Portal de Periódicos da CAPES

Presidential address: The foundations of modern aortic surgery

1998; Elsevier BV; Volume: 27; Issue: 1 Linguagem: Inglês

10.1016/s0741-5214(98)70286-1

1097-6809

Robert B. Smith,

Cardiac, Anesthesia and Surgical Outcomes

"The farther backward you can look, the farther forward you are likely to see." —Sir Winston Churchill It is a high privilege to have served as President of the North American Chapter of the International Society for Cardiovascular Surgery for the past year, quite an eventful one in our specialty. Please permit me to begin by expressing a few words of appreciation to persons who have been important to my professional career over the past 40 years: to my mentors during residency at the Columbia-Presbyterian Medical Center, especially the late Arthur B. Voorhees, Jr.; to my senior colleague at Emory for many years, Garland Perdue; to other faculty associates in the Division of Vascular Surgery at Emory; to our 34 vascular surgery trainees, many of whom are present here today; and, finally, to my own family, especially my wife, Flo, without whose support and forbearance it would not have been possible, and certainly not as much fun. Indeed, I am also indebted to every colleague in this room for your enrichment of the discipline of vascular surgery, our chosen life's work. Now, to the subject at hand, the foundations of modern aortic surgery. As some of you know, the history of vascular surgery has been one of my interests for a number of years, sparked, I am sure, by friendship during training and in subsequent years with Arthur Voorhees, one of the true innovators of surgery.1Smith III., RB Arthur B. Voorhees Jr., pioneer vascular surgeon.J Vasc Surg. 1993; 18: 341-348Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar I have been fortunate that my own professional career has spanned almost the entire modern period of our specialty, since I graduated from medical school exactly 40 years ago this month. For some time I have felt that the current generation of young vascular surgeons should have a better knowledge of the birth and early maturation of modern vascular surgery to appreciate more fully the contributions of our pioneers. Standard infrarenal aortic aneurysm repair has become almost routine to vascular trainees of the 1990s. With expert anesthesia, superior instruments, reliable prostheses, autoinfusion devices, and critical care units, most aortic operations are performed expeditiously, and the patients recover uneventfully and are discharged on the appropriate day as defined by their clinical pathway. Believe me, the early days of aortic surgery were not so routine or predictable. Some colleagues here today, maybe even a few senior to me in years of practice, can well remember the courage, perseverance, and self-sacrifice necessary for both the surgeon and the patient to undertake aortic surgery in those early days. It is exactly that period in our history to which I wish to focus your attention this morning. In preparation for this talk, I have consulted the literature, of course, but I have also been privileged to interview a number of senior surgeons who were important contributors in the decades of the 1950s and 1960s. In addition, I have been able to visit the headquarters of several of the largest graft fabricators in the industry. Finally, through the generosity of Art Voorhees' widow, Margaret, I have received trusteeship of his slide collection and other memorabilia of his career. For all of these various opportunities, I am deeply grateful. Before proceeding, I must pause to commend to you two recently published books on the history of vascular surgery: Band of Brothers, conceived and started by Andrew Dale before his death and finished by his associates, George Johnson and James DeWeese, and Clio: The Arteries, an encyclopedic work compiled by Wiley Barker.2Dale WA Band of brothers: creators of modern vascular surgery. Kachergis Book Design, Pittsboro, N.C1996Google Scholar, 3Clio: the arteries. R. G. Landers Co, Austin, Tex1992Google Scholar I must also express one proviso. There is always the possibility in a presentation of this type that the speaker will fail to include an important contributor or to ascribe sufficient primacy to