A History of Vascular Surgery - part 10 pot

Dotter attended grammar school, where he skipped a grade, and high school in Freeport and was an excellent student.. Dotter rarely served a mechanical device or machine without contempla

Charles Dotter: interventional

a successful stock trader and his mother was an aspiring actress

Dotter attended grammar school, where he skipped a grade, and high school

in Freeport and was an excellent student Dotter was always small for his ageand eschewed competitive sports He turned to mountain climbing as an outletfor his boundless energy and displayed an early mechanical aptitude Dotterderived great satisfaction from working with tools and adopted his own sketch

of a plumber’s tools to symbolize his interest (Figure 22.1) Dotter rarely served a mechanical device or machine without contemplating other uses for it.After graduation from high school in Freeport, Dotter attended Duke Uni-versity He received a bachelor of arts degree in 1941 Dotter returned to NewYork to attend medical school at Cornell, where he met his future wife, PamelaBattie She was a head nurse at New York Hospital and they were married in

ob-1944 Dotter completed his internship at the United States Naval Hospital in St.Albans, New York, and his radiology residency at New York Hospital

In 1950, Dotter became a full-time member of the Cornell University MedicalCollege faculty That year he developed an automatic x-ray roll-film magazinecapable of producing two images per second This became the prototype for thegrid-controlled x-ray tube Two years later, Dotter was appointed Professor andChairman of the Department of Radiology at the University of Oregon MedicalSchool At age 32, he was the youngest person to become chairman of a radiology department in a major American medical school He held the positionfor 32 years, during which he published over 300 manuscripts, produced three scientific training films, and created a new medical specialty: interventional radiology

By the early 1960s, Dotter had written more than 100 articles, many dealingwith the diagnosis of acquired and congenital cardiac lesions, developing newcontrast media, and describing new ways to visualize the peripheral vascularsystem Dotter realized, however, that the key to a new medical specialty basedupon endovascular interventions was the manufacture of catheters of variousshapes and sizes Dotter and his laboratory technicians used blow torches to fab-ricate catheters from speedometer cables, guitar strings, and vinyl cable insula-tion Dotter lacked a reliable means of mass production of wires and catheters

Enter Bill Cook In 1963, Dotter met Cook at the Radiologic Society of NorthAmerica meeting in Chicago Cook later recalled their meeting:

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.

Cook visited Dotter at his lab in Oregon and viewed his sketches of

telescop-ic catheters From these, the first Dotter dilatation set was produced, setting thestage for the first percutaneous transluminal angioplasty Two more importantevents preceded this

In 1963, Dotter conducted a postmortem study of the feasibility of coronaryradiography and endarterectomy He noted that forceful intraluminal hy-draulic injections through stenotic areas led to an increase in flow across theselesions Dotter reasoned that local catheter dilatation might have therapeuticvalue in cases of lower extremity ischemia due to focal stenoses He believed therisk of distal embolization was slight and that percutaneous transluminal di-latation could be a simple and valuable technique

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Figure 22.1 Dotter’s emblem.

The second important event in 1963 was an accident During an abdominalaortogram in a patient with renal artery stenosis, Dotter inadvertently recanal-ized an occluded right iliac artery He immediately pondered the possibilitieshad a balloon been attached to the catheter.

Laura Shaw was 82 years old when she was admitted to the University ofOregon Hospital with gangrene and rest pain of the left foot All of her physicians had recommended an amputation, including her vascular surgeon.When Shaw refused surgery, her vascular surgeon asked Dotter to see her

An angiogram revealed a focal stenosis of the superficial femoral artery and Dotter realized he had the ideal lesion with which to test his dilatingcatheter (Figure 22.2) On January 16, 1964, Dotter performed the first percuta-neous transluminal angioplasty The procedure went well and Shaw’s foot became hyperemic Her rest pain disappeared and within a few months her foot was healed An angiogram performed 3 weeks later demonstrated a patent angioplasty; interventional radiology was born Laura Shaw died of

Figure 22.2 Original Dotter dilating catheter (courtesy of Mrs Enid Ruble).

congestive heart failure nearly 3 years later, “still walking on my own two feet.”Later in the year, Dotter reported good results with 15 angioplasties in 11 lowerextremities (Figure 22.3) He was prescient of other applications for this newtechnique:

206 Chapter 22

Figure 22.3 Charles Dotter (courtesy of Mrs Enid Ruble).

