Cath Lab Digest

On September 7, 1990, Dr. Juan C. Parodi and his team at the Instituto Cardiovascular de Buenos Aires (ICBA, Buenos Aires, Argentina) treated the first endovascular AAA patient. The aneurysm was excluded endoluminally with a Dacron graft that was anchored at the proximal infrarenal neck with a stainless steel balloon-expandable stent. The system was assembled by affixing (with sutures) the fabric tube to an undeployed stent mounted on a large-diameter angioplasty balloon. The contraption was then sheathed inside a large-bore catheter that served as the delivery system. Access to the aorta for delivery and deployment was achieved in a retrograde transluminal fashion through the surgically exposed common femoral artery. It worked, resulting in exclusion and depressurization of the large aneurysm in a patient who had been deemed an unsuitable candidate for standard surgical repair. Much work, experimentation and design preceded the launch of the clinical program. And while the initial few patients in the series were treated using a similar approach (Figure 1), subsequent technical iterations and modifications (Figures 2 and 3) became necessary as lessons were learned with rapidly mounting clinical experience.^[1,2]

Unbeknown to anyone in the Western world at the time, the Ukrainian surgeon Nicholas Volodos had performed endovascular repair of a traumatic-origin thoracic aortic aneurysm as early as 1986.[3] Many years passed before knowledge of such a feat reached this side of the then-prevailing East-West divide. But this and other developments in the U.S. and elsewhere notwithstanding, it was Parodi’s initial clinical experience with endovascular treatment of AAA that became the driving force and stimulus for the truly explosive growth in interest, creativity and investment that followed throughout the 1990s and beyond. Resisted by many surgeons initially, it was to become the most potent agent of change for a specialty that was about to transform itself — dramatically and irreversibly.

In many ways similar to the impact (on cardiology and cardiac surgery) of Gruentzig’s first coronary angioplasty procedure of 1977, Parodi’s initial clinical AAA experience in Buenos Aires went on to become far more than just a new technique or an innovative approach for treatment of a relatively common serious disease. Beyond that, it opened a huge window into a whole new universe… and became, together with other disruptive innovations, one of the pillars of an entirely new way of thinking, practicing and caring for patients. The impact continues to be felt today when a new generation of vascular surgeons and vascular and interventional specialists look upon endovascular treatment and technologies as the very center of their professional career. Endovascular is now mainstream! And the time-honored “conventional” surgical approaches are quickly fading in prominence and frequency.

Will open surgery go away altogether one day soon? The answer is a resounding NO, but it is undeniable that its role has diminished, as it has in many other areas of medicine. Less invasion is the future, if not the obvious present already! And a sign of the overwhelming power of this evolution is the universal embrace we see today from patients, the public at large and physicians everywhere.

References
1. Parodi JC. Endoluminal treatment of arterial diseases using a stent-graft combination: Reflections 20 years after the initial concept. J Endovasc Surg 2007;4:3–4.
2. Parodi JC, Barone A, Piraino R, et al. Endovascular treatment of abdominal aortic aneurysms: Lessons learned. J Endovasc Surg 2007;4:102–110.
3. Volodos NL, Karpovich IP, Troyan VI, et al. Clinical experience of the use of self-fixing synthetic prostheses for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction. Vasa 1991;33:93–95.

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Dr. Frank J Criado is a Board-Certified Vascular Surgeon and Endovascular Specialist at the Union Memorial Hospital-MedStar Health in Baltimore, Maryland – USA.

Dr. Criado is widely acknowledged to be a pioneer in endovascular therapy, with a 20-year + interventional experience. He has contributed extensively to the literature with more than 100 peer-reviewed published articles — mostly on various vascular and endovascular subjects, and Editor-in-Chief of Vascular Disease Management (VDM). He has also been active in clinical research, with a major focus on aortic stent-graft and carotid interventions, and endovascular technologies in general. He was the National Principal Investigator (P.I.) for the Medtronic Talent AAA clinical trials in the U.S., and a member of the Executive Committee for the Medtronic Valor Thoracic trial.

He is a founding member and immediate past President of the International Society of Endovascular Specialists (ISES), founder and current President of the endovascular surgery society of Latinamerica (CELA), and a member of all major US and international vascular and endovascular societies. He is a Fellow of the American College of Surgeons (FACS) and of the Society of Vascular Medicine (FSVM), and a member of the Board of Directors of the Society for Vascular Surgery (SVS).