his work—for any such failings, I apologize in advance. Finally, I would be remiss if I did not acknowledge the invaluable assistance of Jesse Thompson in the quest for historical accuracy. Before we jump directly to the middle of this century, allow me to back up long enough to describe some of the earlier foundations of our discipline. Those of you who have visited the ancient cities of Jerusalem or Luxor know that many modern sites are built on foundations of previous civilizations (Figs. 1 and 2). Fig. 2An Islamic mosque has been constructed on the ruins of the ancient temple at Luxor, Egypt.View Large Image Figure ViewerDownload (PPT)Such is the case with modern vascular surgery, as well. It is safe to assume that among the foundations of vascular surgery one must include the seminal work of Carrel and Guthrie, early in this century at the University of Chicago, and later at the Rockefeller Institute, where Carrel performed homograft aortic replacements and other vascular procedures on experimental animals.4Carrel A Guthrie CC Uniterminal and biterminal venous transplantations.Surg Gynecol Obstet. 1906; 2: 266-286Google Scholar, 5Carrel A Results of the transplantation of blood vessels, organs, and limbs.JAMA. 1908; LI: 1662-1667Crossref Scopus (120) Google Scholar, 6Carrel A Results of the permanent intubation of the thoracic aorta.Surg Gynecol Obstet. 1912; 15: 245-248Google Scholar For his pioneering achievements in vascular surgery and organ transplantation, Alexis Carrel was awarded the Nobel Prize for Physiology and Medicine in 1912. Jose Goyanes7Goyanes J Nuevos trabajos de cirugia vascular, substitucion plastica de las arteries por las venas o arterioplastia venosa.El Siglo Med. 1906; 53: 546-561Google Scholar of Madrid had performed the first successful replacement of a human artery in 1906, which was a venous autograft to bridge an excised popliteal aneurysm. Reynaldo Dos Santos8Dos Santos R Arteriography of the limbs, the aorta, and its abdominal branches.Bull Soc Natl Chir. 1929; 55: 587-601Google Scholar of Portugal subsequently reported angiographic visualization of the abdominal aorta and runoff vessels in 1929. Aortic surgery, largely impossible to consider before that time, took a leap forward in 1923, when Rudolph Matas9Matas R Aneurysm of the abdominal aorta at its bifurcation into the common iliac arteries.Ann Surg. 1940; 112: 909-922Crossref PubMed Google Scholar of New Orleans performed successful ligation of the infrarenal aorta for a leaking luetic aneurysm, truly an incredible technical feat for the period. In the same year, Rene Leriche, the most noted French vascular surgeon of his day, stated: "The ideal treatment of arterial thrombosis is the replacement of the obstructed segment with a vascular graft."10Leriche R Des obliterations arterielles hautes comme causes des insuffisances circulatoires des membres inferieurs.Bull Mem Soc Chir. 1923; 49: 1404-1406Google Scholar This was the same Leriche who 17 years later described the syndrome of occlusive disease of the terminal abdominal aorta that carries his name.11Leriche R Morel A The syndrome of thrombotic obliteration of the aortic bifurcation.Ann Surg. 1948; 127: 193-206Crossref PubMed Scopus (162) Google Scholar In the decade before World War II, a variety of bold attempts were made by surgeons to treat patients who were threatened by enlarging aortic aneurysms or progressive thrombosis of the terminal aorta. Rigid tubes made from a variety of materials had been used for years in an effort to preserve vascular continuity, with uniformly poor results. Arthur Blakemore of the Columbia Presbyterian Medical Center in New York resurrected a previously described method for the introduction of wire and application of an electrical current to induce thrombosis of the aortic aneurysm sac.12Finney JMT The wiring of otherwise inoperable aneurysms.Ann Surg. 1912; 55: 661-681Crossref PubMed Google Scholar, 13Power DA The palliative treatment of aneurysm by "wiring" with Colt's apparatus.Br J Surg. 1921; 9: 27-36Crossref Scopus (20) Google Scholar, 14Blakemore AH Voorhees Jr, AB Aneurysm of the aorta: a review of 365 cases.Angiology. 