radiology, and developed exponentially for the past 25 years.
We look forward to seeing new candidates for the CAQ in Louisville this year and throughout the next 100 years of the ARRS.
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