R. Clement Darling Jr, MD, and the evolution of vascular surgery
2010; Elsevier BV; Volume: 51; Issue: 3 Linguagem: Inglês
10.1016/j.jvs.2009.10.112
ISSN1097-6809
Autores Tópico(s)Vascular Procedures and Complications
ResumoIt is a great honor to serve as the 36th President of the New England Society of Vascular Surgery, the oldest regional vascular society in the country. With this honor, of course, come duty and specifically, the assemblage of a Presidential Address. I have reviewed Presidential Addresses delivered before this Society by my teachers and predecessors. The trends seem clear: decide on fact or philosophy, stick to something you are at least vaguely familiar with, avoid boredom, and remember that, in Boston, tradition must be served. The latter facet is a pleasure, as it has been the great honor of my professional life to lead the Vascular Division at the Massachusetts General Hospital founded by Drs Linton and Darling. I hope there will be a certain satisfaction for our membership this morning, because my topic is bound to both the history of our Society and the evolution of vascular surgery over the past 60 or more years. I take the lead of my teacher in Dr R. Clement Darling Jr's Presidential Address to this Society in 1981, when he recounted the contribution of his teachers of vascular surgery. Giants like Drs Gross, DeBakey, Cooley, and of course, Linton, trained him in this new specialty of arterial reconstructive surgery and set the stage for his numerous and sentinel contributions to our specialty. Clem Darling was my first teacher of vascular surgery and my professional grandfather (Fig 1). I hope to convince you that his contributions to vascular surgery and his stewardship of his pupils created the foundation for the favorable evolution of our specialty and our practice that flourishes today. Although Linton began vascular surgery in New England at the Massachusetts General Hospital (MGH), it remained for Dr Darling to both perfect this new specialty of arterial reconstructive surgery and demonstrate and document the safety, efficacy, and long-term results thereof. Linton was occupied with fundamental technical considerations of this new art of arterial reconstruction. Was end-to-side preferred to end-to-end? Would homografts suffice as arterial replacements? Linton, who had assumed the role of Chief of the Vascular Clinic at the MGH in 1946, was well at work in the surgical treatment of vascular diseases when only venous disease and/or portal hypertension were amenable to direct surgical repair. After the advent of direct operation for both peripheral occlusive disease by Kunlin in 1949 and abdominal aortic aneurysm (AAA) by DuBois in 1951, Linton introduced these new operations to Boston in the 1950s. No student of vascular surgery history should miss the story of these wondrous years, so eloquently detailed in Dr Bruce Cutler's Presidential Address to our Society in 1993, “Robert R. Linton MD—A Legacy of ‘Doing it Right’.”1Cutler B.S. Robert R. Linton, MD: a legacy of “doing it right.”.J Vasc Surg. 1994; 19: 951-963Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar It remained for Dr Darling, who joined Dr Linton in practice in 1960, to provide and document the evidence for the worth of arterial reconstruction in a variety of vascular territories. Furthermore, his contributions, which I will detail shortly, transformed vascular surgery in New England from a series of technical procedures to correct specific problems to a specialty with comprehensive cognitive, diagnostic, and therapeutic mastery of vascular disease. This was an enabling force for the evolution of our specialty when transforming ideas like endovascular therapy subsequently appeared. No Presidential Address can begin without acknowledgment and thanks to the many that made it possible for me to be your 36th President. All of you have your traditions, but please indulge me for a few minutes if I recount the influence of my father. He was a perfect example of what Tom Brokaw and Stephen Ambrose termed “the greatest generation” this country has ever produced. A young teenager in the Depression, he worked in a pharmacy and had aspirations to go to pharmaceutical school. There was no money for that, so like so many of his generation, he joined the military and ultimately spent eight and a half years of the prime of his life in the service of his country. When I was 26, I was studying to complete my medical school examinations. When he was 26, he was climbing in the navigator bombardier's compartment on a B-25, in the horror of World War II's Pacific Theater in 1945. He was witness to history. On August 9, 1945, the Seventh Air Bomber Squadrons were all instructed to maintain a 50-mile airspace berth around Nagasaki. He witnessed the mushroom cloud, and 2 days later, of course, the Great War was over. What mixture of emotions must have filled him? The horror of the War in the Pacific and the dawn of the Nuclear Age, but from a practical standpoint, the anticipated joy of finally going home. Later, when I was about 12 years old, my weekends were spent working in my father's family butcher shop. To give you some perspective, a gallon of gas, a quart of milk, and a pack of cigarettes each cost 28 cents! My father was my first teacher of surgery as he taught me the principles of traction and counter-traction when he taught me how to cut up a chicken! I have two distinct memories. The first is the one time I ever asked him, and the only time he ever talked about, his World War II experiences. He was a navigator bombardier on a B-25; the words “bombs away” brought delight to the entire crew, because that meant it was time to get out of harm's way. On that one occasion I asked him, “What did it feel like to drop bombs?” His only reply was, “I just hope those bombs never killed anybody.” If one understands the history of the Pacific Theater in World War II, it will be recognized that this was the response of a man possessed of a humanism and kindness that I could only hope to bring to the thousands of patients who have come under my care over the past 30 years. The second memory is my distinct remembrance of the look on his face the day I graduated medical school. It was clear to me my father considered this life's fulfillment, his part of the American dream. So you can appreciate that I was very lucky to be born when I was, and of whom I was. My career at the MGH began as a subintern on vascular surgery in September 1976. When I joined Dr Darling's service, I