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’s powerful innovation initially received more interest in Europe thanthe United States, owing to the excellent results obtained in preliminary trials ofthis technique abroad European radiologists referred to percutaneous translu-minal angioplasty as “Dottering” (Figure 22.4)

Dotter pioneered other areas of interventional radiology He developedcatheters with which to retrieve foreign bodies from the vascular and gastro-intestinal systems In 1972, he described a new method for control of acute gas-trointestinal bleeding: selective arterial embolization Dotter described the use

of cyanoacrylate for therapeutic vascular occlusion and he was the first to ploy intra-arterial fibrinolytic agents The original description of intravascularstents was also Dotter’s

em-Despite the appearance of enlarged lymph nodes in his axilla in 1967, Dottercontinued his practice and research, and his outdoor pursuits (Figure 22.5).Until he began suffering night sweats 2 years later, Dotter brooked no inter-ruption of his work schedule A biopsy revealed Hodgkin’s disease, and Dotter

Figure 22.4 Pioneers of interventional radiology: Egerhardt Zeitler (left), Andreas Gruentzig

(center), and Charles Dotter (right) (courtesy of Mrs Enid Ruble).

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Figure 22.5 Charles Dotter rock climbing in central Oregon in 1968 (reproduced with permission

simply arranged his radiation therapy around his clinical responsibilities Heresponded well to therapy, worked throughout, and celebrated by climbing theMatterhorn, without a guide, in 1970 Dotter eventually scaled all 67 peaks ex-ceeding 14 000 feet in the continental United States He also continued his inter-est in painting, photography, classical music, and hiking with his wife and theirthree children Dotter suffered a recurrence of Hodgkin’s disease in 1976, andworked throughout a second course of radiation therapy.

Health problems continued to plague Dotter, and his frenetic daily scheduledid not help In 1979, while backpacking in the Wallowa mountains in easternOregon, he experienced exertional dyspnea In April 1979, Dotter underwent aquadruple coronary bypass, from which he made a slow recovery In February

1980, Dotter survived surgery for a perforated duodenal ulcer and was soonback to teaching, practice, and the outdoors

Dotter’s love of nature, mechanical aptitude, and his simple approach toproblems are all displayed in a letter he wrote to a friend in 1982 Dotter had longbeen interested in the plight of California’s condors and he had visited SantaBarbara on several occasions to observe these birds Several condor eggs hadbeen lost by rolling off the edge of a particular cliff where the birds nested Dotter conceived a solution and immediately wrote and telephoned the author-ities to effect it (Figure 22.6)

Dotter received many awards during his career, including gold medals fromthe Radiologic Society of North America, the Chicago Medical Society, and theChicago Radiological Society, in 1981 He received an American College of

Figure 22.6 Dotter’s solution to lost condor eggs (reproduced with permission from Friedman SG.

Charles Dotter: Interventional radiologist Radiology 1989; 172:921).

Radiology gold medal 2 years later The greatest indication of the regard for Dotter by his peers was his nomination, by an editor of Year Book Medical Publishers, to receive the Nobel Prize in Medicine in 1978 (Figure 22.7).

Dotter’s health failed again in 1983, when he developed recurrent angina anddyspnea on exertion In August 1983, he underwent repeat coronary bypass,and mitral valve replacement The operation lasted 12 hours, and not even Dot-ter could fully recover from such an ordeal He was unable to resume work andhis condition slowly deteriorated During the ensuing months, Dotter was cared

210 Chapter 22

Figure 22.7 Charles Dotter (courtesy of Mrs Enid Ruble).

for at home by his wife and daughter, both nurses In 1985, a tragic year for thefield of radiology, Dotter was readmitted to the hospital for respiratory failure,from which he died on February 15 In that year, three other preeminent interventional radiologists also died: Melvin Judkins, F Mason Sones, Jr., andAndreas Gruentzig.

Dotter’s death evoked an outpouring of praise and sorrow from patients andphysicians around the world (Figures 22.8 and 22.9) Dotter changed the prac-tice of medicine and had an indelible impact upon those who met him Millions

of patients owe their lives and limbs to Dotter’s innovations Dr Leonard Laser,then president of the Oregon Health Sciences University, summarized Dotter’slife best:

Figure 22.8 Letter of sympathy from a patient who had undergone bilateral iliac dilations

(reproduced with permission from Friedman SG Charles Dotter: Interventional radiologist.

Radiology 1989; 172:921).

212 Chapter 22

Figure 22.9 Letter of sympathy from Dr I Rabkin of the Soviet Union (reproduced with permission

from Friedman SG Charles Dotter: Interventional radiologist Radiology 1989; 172:921).

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.

Bibliography

Bilbao MK, Krippaehne WW, Dotter CT Catheter retrieval of foreign body from the

gastro-intestinal tract AJR 1971; 111:473.

Dotter CT Urokon sodium 50%, hypaque 50%, renograffin 59.7% for intravenous urography:

experimental, clinical comparison Radiologica 1956; 7:12.

