Advertisement

Unknown pages in the history of vascular stent grafting

  • Alexei V. Svetlikov
    Correspondence
    Reprint requests: Dr Alexei V. Svetlikov, Department of Vascular Surgery, L.G. Sokolov Clinical Hospital № 122 FMBA of Russia, 194017, Yaroslavsky Ave 14, Apt 8, St. Petersburg, Russia
    Affiliations
    L.G. Sokolov Clinical Hospital N122, St. Petersburg FMBA of Russia, St. Petersburg, Russia

    North-West I.I. Mechnikov State Medical University, St. Petersburg, Russia
    Search for articles by this author
      At the end of the 20th century, endovascular procedures have made an outstanding contribution to the field of vascular surgery. The advantages and promising future of this new treatment modality became evident in an unprecedentedly short period of time. One of the major advances brought by the endovascular approach was the introduction of stent grafting in the management of aortic aneurysms. Literature concerning the history of invention and the first attempts for stent grafting points out the innovative works of Parodi et al
      • Veith F.J.
      • Marin M.L.
      • Cynamon J.
      • Schonholz C.
      • Parodi J.
      1992: J. Parodi, Montefiore, and the first abdominal aortic aneurysm stent graft in the United States.
      • Prinssen M.
      • Verhoeven E.L.
      • Buth J.
      • Cuypers P.W.
      • van Sambeek M.R.
      • Balm R.
      A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.
      • Belov Y.V.
      • Abugov S.A.
      • Serebryakov S.V.
      Comparative analysis of open and endovascular treatment of infrarenal aneurysm.
      • Parodi J.C.
      • Palmaz J.C.
      • Barone H.D.
      Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.
      • Criado F.J.
      EVAR at 20: the unfolding of a revolutionary new technique that changed everything.
      being an inspiring start for the new era of aortic aneurysm repair.
      In the present article, we would like to enlighten some facts from the history of stent grafting that might be unfamiliar to the general public, with a distinct focus on the innovative works of Professor Nikolai L. Volodos (Fig 1) and his colleagues. Prof Volodos' name is well-known to the international surgical community; however, most details of his research work in vascular endografting, especially those from the last decades of the 20th century, are insufficiently covered in the European and North American literature.
      More than 30 years ago, N.L. Volodos, elaborating upon his doctoral thesis, started to search for a vascular graft design with the ability for self-expansion and self-fixation within the vessel lumen. In 1983, a team of scientists from the Harkov Research Institute of General and Emergency Surgery (USSR), headed by N.L. Volodos, constructed the model of a radial cylindrical metallic tube with a Z-shaped lateral frame. The tube, inserted in a vascular graft, could fix the implant securely to the arterial wall. Prof N.L. Volodos has used for his work the only available and widely used synthetic graft in the Soviet Union, produced by the company “Sever” (Leningrad, Soviet Union).

      Lebedev LV, Plotkin LL, Smirnov AD, Vavilov VN, Lukyanov YV, Gorbunov GN. Grafts of arterial vessels. St. Petersburg: Admiralteistvo; 2001. p. 131

      Pokrovsky AV. Clinical angiology. Volume 2. Medicine; 2004. p. 33.

