HISTORICAL VIGNETTES IN VASCULAR SURGERY Norman M. Rich, MD, Section Editor
Charles Dotter and the fiftieth anniversary of endovascular surgery Steven G. Friedman, MD, New York, NY The field of vascular surgery was born from the pioneering work of cardiac and thoracic surgeons in the 1940s and 1950s. The widespread adoption of intraluminal approaches to treat occlusive and aneurysmal disease led to a radical disruption of the field three decades later. Today, there are few vascular territories outside the reach of endovascular techniques, resulting in a transformation in the way in which patients are treated and practitioners are trained. Vascular surgery has successfully co-opted a large portion of the field of interventional radiology, and it was the work of a single individual that set these events in motion.1 Charles Dotter launched the field of interventional radiology with the case of Laura Shaw. Shaw was an 82year-old woman who was admitted to the University of Oregon Hospital with worsening left leg rest pain and gangrene of the foot. All of Shaw’s physicians, including vascular surgeons, recommended below-knee amputation. Shaw stubbornly refused, and it was only after repeated refusals that Dotter was permitted to see her. An angiogram revealed a focal stenosis of the distal superficial femoral artery, and Dotter was ready to test a dilating catheter that he had spent years developing (Fig 1). On January 16, 1964, he performed the first percutaneous transluminal angioplasty.2 The procedure went well, and Shaw’s foot immediately became hyperemic. Shaw experienced complete relief of her rest pain, and her foot healed during the ensuing months. Dotter was concerned about the durability of his procedure and performed a repeat angiogram 3 weeks later. Not only was his angioplasty patent, but Laura Shaw lived for nearly 3 years more. Before her death, she expressed gratitude for the fact that she was “still walking on my own two feet.” Laura Shaw’s limb-saving procedure was made possible by the collaboration between Dotter and William Cook, From the Department of Surgery, Weill Cornell Medical College. Author conflict of interest: none. Reprint requests: Steven G. Friedman, MD, Department of Surgery, Weill Cornell Medical College, New York, NY 10021 (e-mail: stf3001@med. cornell.edu). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2015;61:556-8 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2014.09.012
556
who founded the medical device manufacturer Cook Group. Dotter had already written many articles dealing with new contrast media, diagnosis of acquired and congenital cardiac lesions, and visualization of the peripheral vascular system.3-5 Dotter realized that he would need highly specialized and manifold catheters to perform intraluminal vascular interventions. He and his laboratory colleagues created these from vinyl wire insulation, guitar strings, and speedometer cables. Dotter discussed mass production of these tools when he met Cook, in 1963, at the Radiological Society of North America meeting in Chicago. Cook recollected: “We discussed wire guide and catheter manufacture and what he thought the future would be for angiography. He became excited when he talked of his work, and yes, we discussed angioplasty. He hauled out the picture of his plumber’s wrenches that we’ve all looked at so many times. Once started, his mind went nonstop.” Two important events in 1963 preceded Dotter’s first angioplasty. While he was studying coronary imaging in cadavers, Dotter realized that forceful injections across diseased areas could disrupt and expand obstructing lesions. He reasoned that it should therefore also be possible to dilate similar lesions in leg arteries. The second event was serendipitous. Dotter was performing an abdominal aortogram to specifically assess the renal arteries when he inadvertently advanced his catheter through an occluded iliac artery. This set him wondering about the possibilities had a balloon been attached to the catheter. Soon after the case of Laura Shaw, Dotter reported good results with 15 angioplasties in 11 lower extremities (Fig 2). He imagined other applications for this new technique: “If its use in femoral disease can be taken as an indication, severe proximal narrowing of the coronary artery will be amenable to a manually guided dilator inserted via aortotomy or via the brachial artery by the Sones technic. Proximal stenosis of the renal, carotid, and vertebral arteries appears suitable for transvascular treatment .. It seems reasonable to expect that the transluminal technique for recanalization will extend the scope of treatment beyond the limits of present-day surgery.” Dotter was the first to describe intravascular stents. He used cyanoacrylate for therapeutic vascular occlusion, and
JOURNAL OF VASCULAR SURGERY Volume 61, Number 2
Fig 1. Original Dotter dilating catheter. (From Friedman SG. Charles Dotter: interventional radiologist. Radiology 1989; 172:921-4. Reprinted with permission from the Radiological Society of North America.)
