|Year : 2020 | Volume
| Issue : 4 | Page : 429-431
Curiosity is the mother of invention: Guidewires and catheters
Department of Vascular and Endovascular Surgery, Care Outpatient Centre, Hyderabad, Telangana, India
|Date of Submission||07-Dec-2020|
|Date of Acceptance||07-Dec-2020|
|Date of Web Publication||24-Dec-2020|
Department of Vascular and Endovascular Surgery, Care Outpatient Centre, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sharma P. Curiosity is the mother of invention: Guidewires and catheters. Indian J Vasc Endovasc Surg 2020;7:429-31
A routine day for an endovascular surgeon starts with cannulating the artery with a needle and then passing a guidewire followed by a catheter to perform balloon angioplasty, stenting, or any related endovascular procedure. It is something natural and a routine process that the present era of endovascular surgeons grew up with. However, these techniques have evolved over a period of time, and the history of various diagnostic and therapeutic innovations to treat the spectrum of vascular diseases by percutaneous route is exciting. It is also interesting to know how all the innovators persevered despite the ridicule from their peers and wisely exploited serendipitous observations that were way ahead of their time.
| Angiography|| |
Human race has always been curious, and this curiosity has unleashed an array of medical innovations. In 400 BC, cardiac valve function was studied in cadavers using catheters made from hollow reeds and pipes. In 1711, Hales conducted the first cardiac catheterization of horse using brass pipes, a glass tube, and the trachea of a goose. A young German surgical resident Werner Forssmann in 1929 manipulated a surgical nurse Gerda Ditzen to attempt cardiac catheterization. Tying her to the table, Forssmann quickly anesthetized his own antecubital fossa while deceiving the nurse to prepare her elbow for a cut down. Forssmann quickly performed the cut down on his left elbow and inserted a ureteral catheter to its full length of 65 cm inside. He then released the angry deceived nurse and ordered her to follow him to the X-ray room in the basement, where he documented the catheter's position in his right atrium. He mentioned that the length of the catheter was not sufficient for further advancement into the heart. It is recorded that Forssmann stopped his self-experiments only when he had used all his veins with 17 cut downs. This electrifying work by Forssmann was ridiculed by the medical fraternity and he was vilified as a dangerous quack. In 1941, at Bellevue Hospital, Richard and Cournard used modified radiopaque urethral catheters to study right heart physiology. In 1956, they shared Noble Prize with Forssmann for their landmark work, and Cournand in his acceptance speech mentioned that “the cardiac catheter was Key to the lock.”
| Percutaneous Intervention – Seldinger Technique|| |
The concept of arteriography was accepted with some reluctance. Peripheral arteries such as femoral, radial, and carotid were surgically exposed to place injecting needles. Jonson in Stockholm introduced coaxial needles in common carotid artery, directing them downward. After the inner needle was removed, a silver thread with a blunt tip was carefully inserted into the outer cannula and pushed beyond the carotid and innominate arteries into the aorta. The introduction of this co-axial puncture technique was one of the major breakthroughs to minimize arterial injury during the arteriography. However, a safe method to avoid surgical placement of suitable catheter was lacking. An enterprising young radiologist, Seldinger, at the Karolinska Institute in Stockholm, came up with a path-breaking solution for this problem. Dr. Seldinger thought of fitting a needle into the end of the catheter through the side hole so that he can introduce the catheter and remove the needle afterward. He observed that the catheter was not rigid enough and needed some support so that it can be easily advanced into the blood vessel. This is how the discovery of guidewire happened to support the advancement of the catheter. Dr. Seldinger while working on the puncturing technique in his lab was holding the needle, the guidewire, and the catheter. He was wondering about the right way to use it to minimize the damage to the vessel. At this time, “common sense” struck him and he invented the Seldinger technique of percutaneous arterial cannulation (1976) [Figure 1].
| Percutaneous Transluminal Angioplasty|| |
Constant refining of the available methods of catheterization techniques were in progress. In 1963, Dotter inadvertently recanalised an occluded right iliac artery by introducing a percutaneous catheter retrograde through the occlusion while performing an abdominal aortogram for a renal artery stenosis patient. Dotter immediately realized the potential therapeutic importance of this serendipitous discovery. Dotter did studies on cadaveric peripheral arteries and used sequential dilators and balloon-mounted catheters to augment recanalization of stenosed vessels snowplow effect. On January 16, 1964, Dotter and Judkins performed the first intentional transluminal dilatation in a 82-year-old woman who had gangrene due to left popliteal artery stenosis. Dotter passed a guidewire through the stenosis that was dilated with double, coaxial rigid polyethylene catheters. This method of recanalization known as “Dotter technique” was similar to the treatment of urethral stricture by Egyptians in 300 BC. However, this technique was crude, cumbersome, and risky as it involved the need to introduce large-bore, rigid dilators percutaneously and then apply large shear force to dilate the stiff atherosclerotic vessels in addition to jeopardizing the branch vessels simultaneously due to snowplow effect. Several investigators made attempts to improvise Dotter's technique. Staple TM in 1968 used sequential large, single dilators with taper ends, and Zeitler et al. added two side holes for contrast injection. The introduction of dilating balloon to the catheter for vascular intervention was a crucial step as it made the entire system more flexible and smaller to work via radial forces rather than by shear forces. The first therapeutic balloon-tipped catheter of any kind was devised by Arnott in 1819 and improvised by Reybard in 1855, which was used to dilate urethral strictures. In the 1950s, Gianturco had constructed a latex balloon-tipped catheter for peripheral angioplasty, but did not use it in patients till 1971. Around the same time, Fogarty had introduced a latex balloon-tipped catheter for removal of vascular emboli (1963). Dotter et al. devised a woven fiberglass sheath-reinforced latex balloon-tipped catheter in 1966, however he noticed that bare latex was too compliant to exert sufficient radial forces on rigid plaque. In 1971, Gianturco successfully dilated a femoral artery using a polyolefin electrical shrink tubing, however the patient died that night from an access-site complication. Portsmann in 1973 improvised Dotter's technique and used “Korsett” catheter consisting of a latex balloon surrounded by a catheter with Teflon struts to form a cage. Later, in 1974, Dotter improvised Porstmann's balloon by creating latex balloon catheters caged with woven fiberglass and then by Teflon struts.