1954; 5: 209-231Crossref PubMed Scopus (14) Google Scholar In 1938, he reported wire insertion in 11 patients who had thoracic or abdominal aortic aneurysms; most eventually died of aneurysm rupture, but one patient survived for 2 years.15Blakemore AH King BG Electrothermic coagulation of aortic aneurysms.JAMA. 1938; 111: 1821-1827Crossref Scopus (35) Google Scholar In the same period, other surgeons used a variety of materials to wrap aneurysms in an effort to retard expansion or to induce periarterial fibrosis, which might secondarily serve to arrest enlargement. Cellophane wrapping was investigated by Pearse,16Pearse HE Experimental studies of the gradual occlusion of large arteries.Ann Surg. 1940; 112: 923-937Crossref PubMed Google Scholar Harrison and Chandy,17Harrison PW Chandy J A subclavian aneurysm cured by cellophane fibrosis.Ann Surg. 1943; 118: 478-481Crossref PubMed Google Scholar and Abbott.18Abbott OA Clinical experiences with the application of polythene cellophane upon aneurysms of the thoracic vessels.J Thorac Surg. 1949; 18: 435-461PubMed Google Scholar Other materials, including fascia lata, skin, and polyvinyl sponge, were also used, but largely to no avail because the aneurysms grew relentlessly despite circumferential wrapping.19Lowenberg EL Aneurysms of the abdominal aorta; report of two casee treated by "cutis grafting.".Angiology. 1950; 1: 396-404Crossref PubMed Scopus (4) Google Scholar, 20de Takats G Marshall MR Surgical treatment of arteriosclerotic aneurysms of the abdominal aorta.Arch Surg. 1952; 64: 307-319Crossref Scopus (6) Google Scholar, 21Wylie EJ Kerr E Davies O Experimental and clinical experiences with the use of fascia lata applied as a graft about major arteries after thrombo-endarterectomy and aneurys- morrhapy.Surg Gynecol Obstet. 1951; 93: 257-272PubMed Google Scholar Even after prosthetic graft materials later became available, we found at Emory that the wrapping method was no match for the lateral pressure exerted by an expanding aneurysm.22Smith III, RB Costantino MJ Perdue Jr, GD Is there a place for external grafting of arterial aneurysms in selected patients?.J Cardiovasc Surg (Torino). 1979; 20: 13-20PubMed Google Scholar But to drop back to other so-called alternative techniques, some surgeons had chosen the more direct approaches of ligation or banding of the aorta or the tangential excision of suitable saccular aneurysms. Halsted was an advocate of banding. He banded the aorta for control of a painful aneurysm in 1910, only to have the patient die 6 weeks later when the band eroded the aorta.3Clio: the arteries. R. G. Landers Co, Austin, Tex1992Google Scholar As early as 1936, Leriche advocated terminal aortectomy and bilateral lumbar sympathectomy for treatment of aortic occlusive disease, in the belief that thrombus in the aortic lumen tended to migrate and also that thrombus incited an inflammatory response with peripheral vasoconstriction.11Leriche R Morel A The syndrome of thrombotic obliteration of the aortic bifurcation.Ann Surg. 1948; 127: 193-206Crossref PubMed Scopus (162) Google Scholar Dan Elkin and Fred Cooper of Atlanta described a limited experience with this treatment.23Elkin DC Cooper Jr, FW Surgical treatment of insidious thrombosis of the aorta.Ann Surg. 1949; 130: 417-427Crossref Scopus (3) Google Scholar Geza de Takats of Chicago summarized the cases of 37 patients who had undergone total aortic ligation over the preceding century, only eight of whom had survived for 6 months or longer.20de Takats G Marshall MR Surgical treatment of arteriosclerotic aneurysms of the abdominal aorta.Arch Surg. 1952; 64: 307-319Crossref Scopus (6) Google Scholar In general, the prevailing attitude concerning aortic surgery was quite pessimistic, as reflected in I. A. Bigger's address to the American Surgical Association in 1940: "Judging from the literature, only a small number of surgeons have felt that direct surgical attack on aneurysms of the abdominal aorta was justifiable, and it must be admitted that the results obtained by surgical intervention have been discouraging."24Bigger IA The surgical treatment of aneurysm of the abdominal aorta.Ann Surg. 1940; 112: 879-894Crossref PubMed Google Scholar The experiences of World War II did little to advance the cause of aortic surgery, but enthusiasm increased somewhat in 1944 when Alexander and Byron of Ann Arbor