Dotter CT Left ventricular and systemic arterial catheterization: a simple percutaneous

method using a spring guide Am J Roentgenol 1960; 83:969.

Dotter CT Transluminally placed coil-spring endarterial tube grafts: long term patency in

canine popliteal artery Invest Radiol 1969; 4:329.

Dotter CT, Judkins MP Transluminal treatment of arteriosclerotic obstuction Description of a

new technic and a preliminary report of its application Circulation 1964; 30:654.

Dotter CT, Steinberg I The diagnosis of congenital aneurysm of the pulmonary artery N Engl J Med 1949; 240:51.

Dotter CT, Steinberg I Advances in angiocardiography Med Clin North Am 1950; 34:745.

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 1971; 111:467.

Dotter CT, Goldman ML, Roesch, J Instant selective arterial occlusion with isobutyl

Gruentzig AR, Hopff H Perkutaene rekanalisation chronischer arterieller verschluess mit

einem neuen dilatationskatheter Dtsch Med Wschr 1974; 99:2502.

Gruentzig AR, Kumpe DA Technique of percutaneous transluminal angioplasty with the

Gruentzig balloon catheter Am J Roentgenol 1979; 132:547.

Gruentzig AR, Myler RK, Hanna ES, et al Coronary transluminal angioplasty (abstract) Circulation 1977; 56(Suppl II):319.

Johnston KW, Rae M, Hogg-Johnston SA, et al 5-year results of a prospective study of neous transluminal angioplasty Ann Surg 1987; 206:403.

percuta-Katzen BT, Change J, Knox G Percutaneous transluminal angioplasty with the Gruentzig

balloon catheter Arch Surg 1979; 114:1389.

Niles NR, Dotter CT Coronary radiography and endarterectomy Postmortem study of

feasibility of surgery Circulation 1963; 28:190.

Porstmann W Ein neuer korsett-ballonkatheter zur transluminalen rekanalisation nach Dotter

unter besonderer beruecksichtigung von obliterationen an den beckenarterien Radiol Diagn

1973; 14:239.

Porstmann W, Wierny L Intravasale rekanalisation inoperabler arterieller obliterationen

Zentralbl Chir 1967; 92:1586.

Roesch J, Dotter CT, Brown MJ Selective arterial embolization: a new method for control of

acute gastrointestinal bleeding Radiology 1972; 102:303.

Sanborn TA, Greenfield AJ, Guben JK, et al Human percutaneous and intraoperative laser thermal angioplasty – Initial clinical results as an adjunct to balloon angioplasty J Vasc Surg

C H A P T E R 2 3

Thomas Fogarty

214

Wine comes in at the mouth

And love comes in at the eye;

That’s all we shall know for truth

Before we grow old and die.

(William Butler Yeats)

Thomas Fogarty was born in Cincinnati, Ohio, on February 25, 1934 He

attend-ed Catholic grade school and was an average student When Fogarty was 10years old his father died, forcing him to begin delivering newspapers and mowing lawns to help make ends meet In the eighth grade, Fogarty beganworking in the central supply department of Good Samaritan Hospital Fogartyremained at Good Samaritan during his attendance at Roger Bacon HighSchool, eventually becoming a scrub technician It was in this role that he met Dr.Jack Cranley, an eminent vascular surgeon of that time

As a teenager, Fogarty preferred boxing and riding motorcycles to studying.One of his friends owned a Cushman motor scooter with a treacherous gearbox.When shifting from a high to low gear the scooter would accelerate wildly, oftenpropelling the rear passenger into the street Fogarty and his friend developed acentrifugal clutch to ease the transition between gears, and Cushman eventual-

ly adopted it as their own At the age of 16, Fogarty learned the value of a patentthe hard way (Figure 23.1)

Fogarty performed poorly in high school and had difficulty obtaining mendations for college His principal commented that it would be an enormouswaste of money and effort for any college to accept him Nevertheless, in 1952Fogarty entered Xavier University under probation Contrary to predictions, hedid well and graduated with honors While he was a premedical student, Foga-rty worked nights and weekends for tuition money and self-support

recom-Following college graduation, Fogarty entered The University of CincinnatiCollege of Medicine where he continued to work with Cranley During his highschool years, while working as an operating room scrub technician, Fogarty hadnoticed that embolectomies were cumbersome procedures and they were oftenunsuccessful They were performed using suction catheters, saline flushes, localremoval via multiple arteriotomies, vein strippers, corkscrew devices, andmilking with Esmarch bandages The variety of techniques used underscoredthe absence of a reliable one Fogarty surmised there should be a better way toperform embolectomies, but he had no time to develop alternative methodsuntil he was in medical school There he began tinkering with latex gloves andureteral catheters in an effort to design an efficient clot-removal device