Fig 2. Charles Dotter. (From Friedman SG. Charles Dotter: interventional radiologist. Radiology 1989; 172:921-4. Reprinted with permission from the Radiological Society of North America.)
he developed techniques and a new array of catheters to snare foreign bodies from the gastrointestinal and vascular systems.6,7 Dotter’s mechanical aptitude was evinced as a child. He was small for his age, so instead of participating in sports
Friedman 557
Fig 3. Dotter’s emblem. (From Friedman SG. Charles Dotter: interventional radiologist. Radiology 1989; 172:921-4. Reprinted with permission from the Radiological Society of North America.)
with his classmates, he preferred to tinker with any gadgets or tools he could get hold of. So motivated was he by tests of mechanical aptitude that he created his own logo to symbolize this passion (Fig 3). Dotter’s boundless enthusiasm and work ethic enabled him to breeze through Duke University as an undergraduate and Cornell Medical College. After medical school graduation, Dotter was an intern at the United States Naval Hospital in St. Albans, NY. Dotter then returned to Cornell for his residency in radiology. He became a Cornell faculty member in 1950, where he performed important research leading to the development of grid-controlled x-ray tubes. At the age of 32, Dotter notched another remarkable achievement when he became the youngest chairman of a radiology department at an American medical school, the University of Oregon. Dotter remained chairman at Oregon for 32 years, during which he produced three scientific training films, published more than 300 manuscripts, and created the medical specialty of interventional radiology. Dotter was diagnosed with Hodgkin disease in 1969. For the previous 2 years, he had ignored axillary lymph nodes, fearing interruption of his work and lifestyle. He scheduled his radiation treatments about his work schedule. Dotter responded to this therapy and celebrated by ascending the Matterhorn guideless, in 1970. Dotter also continued to paint, to take outdoor photographs, and to pursue his love of classical music. He endured a second round of radiation treatment in 1976 for recurrent disease. Dotter’s health continued to decline, however, and in 1979 he underwent a difficult coronary bypass. The following year, he suffered a perforated duodenal ulcer and required emergency surgery. Ever indefatigable, Dotter survived both operations and returned to his daily schedule. Four years later, Dotter required another coronary bypass and mitral valve replacement but was unable to fully recover from this 12-hour
JOURNAL OF VASCULAR SURGERY February 2015
558 Friedman
ordeal. In early 1985, he was readmitted to the hospital for respiratory failure, and he died on February 15. That year was catastrophic for the field as three other pre-eminent interventional radiologists also died: Melvin Judkins, F. Mason Sones, Jr, and Andreas Gruentzig. Dotter received many accolades and awards during his career. Among the most prestigious were gold medals from the American College of Radiology, the Radiological Society of North America, and the Chicago Medical and Radiological Societies. An editor of Year Book Medical Publishers nominated Dotter for the Nobel Prize in Medicine in 1978. Dotter’s death stunned and saddened his colleagues and patients from around the world. Many owed their lives and limbs to him. Dr Leonard Laser, then president of the Oregon Health Sciences University, summarized Dotter’s life best: “Rarely in the course of a medical career is an individual granted the opportunity to alter forever the course of medicine for human good. Charles Dotter was one of those happy few.”
REFERENCES 1. Friedman SG. Charles Dotter: interventional radiologist. In: Friedman SG, editor. A history of vascular surgery. 2nd ed. New York: Blackwell Futura Publishing Co; 2005. 2. Dotter CT, Roesch J, Bilbao MK. Transluminal extraction of catheter and guide fragments from the heart and great vessels: 29 collected cases. Am J Roentgenol Radium Ther Nucl Med 1971;111:467-72. 3. Dotter CT. Urokon sodium 50%, hypaque 50%, renograffin 59.7% for intravenous urography: experimental, clinical comparison. Radiologica 1956;7:12. 4. Dotter CT. Left ventricular and systemic arterial catheterization: A simple percutaneous method using a spring guide. Am J Roentgenol Radium Ther Nucl Med 1960;83:969-84. 5. Dotter CT. Transluminally placed coil-spring endarterial tube grafts: long term patency in canine popliteal artery. Invest Radiol 1969;4: 329-32. 6. Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction. Description of a new technic and a preliminary report of its application. Circulation 1964;30:654-70. 7. Dotter CT, Goldman ML, Roesch J. Instant selective arterial occlusion with isobutyl 2-cyanoacrylate. Radiology 1975;114:227-30.