reported the first successful proximal and distal ligation of the thoracic aorta for removal of a fusiform aneurysm.25Alexander J Byron FX Aortectomy for thoracic aneurysm.JAMA. 1944; 126: 1139-1145Crossref Scopus (17) Google Scholar In the same year, Clarence Crafoord of Sweden successfully resected and performed an end-to-end reanastomosis for coarctation of the thoracic aorta, another important foundation stone in the edifice of vascular surgery.26Crafoord C Nylin G Congenital coarctation of the aorta and its surgical treatment.J Thorac Surg. 1945; 14: 347-361Google Scholar Crafoord's feat was repeated in this country the following year by Robert Gross of Boston.27Gross RE Surgical correction for coarctation of the aorta.Surgery. 1945; 18: 673-678PubMed Google Scholar Harris Shumacker, then of New Haven, Conn., performed a similar successful resection and reanastomosis in 1947, after his release from military duty.28Shumacker Jr, HB Coarctation and aneurysm of the aorta.Ann Surg. 1948; 127: 655-665Crossref Scopus (22) Google Scholar It should be noted that Charles Hufnagel of Washington, D.C., experimented with permanent intubation of the thoracic aorta with rigid tubes of methacrylate, but results were marred by frequent erosion of the vessel.29Hufnagel CA Permanent intubation of the thoracic aorta.Arch Surg. 1947; 54: 382-389Crossref PubMed Google Scholar Denton Cooley and Michael DeBakey of Houston successfully performed lateral aortorrhaphy of a saccular aneurysm of the thoracic aorta, and Henry Bahnson of Baltimore affirmed the efficacy of that approach in highly selected patients.30Cooley DA DeBakey ME Surgical considerations of intrathoracic aneurysms of the aorta and great vessels.Ann Surg. 1952; 135: 660-680Crossref PubMed Scopus (60) Google Scholar, 31Bahnson HT Considerations in the excision of aortic aneurysms.Ann Surg. 1953; 138: 377-386PubMed Google Scholar At that juncture, it was obvious that further progress would not be possible without a suitable flexible conduit to replace resected segments of the thoracic or abdominal aorta. Once again, Robert Gross deserves credit as a major innovator, because he was the first to use harvested, preserved homografts for treatment of coarctation of the aorta and to establish an aorta-to-pulmonary artery shunt for alleviation of tetralogy of Fallot.32Gross RE Hurwitt ES Bill Jr, AH Peirce II, EC Preliminary observations on the use of human arterial grafts in the treatment of certain cardiovascular defects.N Engl J Med. 1948; 239: 578-579Crossref PubMed Scopus (73) Google Scholar, 33Gross RE Bill Jr, AH Peirce II, EC Methods for preservation and transplantation of arterial grafts: observations on arterial grafts in dogs. Report of transplantation of preserved arterial grafts in 9 human cases.Surg Gynecol Obstet. 1949; 88: 689-701PubMed Google Scholar By his contributions, the modern era of vascular grafting began. Two years later, in 1950, Jacques Oudot of Paris performed the first resection and homograft replacement of a thrombosed aortic bifurcation, fulfilling the prophecy of his fellow countryman Leriche 27 years earlier.34Oudot J Beaconsfield P Thrombosis of the aortic bifurcation treated by resection and homograft replacement.Arch Surg. 1953; 66: 365-374Crossref Scopus (50) Google Scholar The following year, Charles Dubost and associates, also of France, treated an infrarenal abdominal aortic aneurysm by insertion of a thoracic aortic homograft that had been preserved for 3 weeks: "Three months after the operation the patient was in perfect health."35Dubost C Allary M Oeconomos N Resection of an aneurysm of the abdominal aorta: reestablishment of the continuity by a preserved human arterial graft, with result after five months.Arch Surg. 1952; 64: 405-408Crossref Scopus (506) Google Scholar DeBakey and Cooley performed the first similar case in this country 1 year later, only days after Brock's first repair in Britain.36DeBakey ME Cooley DA Surgical treatment of aneurysm of abdominal aorta by resection and restoration of continuity with homograft.Surg Gynecol Obstet. 