      In fact, it was the first model of self-expandable and self-fixing vascular graft ever. The method of placing the vascular graft in the natural artery using an engineered expandable was called remote endografting.
      It required more than a year for N.L. Volodos' team to improve their stent graft design, search for optimal structural materials, and develop a specific device for radial force measurement. At the same time, a graft delivery set of instruments was engineered and later produced. In 1984, N.L. Volodos performed experimental studies on animals using his innovative surgical equipment. In May 1984, he submitted the required documentation concerning the use of his invention to the USSR patent agency (Fig 2, A and B). The fact that this was a long-awaited invention is supported by an analogous application from the Gianturco company in the United States in October 1984 (the patent holder is Cook). Unfortunately, the USSR patent for invention did not have international validity at that time, whereas Gianturco received complete international certification. This is why Gianturco's device became familiar in the world sooner than N.L. Volodos' invention. The first scientific paper on the use of this engineered device was published by N.L. Volodos in March 1985.
      • Volodos N.L.
      • Shekhanin V.E.
      • Karpovich I.P.
      Self-fixing graft for distant endografting of aorta and other arteries. Modern approaches for prophylaxis and treatment of arteries diseases.
      Figure thumbnail gr2a
      Fig 2A and B, Patent from May 22, 1984, describing the initial idea of the model of radial cylindrical metallic tube with Z-shaped lateral frame.
      Figure thumbnail gr2b
      Fig 2A and B, Patent from May 22, 1984, describing the initial idea of the model of radial cylindrical metallic tube with Z-shaped lateral frame.
      In May 1985, N.L. Volodos, for the first time in modern history, performed iliac artery stent grafting. Endovascular grafting was accomplished together with femoral-tibial bypass surgery. This innovative combined approach would be called today a hybrid vascular procedure. This unique clinical observation was published in Vestnik Khirurgii im I.I. Grekova in 1986.
      • Volodos N.L.
      • Shekhanin V.E.
      • Karpovich I.P.
      • Troyan V.I.
      • Guriev Y.A.
      A self-fixing synthetic blood vessel endoprosthesis.
      The patient showed good patency for both treated arterial segments on the 1-year follow-up interval; unhappily though, he soon had a stroke and passed away. Meanwhile, N.L. Volodos and his colleagues continued to gain experience in stent grafting for iliac artery stenotic and occlusive disease. During the following few years, they performed 19 procedures of this kind.
      In 1986, N.L. Volodos used a stent graft with the same design for endografting of the abdominal aorta in a patient with Leriche syndrome. During this procedure, the stent graft was introduced into the aorta by an unsophisticated delivery system through an aortotomy incision placed distally to the target level of the graft placement. The procedure was performed through a midline laparotomy incision. This ensured shortening of aortic clamping time when compared with the time needed for conventional proximal end-to-side anastomosis during open surgery.
      The first procedure using the original stent graft for the treatment of abdominal aortic aneurysm was attempted in 1987.
      In the same year. successful stent grafting was performed for aneurismal disease of the thoracic aorta using only femoral access. This case was published in Grudnaya Khirurgiya (Thoracic Surgery) in 1988.
      • Volodos N.L.
      • Shekhanin V.E.
      • Karpovich I.P.
      • Troyan V.I.
      • Yakovenko L.F.
      • Keremet L.S.
      • et al.
      Case of distant transfemoral endografting of traumatic thoracic aneurysm by self-fixing graft.
      The patient died from a heart attack in 2005 with the stent graft remaining patent for almost 18 years.
      In February 1990, N.L. Volodos, for the first time, presented his clinical experience with stent grafting at the Second International Congress of Interventional Radiology that was held in Toulouse, France.
      • Volodos N.L.
      • Karpovich I.P.
      • Shekhanin V.E.
      • Ternyak N.E.
      • Yakovenko L.F.
      • Neoneta A.S.
      • et al.
      Self-fixing synthetic prosthesis for distance and intraoperational endoproshtetics aorta and iliac arteries.
      In May 1991, N.L. Volodos pioneered in the combined endovascular and open (hybrid) repair of aortic arch and adjacent segment of descending aorta. Two surgical approaches have been used: one from the ascending aorta, where the branch of aortic graft has been secured with sutures, and another one from the femoral artery. Aortic arch debranching was performed prior to graft placement; the left common carotid artery was transpositioned to the brachiocephalic trunk together with carotid-subclavian bypass surgery. The patient is alive and had no signs of graft failure on her last follow-up visit. This clinical observation was published in Vasa (1991) and Seminars in Interventional Radiology (1998).
      • Volodos N.L.
      • Karpovich I.P.
      • Troyan V.I.
      • Kalashnikova Y.V.
      • Shekhanin V.E.
      • Ternyak N.E.
      • et al.
      Clinical experience of the use of self-fixing synthetic prosthesis for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction.
      • Volodos N.L.
      • Karpovich I.P.
      • Troyan V.I.
      • Kalashnikova Yu.V.
      • Shekhanin V.E.
      • Volodos S.N.
      • et al.
      Endovascular stented grafts for thoracic, abdominal aortic and iliac artery disease: clinical experience in the Ukraine from 1985.
      This proposed hybrid procedure is still of clinical importance and widely used nowadays.
      In 1993, N.L. Volodos' team succeeded in performing a descending thoracic aneurysm endovascular repair (stent grafting). The treated aneurysm was complicated by aortobronchial fistula and massive pulmonary hemorrhage. In this procedure, two surgical approaches have been used, femoral and axillary. The patient is still alive without any significant lifestyle limitations during the 17 years following this surgery. This clinical case has been presented at the VII International Congress “Endovascular interventions on the cutting edge” held in Arizona in 1994.
      • Volodos N.L.
      • Karpovich I.P.
      • Troyan V.I.
      • Neoneta A.S.
      • Volodos S.N.
      • Kalashnikova Y.V.
      • et al.
      International Congress VII. Endovascular interventions. On the cutting edge. Transfemoral endovascular grafting of the aortoiliac segment with the bifurcated selffixing synthetic endoprosthesis. Presented at the International Congress VII on Endovascular Interventions; February 13-17, 1994, Phoenix, AZ.