Submitted Jul 10, 2014; accepted Sep 17, 2014.
Charles Dotter and the fiftieth anniversary of endovascular surgery Steven G. Friedman, MD, New York, NY The field of vascular surgery was born from the pioneering work of cardiac and thoracic surgeons in the 1940s and 1950s. The widespread adoption of intraluminal approaches to treat occlusive and aneurysmal disease led to a radical disruption of the field three decades later. Today, there are few vascular territories outside the reach of endovascular techniques, resulting in a transformation in the way in which patients are treated and practitioners are trained. Vascular surgery has successfully co-opted a large portion of the field of interventional radiology, and it was the work of a single individual that set these events in motion.1 Charles Dotter launched the field of interventional radiology with the case of Laura Shaw. Shaw was an 82year-old woman who was admitted to the University of Oregon Hospital with worsening left leg rest pain and gangrene of the foot. All of Shaw’s physicians, including vascular surgeons, recommended below-knee amputation. Shaw stubbornly refused, and it was only after repeated refusals that Dotter was permitted to see her. An angiogram revealed a focal stenosis of the distal superficial femoral artery, and Dotter was ready to test a dilating catheter that he had spent years developing (Fig 1). On January 16, 1964, he performed the first percutaneous transluminal angioplasty.2 The procedure went well, and Shaw’s foot immediately became hyperemic. Shaw experienced complete relief of her rest pain, and her foot healed during the ensuing months. Dotter was concerned about the durability of his procedure and performed a repeat angiogram 3 weeks later. Not only was his angioplasty patent, but Laura Shaw lived for nearly 3 years more. Before her death, she expressed gratitude for the fact that she was “still walking on my own two feet.” Laura Shaw’s limb-saving procedure was made possible by the collaboration between Dotter and William Cook, From the Department of Surgery, Weill Cornell Medical College. Author conflict of interest: none. Reprint requests: Steven G. Friedman, MD, Department of Surgery, Weill Cornell Medical College, New York, NY 10021 (e-mail: stf3001@med. cornell.edu). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2015;61:556-8 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2014.09.012
556
who founded the medical device manufacturer Cook Group. Dotter had already written many articles dealing with new contrast media, diagnosis of acquired and congenital cardiac lesions, and visualization of the peripheral vascular system.3-5 Dotter realized that he would need highly specialized and manifold catheters to perform intraluminal vascular interventions. He and his laboratory colleagues created these from vinyl wire insulation, guitar strings, and speedometer cables. Dotter discussed mass production of these tools when he met Cook, in 1963, at the Radiological Society of North America meeting in Chicago. Cook recollected: “We discussed wire guide and catheter manufacture and what he thought the future would be for angiography. He became excited when he talked of his work, and yes, we discussed angioplasty. He hauled out the picture of his plumber’s wrenches that we’ve all looked at so many times. Once started, his mind went nonstop.” Two important events in 1963 preceded Dotter’s first angioplasty. While he was studying coronary imaging in cadavers, Dotter realized that forceful injections across diseased areas could disrupt and expand obstructing lesions. He reasoned that it should therefore also be possible to dilate similar lesions in leg arteries. The second event was serendipitous. Dotter was performing an abdominal aortogram to specifically assess the renal arteries when he inadvertently advanced his catheter through an occluded iliac artery. This set him wondering about the possibilities had a balloon been attached to the catheter. Soon after the case of Laura Shaw, Dotter reported good results with 15 angioplasties in 11 lower extremities (Fig 2). He imagined other applications for this new technique: “If its use in femoral disease can be taken as an indication, severe proximal narrowing of the coronary artery will be amenable to a manually guided dilator inserted via aortotomy or via the brachial artery by the Sones technic. Proximal stenosis of the renal, carotid, and vertebral arteries appears suitable for transvascular treatment .. It seems reasonable to expect that the transluminal technique for recanalization will extend the scope of treatment beyond the limits of present-day surgery.” Dotter was the first to describe intravascular stents. He used cyanoacrylate for therapeutic vascular occlusion, and
JOURNAL OF VASCULAR SURGERY Volume 61, Number 2
Fig 1. Original Dotter dilating catheter. (From Friedman SG. Charles Dotter: interventional radiologist. Radiology 1989; 172:921-4. Reprinted with permission from the Radiological Society of North America.)