1953; 97: 257-266PubMed Google Scholar, 37Brock RC Discussion on reconstructive arterial surgery.Proc Roy Soc Med. 1953; 46: 115-130PubMed Google Scholar Soon thereafter, Brock described the arduous state of aortic surgery: "These cases are long, anxious, tiring, one might even say exhausting...."37Brock RC Discussion on reconstructive arterial surgery.Proc Roy Soc Med. 1953; 46: 115-130PubMed Google Scholar It should also be noted that during that period Charles Rob and Felix Eastcott were actively involved in developing the first frozen human artery bank at St. Mary's Hospital in London. Ormand Julian and associates of Chicago successfully operated on an occluded aorta with homograft insertion in 1952.38Julian OC Grove WJ Dye WS et al.Direct surgery of arteriosclerosis.Ann Surg. 1953; 138: 387-403PubMed Google Scholar Henry Bahnson is credited with the first successful repair of a ruptured aortic aneurysm in 1953.3Clio: the arteries. R. G. Landers Co, Austin, Tex1992Google Scholar Thereafter, enthusiasm for homografts swelled over the next decade but then waned because of frequent degeneration of the grafts, as well as difficulty with the harvesting and banking of the grafts.39Swan H Robertson HT Johnson ME Arterial homografts. I. The fate of preserved aortic grafts in the dog.Surg Gynecol Obstet. 1950; 90: 568-579PubMed Google Scholar, 40Deterling Jr, RA Coleman Jr, CC Parshley MS Experimental studies of the frozen homologous aortic graft.Surgery. 1951; 29: 419-440PubMed Google Scholar, 41DeBakey ME Creech Jr, O Cooley DA Halpert B Structural changes in human aortic homografts.Arch Surg. 1954; 69: 472-482Crossref Scopus (4) Google Scholar Gross had acknowledged in a preliminary report that the short-term results of human homograft implantation, up to 3 years, had been gratifying but that "no final conclusion should be made until these patients have been followed for several decades."42Gross RE Treatment of certain aortic coarctations by homologous grafts.Ann Surg. 1951; 134: 753-768PubMed Google Scholar In a summary report of extensive experience with arterial homografts, Szilagyi and colleagues observed serious deterioration of structural integrity over time and predicted their failure as a vascular substitute.43Szilagyi E McDonald RT Smith RF Whitcomb JG Biologic fate of human arterial homografts.Arch Surg. 1957; 75: 506-529Crossref Scopus (67) Google Scholar It was exactly in this period that Arthur Voorhees made his momentous contribution to the foundation being laid in our specialty.1Smith III., RB Arthur B. Voorhees Jr., pioneer vascular surgeon.J Vasc Surg. 1993; 18: 341-348Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Art had completed a straight internship in surgery at Presbyterian Hospital in 1947 and remained an additional year to work in the research laboratory of Arthur Blakemore while awaiting an assignment at the Brooke Army Medical Center to begin the following year. Under Blakemore's direction, Art was assigned the difficult task of developing a mitral valve replacement in a canine model. In the absence of cardiopulmonary bypass, the procedure was technically demanding, requiring blind placement of silk support sutures to function as "chordae tendinae" for the homograft valve. In the spring of 1948, while performing an autopsy on one of the animals several months after valve implantation, Art noticed that a silk suture bridging the ventricular cavity was coated with a glistening layer of what appeared to be endocardium. In a moment of inspiration, he speculated that "a piece of cloth might react in a similar way."44Voorhees Jr, AB The origin of the permeable arterial prosthesis: A personal reminiscence.Surg Rounds. 1988; 2: 79-84Google Scholar Later, he wrote: "As an outgrowth of this observation it was conceived that if arterial defects were bridged by prostheses constructed of a fine mesh cloth, leakage of blood through the walls of the prosthesis would be terminated by the formation of fibrin plugs and would thus allow the cloth tube to conduct arterial flow."45Voorhees Jr, AB Jaretzki III, A Blakemore AH The use of tubes constructed from Vinyon "N" cloth in bridging arterial defects.Ann Surg. 1952; 135: 332-336Crossref PubMed Scopus (299) Google Scholar Art acknowledged that he was not aware at that time of Guthrie's suggestion 30 years earlier that an implant need serve only as scaffolding for ingrowth of host tissue.46Guthrie CC End-results of arterial restitution