      Conclusions

      It is worth pointing out major advances and innovative ideas of Professor N.L. Volodos' team with their outstanding impact in the history of vascular stent grafting:
      • Z-shaped model of radial cylindrical stent was first invented for the self-fixing expandable vascular endograft.
      • Pioneering experience in the following surgical procedures:
        • 1.
          Iliac artery stent grafting for occlusive disease;
        • 2.
          Stent grafting of thoracic part of descending aorta (1987);
        • 3.
          Intraoperative stent grafting of abdominal aortic aneurysm using a self-fixing synthetic endograft (1987);
        • 4.
          Attempts on stent grafting of abdominal aortic aneurysm with whole self-fixing bifurcated endograft using two femoral approaches (1989)
          • Volodos N.L.
          • Karpovich I.P.
          • Shekhanin V.E.
          • Ternyak N.E.
          • Yakovenko L.F.
          • Neoneta A.S.
          • et al.
          Self-fixing synthetic prosthesis for distance and intraoperational endoproshtetics aorta and iliac arteries.
          ;
        • 5.
          Combined endovascular and open surgical repair of aortic arch using debranching technique accomplished via two surgical approaches – ascending aorta and common femoral artery (1991); and
        • 6.
          Stent grafting of descending thoracic aorta for aneurismal disease complicated by aortobronchial fistula and massive pulmonary hemorrhage (1993).
      It is therefore important to emphasize that Professor N.L. Volodos and colleagues' achievements in the engineering, experimental testing, and clinical implication of vascular endografts used for the treatment of patients with aortic and major arteries disorders undoubtedly constitute a distinguished priority and should be ranked accordingly in the history of endovascular surgery.

      References

        • Veith F.J.
        • Marin M.L.
        • Cynamon J.
        • Schonholz C.
        • Parodi J.
        1992: J. Parodi, Montefiore, and the first abdominal aortic aneurysm stent graft in the United States.
        Ann Vasc Surg. 2005; 19: 749-751
        • Prinssen M.
        • Verhoeven E.L.
        • Buth J.
        • Cuypers P.W.
        • van Sambeek M.R.
        • Balm R.
        A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.
        N Engl J Med. 2004; 351: 1607-1618
        • Belov Y.V.
        • Abugov S.A.
        • Serebryakov S.V.
        Comparative analysis of open and endovascular treatment of infrarenal aneurysm.
        Kardiol serdečno-sosud hir. 2009; 5: 38-43
        • Parodi J.C.
        • Palmaz J.C.
        • Barone H.D.
        Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.
        Ann Vasc Surg. 1991; 5: 491-499
        • Criado F.J.
        EVAR at 20: the unfolding of a revolutionary new technique that changed everything.
        J Endovasc Ther. 2010; 17: 789-796
      1. Lebedev LV, Plotkin LL, Smirnov AD, Vavilov VN, Lukyanov YV, Gorbunov GN. Grafts of arterial vessels. St. Petersburg: Admiralteistvo; 2001. p. 131

      2. Pokrovsky AV. Clinical angiology. Volume 2. Medicine; 2004. p. 33.

        • Volodos N.L.
        • Shekhanin V.E.
        • Karpovich I.P.
        Self-fixing graft for distant endografting of aorta and other arteries. Modern approaches for prophylaxis and treatment of arteries diseases.
        All Soviet Union conference, MoscowMar 20-22, 1985
        • Volodos N.L.
        • Shekhanin V.E.
        • Karpovich I.P.
        • Troyan V.I.
        • Guriev Y.A.
        A self-fixing synthetic blood vessel endoprosthesis.
        Vestn Khir Im I I Grek. 1986; 137: 123-125
        • Volodos N.L.
        • Shekhanin V.E.
        • Karpovich I.P.
        • Troyan V.I.
        • Yakovenko L.F.
        • Keremet L.S.
        • et al.
        Case of distant transfemoral endografting of traumatic thoracic aneurysm by self-fixing graft.
        Grudnaya Khirurhia. 1988; 6: 84-86
        • Volodos N.L.
        • Karpovich I.P.
        • Shekhanin V.E.
        • Ternyak N.E.
        • Yakovenko L.F.
        • Neoneta A.S.
        • et al.
        Self-fixing synthetic prosthesis for distance and intraoperational endoproshtetics aorta and iliac arteries.
        Congress International, Toulouse, FranceFebruary 28-March 2, 1990
        • Volodos N.L.
        • Karpovich I.P.
        • Troyan V.I.
        • Kalashnikova Y.V.
        • Shekhanin V.E.
        • Ternyak N.E.
        • et al.
        Clinical experience of the use of self-fixing synthetic prosthesis 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 Suppl. 1991; 33: 93-95
        • Volodos N.L.
        • Karpovich I.P.
        • Troyan V.I.
        • Kalashnikova Yu.V.
        • Shekhanin V.E.
        • Volodos S.N.
        • et al.
        Endovascular stented grafts for thoracic, abdominal aortic and iliac artery disease: clinical experience in the Ukraine from 1985.
        Semin Intervent Radiol. 1998; 15: 89-95
        • Volodos N.L.
        • Karpovich I.P.
        • Troyan V.I.
        • Neoneta A.S.
        • Volodos S.N.
        • Kalashnikova Y.V.
        • et al.
        International Congress VII. Endovascular interventions. On the cutting edge. Transfemoral endovascular grafting of the aortoiliac segment with the bifurcated selffixing synthetic endoprosthesis. Presented at the International Congress VII on Endovascular Interventions; February 13-17, 1994, Phoenix, AZ.
        Abstract published in J Interv Cardiol. 1994; 7: 88