Fig 2. Charles Dotter. (From Friedman SG. Charles Dotter: interventional radiologist. Radiology 1989; 172:921-4. Reprinted with permission from the Radiological Society of North America.)
he developed techniques and a new array of catheters to snare foreign bodies from the gastrointestinal and vascular systems.6,7 Dotter’s mechanical aptitude was evinced as a child. He was small for his age, so instead of participating in sports
Friedman 557
Fig 3. Dotter’s emblem. (From Friedman SG. Charles Dotter: interventional radiologist. Radiology 1989; 172:921-4. Reprinted with permission from the Radiological Society of North America.)
with his classmates, he preferred to tinker with any gadgets or tools he could get hold of. So motivated was he by tests of mechanical aptitude that he created his own logo to symbolize this passion (Fig 3). Dotter’s boundless enthusiasm and work ethic enabled him to breeze through Duke University as an undergraduate and Cornell Medical College. After medical school graduation, Dotter was an intern at the United States Naval Hospital in St. Albans, NY. Dotter then returned to Cornell for his residency in radiology. He became a Cornell faculty member in 1950, where he performed important research leading to the development of grid-controlled x-ray tubes. At the age of 32, Dotter notched another remarkable achievement when he became the youngest chairman of a radiology department at an American medical school, the University of Oregon. Dotter remained chairman at Oregon for 32 years, during which he produced three scientific training films, published more than 300 manuscripts, and created the medical specialty of interventional radiology. Dotter was diagnosed with Hodgkin disease in 1969. For the previous 2 years, he had ignored axillary lymph nodes, fearing interruption of his work and lifestyle. He scheduled his radiation treatments about his work schedule. Dotter responded to this therapy and celebrated by ascending the Matterhorn guideless, in 1970. Dotter also continued to paint, to take outdoor photographs, and to pursue his love of classical music. He endured a second round of radiation treatment in 1976 for recurrent disease. Dotter’s health continued to decline, however, and in 1979 he underwent a difficult coronary bypass. The following year, he suffered a perforated duodenal ulcer and required emergency surgery. Ever indefatigable, Dotter survived both operations and returned to his daily schedule. Four years later, Dotter required another coronary bypass and mitral valve replacement but was unable to fully recover from this 12-hour
JOURNAL OF VASCULAR SURGERY February 2015
558 Friedman
ordeal. In early 1985, he was readmitted to the hospital for respiratory failure, and he died on February 15. That year was catastrophic for the field as three other pre-eminent interventional radiologists also died: Melvin Judkins, F. Mason Sones, Jr, and Andreas Gruentzig. Dotter received many accolades and awards during his career. Among the most prestigious were gold medals from the American College of Radiology, the Radiological Society of North America, and the Chicago Medical and Radiological Societies. An editor of Year Book Medical Publishers nominated Dotter for the Nobel Prize in Medicine in 1978. Dotter’s death stunned and saddened his colleagues and patients from around the world. Many owed their lives and limbs to him. Dr Leonard Laser, then president of the Oregon Health Sciences University, summarized Dotter’s life best: “Rarely in the course of a medical career is an individual granted the opportunity to alter forever the course of medicine for human good. Charles Dotter was one of those happy few.”
REFERENCES 1. Friedman SG. Charles Dotter: interventional radiologist. In: Friedman SG, editor. A history of vascular surgery. 2nd ed. New York: Blackwell Futura Publishing Co; 2005. 2. Dotter CT, Roesch J, Bilbao MK. Transluminal extraction of catheter and guide fragments from the heart and great vessels: 29 collected cases. Am J Roentgenol Radium Ther Nucl Med 1971;111:467-72. 3. Dotter CT. Urokon sodium 50%, hypaque 50%, renograffin 59.7% for intravenous urography: experimental, clinical comparison. Radiologica 1956;7:12. 4. Dotter CT. Left ventricular and systemic arterial catheterization: A simple percutaneous method using a spring guide. Am J Roentgenol Radium Ther Nucl Med 1960;83:969-84. 5. Dotter CT. Transluminally placed coil-spring endarterial tube grafts: long term patency in canine popliteal artery. Invest Radiol 1969;4: 329-32. 6. Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction. Description of a new technic and a preliminary report of its application. Circulation 1964;30:654-70. 7. Dotter CT, Goldman ML, Roesch J. Instant selective arterial occlusion with isobutyl 2-cyanoacrylate. Radiology 1975;114:227-30.
Submitted Jul 10, 2014; accepted Sep 17, 2014.