with devitalized tissue.JAMA. 1919; 73: 186-187Crossref Scopus (15) Google Scholar Evidently, he was also unaware of the earlier reports by Dorfler in Germany and Carson in the United States that silk sutures in the lumen of an artery sometimes became encapsulated by a fine veil coating.47Dorfler J Ueber arteriennaht.Beitr Klin Chir. 1899; 26: 781-825Google Scholar, 48Vascular surgery.in: Modern operative surgery. Cassel and Co, London1924: 378-380Google Scholar Of course, none of these earlier observers had made the epochal leap from an interesting experimental observation to the concept of a fabric tube, as proposed by Voorhees. His first effort in the animal laboratory using a conduit fashioned from his wife's silk handkerchief was only partially successful. Then during his 2-year tour at the Surgical Research Unit in San Antonio, Tex., Art performed a limited number of experiments using nylon parachute cloth as an aortic prosthesis. From that experience he concluded: "The cloth had to be strong, inert, stable, of the right porosity, supple, and yet easily traversed by a fine needle."44Voorhees Jr, AB The origin of the permeable arterial prosthesis: A personal reminiscence.Surg Rounds. 1988; 2: 79-84Google Scholar Upon returning to Presbyterian Hospital in 1950 to begin his surgical residency, Art resumed his work on vascular grafts in Blakemore's laboratory. Following advice from an orthopaedic resident, Wallace Blunt, Art secured a bolt of Vinyon-N fabric from the Union Carbon and Carbide Corporation. The plastic material, Vinyon-N, had been designed to be used as sail cloth but had proved too inert to hold a dye and thus had no commercial value. Art found it quite suitable for his experiments, however, in which he prepared a variety of straight tube grafts on Margaret's sewing machine and then sutured them into the abdominal aortas of mongrel dogs. Early implantations were demanding and tedious: "We were often hard pressed to separate our technical ineptitude, the perversity of our handcrafted materials, and the variations of host response, in analyzing our end results."49Voorhees Jr, AB The development of arterial prostheses.Arch Surg. 1985; 120: 289-295Crossref PubMed Scopus (14) Google Scholar By the end of 1950, implants had been performed in 30 dogs, three quarters of which survived the operative procedure. Animals were killed according to a predetermined schedule ranging from hours to months, and eventually up to 8 years, to provide a portrayal of graft healing. By the middle of 1951 there were sufficient data to prepare an optimistic preliminary report that was published in the Annals of Surgery in March 1952: "The use of tubes constructed from Vinyon "N" cloth in bridging arterial defects," coauthored by Voorhees, Jaretzki, and Blakemore.45Voorhees Jr, AB Jaretzki III, A Blakemore AH The use of tubes constructed from Vinyon "N" cloth in bridging arterial defects.Ann Surg. 1952; 135: 332-336Crossref PubMed Scopus (299) Google Scholar Later that year, when Art was a senior resident, the first synthetic graft implantation was performed in a patient with a ruptured abdominal aortic aneurysm.50A history of vascular surgery. Futura Publishing Co, Mount Kisco, Calif1989: 135Google Scholar Blakemore had planned to use an aortic homograft, but because none was available Art prepared a bifurcated graft of Vinyon cloth. Although the patient died of coagulopathy, the graft was intact and patent at autopsy, providing sufficient encouragement to implant a graft in a second patient electively a few weeks later; the patient survived. Over the following year, 16 additional aneurysms were similarly treated, with an impressive 56% survival rate.51Blakemore AH Voorhees Jr, AB The use of tubes constructed from Vinyon "N" cloth in bridging arterial defects—experimental and clinical.Ann Surg. 1954; 140: 324-334Crossref PubMed Google Scholar At about the same time, Harris Shumacker successfully repaired a ruptured abdominal aortic aneurysm with a conduit prepared from a sheet of nylon.52Shumacker HB In discussion of Blakemore's paper.Ann Surg. 1954; 140: 324-334Crossref PubMed Scopus (85) Google Scholar To fully appreciate the achievements of that era, one must understand that hemostasis was a constant challenge both because of the variability of fabrics and because of the misconception that aneurysms had to be completely excised to avoid contamination.38Julian OC Grove WJ Dye WS et al.Direct surgery of arteriosclerosis.Ann Surg. 1953; 138: 387-403PubMed Google Scholar, 53Dale WA Band of brothers: creators of modern vascular surgery. 