The technically adroit specialists were evolving their techniques and a critical turning point occurred when Andreas Gruentzig stepped to the fore. After a rotating internship and a research fellowship in epidemiology, Gruentzig began studying peripheral vascular disease in Germany under the direction of Eberhardt Zeitler. One of the Gruentzig's patients asked him whether it was possible to “clean” his obstructed arteries like a plumber cleans tubes using wire brushes. This was the moment when he started thinking about therapeutic vascular interventions. Gruentzig learned Dotter technique of transluminal angioplasty from Zeitler and started performing peripheral and renal arterial recanalization at Darmstadt Hospital in 1969 and at University Hospital in Zurich in 1971. Gruentzig had seen Porstmann latex balloon with a slotted angiographic catheter and started working to make a perfect catheter that would provide a nondistensible balloon. He used to work in his kitchen with his assistant, Maria Schlumpf, and her husband, Walter, and tested many versions of balloons by attaching them with thread and epoxic glue to diagnostic catheters. Initially, he used a silk mesh to entrap the expanding balloon. Hopf, an emeritus professor of chemistry in Zurich, suggested the use of polyvinyl chloride for making the balloon, instead of latex. Gruentzig formed aneurysmal segments within the polyvinyl chloride (PVC) tubings by using heat molding and compressed air [Figure 2][Figure 3]. Due to the inbuilt strength of PVC, the silk mesh for external constraint was not required. A hole was punctured in the catheter to facilitate balloon inflation from the main lumen. To prevent the escape of fluid from the end of catheter, an occlusion stylet was passed end to end to block the catheter during balloon inflation. On February 12, 1974, he used this single-lumen device to perform the first of numerous human balloon peripheral angioplasties in a patient's superficial femoral artery. However, this assembly was bulky and large and in 1975, he developed a coaxial system with a channel between the diagnostic catheter and the PVC tube for balloon inflation. This invention of double-lumen catheter was a stepping stone in improvising the technique of balloon angioplasty. All of Gruentzig's catheters were made at night or on weekends in his kitchen as no company was willing to make it. In 1976, Schneider (Minneapolis, MN, USA) and Cook Company decided to make double-lumen catheters. The proximal lumen was used for rigid balloon inflation up to balloon pressure of 6 atm; the distal lumen was used for pressure monitoring and contrast injection.
|Figure 2: Top to bottom – Single, tapered Dotter catheter_coaxial Dotter catheter system_slotted expanding Porstmann catheter_and early coaxial Gruentzig design|
Click here to view
Dotter in his first article in 1964 had envisioned the application of balloon angioplasty in atherosclerotic vessel that was translated into clinical application by Gruentzig within a little more than a decade. This was one of the best early examples of translational medicine in recent medical history.
| Angioplasty Equipment|| |
Similar to the ongoing refinement in double-lumen catheter, there was great interest in improving guide catheters. Earlier, the double-lumen device had guidewire directly attached to the end of balloon. The stiff wire made steering and negotiating through narrow areas of the vessel extremely difficult and dangerous too. Techniques were developed to direct the guide catheter selectively into the target artery to achieve an adequate platform for passage of a large-profile balloon catheter, to achieve an adequate backup platform to cross-tight lesions with these high-profile catheters, for exchanging guide catheters and for shaping the catheters to enter bent or unusual anatomy vessels. This led to the discovery of soft tipped catheters by Van Tassel et al. In 1982, due to the constant urge by Greuntzig, companies started making steerable guidewires. In the 1980s, Japanese company Terumo Corporation made a multilayered composite structure glidewire. This nitinol core and hydrophilic-coated, soft, flexible-tip glidewire was able to traverse total occlusions and could cross difficult arteries when nothing else would work!
In conclusion, in spite of failures and ridicule by many, all the charismatic innovators continued to keep the internal flame of curiosity burning, that, led to the present-day endovascular procedures safe and successful.
You of all people must know how wide the gap between the IDEA + THE Gadget. It's the latter which pays off.
– Charles T. Dotter, M. D.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]