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HISTORICAL VIGNETTE
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 69-71

Arthur B. Voorhees, Jr.: Inventor of prosthetic vascular graft – A birth centennial tribute


1 Department of Vascular and Endovascular Surgery, Starcare Hospital, Kozhikode, Kerala, India
2 Department of General Surgery, Trivandrum Medical College, Thiruvanthapuram, India
3 Department of Anesthesia, Baby Memorial Hospital, Kozhikode, Kerala, India

Date of Submission23-May-2021
Date of Acceptance24-May-2021
Date of Web Publication30-Aug-2021

Correspondence Address:
Sunil Rajendran
Department of Vascular and Endovascular Surgery, Starcare Hospital, Kozhikode, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_57_21

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How to cite this article:
Rajendran S, Sreekumar R C, Chandran J. Arthur B. Voorhees, Jr.: Inventor of prosthetic vascular graft – A birth centennial tribute. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:69-71

How to cite this URL:
Rajendran S, Sreekumar R C, Chandran J. Arthur B. Voorhees, Jr.: Inventor of prosthetic vascular graft – A birth centennial tribute. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Nov 28];8, Suppl S1:69-71. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/69/324947



Hundreds of thousands of lives, limbs, and brains have been saved throughout the world by the development of vascular surgery, the field opened up by the pioneers, Dr Arthur Voorhees and Dr Arthur Blakemore.” – Levin SM[1]

Arthur Bostwick Voorhees, Jr., [Figure 1] fondly referred to as “Art” was born in 1921 in Moorestown, near Philadelphia, New Jersey. His father, Stephen Court van Voorhees, a Dutch American who served in the Army during World War I, had an inherent ability to innovate techniques to resolve problems in their day-to-day lives.[2] His father's unique ability greatly influenced inquisitive little Arthur, which he tried to emulate throughout his life.
Figure 1: Dr. Arthur Voorhees (1921–1992)

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At the height of World War II, in 1943, Arthur was inducted into medical education at the College of Physicians and Surgeons of Columbia University, as part of an accelerated wartime program sponsored by the Army.[2] During his days at the medical school, he was deeply influenced by Dr. Hugh Auchincloss and was attracted toward the discipline of surgery. After graduation in 1946, during his 1-year surgical internship at Columbia-Presbyterian Hospital, New York, he became acquainted with Dr. Arthur H Blakemore, one of the best portal hypertension surgeons.[1],[2] Greatly impressed by Art's aptitude in medical research, Blakemore offered him a 1-year research fellowship. The association between Art and his mentor spurred the invention and development of prosthetic arterial substitutes.

Blakemore immediately assigned Art to commence animal experiments involving the development of a bioprosthetic mitral valve from inferior vena cava homograft. In these valves, silk support sutures were used to create structures that would function as “chordae tendineae.”[2],[3] In 1948, during one of the autopsies of animals involved in these implantations, Art observed an endocardium-like covering over a silk suture traversing the ventricular cavity.[1],[2],[3] Many years before this serendipitous event, similar observations of silk sutures becoming encapsulated by a fine veil coating and serving as a scaffolding for ingrowth of fibroblasts and later neoendothelium were recorded by Guthrie in the United States, and also later by Dorfler in Germany.[4],[5] It is probable these investigators did not think any further. However, this observation made Arthur speculate that a fine mesh of cloth would behave similarly and could be used to bridge arterial defects.[2],[3] Upon presenting this hypothesis of the “cloth prosthesis” to his chief, Blakemore readily accepted and asked Art to carry on with the animal experiments.[6] Soon after, the first tube prosthesis made out of a silk handkerchief was fabricated by Art on his wife's (Margaret Voorhees) sewing machine.[2],[3] However, after implantation in an acute dog model, this tube functioned for only 1 h, and the animal died soon after.[2]

Further experiments with nylon parachute cloth also met with limited success, in which only one out of six dogs survived at 1 month with a patent graft.[2] After these initial experiments, Arthur noted in conclusion that “The cloth had to be strong, inert, stable, of right porosity, supple and yet traversed by a fine needle.”[6] The quest for a suitable material for his experiments ended in early 1950 when he met the orthopedic resident, Wallace Blunt, who was working on a synthetic tendon project. Blunt suggested using fabric Vinyon-N supplied by the Union Carbon and Carbide Corporation, which met almost all of Art's criteria for a tubular prosthesis.[7]

Over the next year, a variety of tubular prostheses were fashioned using Vinyon-N fabric on his wife's sewing machine and implanted into abdominal aortas of thirty mongrel dogs.[2] The ends of grafts were folded back in French cuff style [Figure 2] to minimize fraying, and silk sutures or Vitallium cuffs designed by Blakemore and Lord were used for anastomosis.[2],[8] A preliminary report of their experience with Vinyon-N fabric in the first 15 dog experiments was published in the Annals of Surgery in 1952.[8] By early 1953, the team at Columbia-Presbyterian Medical Center was ready for human implantation of synthetic vascular grafts, but its first use in humans was more of an accident.
Figure 2: Vinyon-N prostheses with ends of grafts folded back in French cuff style