313. Kachergis Book Design, Pittsboro, N.C1996Google Scholar The early grafts frequently leaked from their home-sewn seams or frayed at the cut ends, which prompted Voorhees and others to heat-seal the ends or to turn back the grafts, French-cuff style, to facilitate suturing. In March 1954 Art reviewed the Presbyterian data at a Symposium on Vascular Transplants sponsored by the National Research Council.54Levin SM Reminiscences and ruminations: vascular surgery then and now.Am J Surg. 1987; 154: 158-162Abstract Full Text PDF PubMed Scopus (8) Google Scholar Panelists included Robert Gross, Charles Hufnagel, Harris Shumacker, and Michael DeBakey. It was evident that a new era had indeed begun in vascular surgery. One month later, Blakemore and Voorhees presented both animal and human data at the American Surgical Association meeting, which were published later that same year in the Annals of Surgery.51Blakemore AH Voorhees Jr, AB The use of tubes constructed from Vinyon "N" cloth in bridging arterial defects—experimental and clinical.Ann Surg. 1954; 140: 324-334Crossref PubMed Google Scholar The new field of vascular prostheses had been opened, and it expanded rapidly under sponsorship of a number of influential American surgeons. Other prosthetic materials were introduced by the industry, and surgical meetings and journals during that time focused on textile lexicon, debating the relative merits of porosity, denier, taffeta, crimp, and other elements of fiber fabrication.55Callow AD Historical development of vascular grafts.in: Vascular grafts. Appleton Century-Crofts, New York1978: 5-22Google Scholar Vinyon-N rapidly gave way to competitive fibers with more favorable physical properties, including Orlon, Teflon, nylon, and Dacron.56Hufnagel CA The use of rigid and flexible plastic prostheses for arterial replacement.Surgery. 1955; 37: 165-174PubMed Google Scholar, 57Girvin GW Wilhelm MC Merendino KA The use of Teflon fabric as arterial grafts.Am J Surg. 1956; 92: 240-247Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 58Harrison JH Swanson DS Lincoln AF A comparison of the tissue reactions to plastic materials: Dacron, ivalon sponge, nylon, orlon, and teflon.Arch Surg. 1957; 104: 139-144Crossref Scopus (31) Google Scholar, 59DeBakey ME Jordan Jr, GL Beall Jr, AC et al.Basic biologic reactions to vascular grafts and prostheses.Surg Clin North Am. 1965; 45: 477-497PubMed Google Scholar Although vascular surgeons were key to these developments, we must acknowledge that industrial entrepreneurs and textile engineers were important collaborators. In the early days of vascular graft insertion, the materials were not custom-made for use as medical devices; the yarns used and most of the early conduits were, in fact, "borrowed" from commercial textile applications. Voorhees lamented the absence of industrial support for development in the initial phase: "Materials were procured wherever they could be found; tubes were cut and sewn in scrub rooms...unsophisticated, often cranky, prototypes..."60Voorhees Jr, AB How it all began.in: Vascular grafts. 3. Appleton Century-Crofts, New York1978Google Scholar (Fig. 3). Michael DeBakey and associates in Houston rapidly became the leading advocates of Dacron, a fabric well established in the garment industry. In cooperation with Professor Thomas Edman of the Philadelphia College of Textiles and Science, DeBakey sponsored the development of a knitting machine capable of producing seamless knitted Dacron tubes in various sizes and in the form of bifurcations.61Edman T Fundamentals of vascular grafting. 119. McGraw-Hill Book Co, New York1963Google Scholar Within less than 4 years, he and his colleagues at Baylor had implanted more than 1000 synthetic grafts with a 90% success rate.62DeBakey ME Cooley DA Crawford ES Morris Jr, GC Clinical application of a new flexible knitted Dacron arterial substitute.Am Surg. 1958; 24: 862-869PubMed Google Scholar One mus