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In recent years before 1953, preserved aortic homografts were successfully used by many surgeons all over the world to repair defects in the aorta.[3] Aortic homografts were made available through aorta banks to the surgeons and, in 1951, a similar facility was also opened in New York.[1] In February 1953, Blakemore, Voorhees, and Levin operated on a patient with a ruptured abdominal aortic aneurysm at the Presbyterian Hospital, New York.[1] Only after the surgery had begun, did the nurse inform the team that the homograft was not available at the aorta bank in the city. Blake turned to his team and said, “We'll just have to make one of our own.”[9] Art and Levin scrubbed out of the operation, rushed to the experimental laboratory, and customized a tube graft from Vinyon-N on the sewing machine and got it autoclaved.[9] Three hours into the operation, Blake and his team used this graft to replace the aorta of that patient, which marked the first human implantation of a prosthetic aortic graft.[1],[3],[9] Unfortunately, the patient died due to a postoperative bleeding complication unrelated to graft insertion.[2]

However, Blakemore was highly impressed with the Vinyon prosthesis and, from then on, used these grafts for both emergency and elective aortic repairs. The results of these human implantations were published in the Annals of Surgery in 1954.[10] Around this time, there was a growing skepticism among surgeons about the long-term durability of aortic homografts. Szilagyi et al., in an extensive experience with arterial homografts, reported deterioration as early as 2 years and predicted their failure as a durable vascular substitute.[11] This renewed the interest in many vascular surgeons for further research into the development of prosthetic grafts and provided the much-needed impetus for Art's invention. Voorhees, like his chief, was the epitome of ethical medical practice, and he never sought any recognition for their contributions to the field of medicine. Vinyon graft and its further modifications never carried with it the name of its inventors. His team also never made any effort to patent their groundbreaking invention, which would have been worth millions. They simply wished that this product should be freely available for the benefit of all patients.

Soon, Michael DeBakey in Houston and Sterling Edwards in Alabama embarked on a similar project and developed prostheses made of Dacron and Nylon, respectively. By the 1960s, these products were marketed by the U.S. Catheter and Instrument Company as DeBakey Dacron grafts and Edwards-Tapp nylon grafts.[12],[13] Over the years, more such prosthetic materials were introduced, leading to the development of smaller diameter grafts made of inert materials such as polytetrafluoroethylene and, eventually, the present-day aortic stent-grafts.

Today, prosthetic grafts are an indispensable part of vascular surgery and present-day vascular and cardiac surgeons remain greatly indebted to the path-breaking efforts of this gentleman surgeon. Voorhees is one of the lesser-known vascular surgeons of the past, who deserved far more accolades, honor, and glory for his contributions. In recognition of his meritorious work, D.E. Szilagyi wrote, “It is a well-known truism that the development of vascular surgery would have been unthinkable without the introduction of clinically serviceable arterial substitutes.”[14] On the 100th birth anniversary of Arthur B. Voorhees, Jr., the Vascular Society of India is proud to honor this genius vascular surgeon.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Levin SM. Breakthrough: Arthur Blakemore and Arthur Voorhees. Jr. J Vasc Surg 2012;55:1829-31.  Back to cited text no. 1
    
2.
Smith RB 3rd. Arthur B. Voorhees, Jr.: Pioneer vascular surgeon. J Vasc Surg 1993;18:341-8.  Back to cited text no. 2
    
3.
Smith RB 3rd. The foundations of modern aortic surgery. J Vasc Surg 1998;27:7-15.  Back to cited text no. 3
    
4.
Guthrie CC. End-results of arterial restitution with devitalized tissue. JAMA 1919;73:186-7.  Back to cited text no. 4
    
5.
Dorfler J. Ueber arteriennaht. Beitr Klin Chir 1899;26:781-825.  Back to cited text no. 5
    
6.
Voorhees AB Jr. The origin of the permeable arterial pros- thesis: A personal reminiscence. Surg Rounds 1988;2:79-84.  Back to cited text no. 6
    
7.
Voorhees AB Jr., Jaretzki A 3rd, Blakemore AH. The use of tubes constructed from vinyon “N” cloth in bridging arterial defects. Ann Surg 1952;135:332-6.  Back to cited text no. 7
    
8.
Blakemore AH, Lord JW. A nonsuture method of blood vessel anastomosis: Review of experimental study report of clinical cases. Ann Surg 1945;121:435-52.  Back to cited text no. 8
    
9.
Levin SM. Reminiscences and ruminations: Vascular surgery then and now. Am J Surg 1987;154:158-62.  Back to cited text no. 9
    
10.
Blakemore AH, Voorhees AB Jr. The use of tubes constructed from vinyon N cloth in bridging arterial defects; experimental and clinical. Ann Surg 1954;140:324-34.  Back to cited text no. 10
    
11.
Szilagyi DE, Mcdonald RT, Smith RF, Whitcomb JG. Biologic fate of human arterial homografts. AMA Arch Surg 1957;75:506-27.  Back to cited text no. 11
    
12.
DeBakey ME, Cooley DA, Crawford ES, Morris GC Jr. Clinical application of a new flexible knitted Dacron arterial substitute. 1958. Am Surg 2008;74:381-6.  Back to cited text no. 12
    
13.
Edwards WS, Tapp JS. Peripheral artery replacement with chemically treated nylon tubes. Surg Gynecol Obstet 1956;102:443-9.  Back to cited text no. 13
    
14.
Szilagyi DE. Perspectives in vascular grafting. In: Sawyer PN, Kaplitt MJ, editors. Vascular Grafts. New York: Appleton- Century-Crofts; 1978. p. 23-6.  Back to cited text no. 14
    


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