discovered the specialty that seemed to suit me so well, because the vascular surgeon was the expert in the diagnosis, clinical decision making, and execution of the surgical treatment of the patient afflicted with vascular disease. As I began internship, I was committed to a career in vascular surgery. Dr Darling gave me an autographed copy of the Haimovici's Textbook of Vascular Surgery and wrote to me after my subinternship that he had “reported on my good behavior to those who matter around here.” Thus, my matriculation on the surgical house staff at the MGH I attribute to Dr Darling, and his retirement from clinical surgery was the occasion of my appointment to the faculty at the MGH in 1986. My teachers in residency were giants in the world of surgery. To Jerry Austen, who appointed me and who shepherded my career, and who I still call on for wisdom, I owe a great deal. World-class surgeons Ron Malt, George Nardi, Mort Buckley, C.A. Wang, and the great Professor Hermes Grillo, were my teachers in those formative years. A special thanks is in order to my current Chief, Andy Warshaw, who appointed me Chief of the MGH Vascular Division 8 years ago. Bill Abbott, 30th President of this Society, my predecessor as Division Chief, welcomed me into his laboratory, facilitated my evolution in academic vascular surgery, yet allowed me as a young faculty member my own particular mode of growth. No surgeon can be effective in isolation, and my partners and colleagues in the Division of Vascular and Endovascular Surgery at the MGH are responsible for the fact that it is so much fun to come to work every day. In particular, my senior partner, David Brewster, 27th President of this Society, has been a teacher, mentor, and friend now for 33 years. When one considers the evolution of vascular surgery, Dr Brewster's contributions have been sentinel. As most of you know, he led the charge in transition to endovascular aneurysm repair (EVAR) for treatment of AAA when he performed the first such procedure in New England at the MGH in 1994. His Presidential Address to this Society—just 9 years ago—on the merits of EVAR profoundly influenced my own thinking towards this technology.2Brewster D.C. Presidential address: What would you do it it were your father? Reflections on endovascular abdominal aortic aneurysm repair.J Vasc Surg. 2001; 33: 1139-1147Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Today, some 70% of AAAs treated at MGH are managed with EVAR. At the other end of the spectrum, my younger and newest associates, Drs Mark Conrad and Virendra Patel, have provided me with the great satisfaction of bringing the next generation of academic vascular surgeons along. I am so pleased my wife of 35 years, Chris, is here with us today. The life of a resident and then surgeon being what it is, she has shouldered the bulk of the parenting of our five children and currently, the two dogs, and she never once said “do you have to make rounds today?” Well, maybe once. The history of vascular surgery at the MGH genuinely is the history of vascular surgery, and Dr Darling's major contributions to that, we will get to in just a moment. My hypothesis is that the maturation of vascular surgery into the modern era, shepherded by R. Clement Darling Jr, was an enabling force in the evolution of our practice and our specialty. Dr Darling taught the mastery of the total disease process afflicting the vascular surgery patient and the absolute insistence that a practicing vascular surgeon should be totally familiar with the disease process of atherosclerosis, its pathophysiology, all of the clinical manifestations, and yes, complications of treatment; this would maintain the vascular surgeon as the only logical specialist to provide total vascular patient care. Parenthetically, as noted below, Linton and Darling were, in fact, innovators in endovascular as well as traditional vascular surgery. Clem Darling was born in California but spent most of his formative years in Southeastern Massachusetts. As a young boy, he grew up on the Laneway Farm in Taunton. The farm was owned by a Dr Gamble, who was a Harvard chemistry professor, and was managed by Clem's father. His was a boyhood of hard knocks and hard work, and despite the Harvard connection at the farm, or perhaps because of it, by age 18, Clem had joined the U.S. Marine Corps in the waning days of World War II. He served in the Far East, one time being hospitalized with malaria in China. He wrote to Clem Hiebert, MD, who would subsequently introduce him for his Presidential Address before this Society, that his experiences in a military hospital surrounded by maimed, war-wounded soldiers was the thing that piqued his interest in medicine and surgery. He was only 18 at the time, and the impact was profound. His own words were “particularly to see how mutilated one can be and live, and yet at the same time to see how well one can look and yet die.” He was decorated for his work in the Far East and was honorably discharged as a 1st Lieutenant in the Marine Corps; this was a facet of his life that was both a source of great pride for Dr Darling and offered a perspective of life that I can perhaps simplify as a no-nonsense, get the job done approach, that would forever influence his professional career. He was no academic star during his undergraduate years at Boston University, and he relates that he was finally accepted at the Boston University Medical School only the day before classes started! In 1953, however, he would graduate first in his medical school class and become the first Boston University graduate to ever be accepted as an intern at the MGH. His initial introduction to cardiovascular disease was during a stint working in pathology with Dr Robert Gross at the Children's Hospital. Darling apparently learned the benefit of a degree of boldness in surgical decision making from Dr Gross, who performed the first direct aortic replacement in Boston for coarctation with arterial homografts around 1945. Indeed, the very first paper on Clem's curriculum vitae was a study of 17 cases of total anomalus pulmonary venous drainage published in 1957 with Dr Gross as he was finishing residency.3Darling R.C. Rothney W.B. Craig J.J. Total pulmonary venous drainage into the right side of the heart: report of 17 cases.Lab Invest. 1957; 6: 44-64PubMed Google Scholar More than 20 years later, at the time of Dr Darling's presidency, Dr Robert Gross would acknowledge Clem's appointment, making him an honorary member of the New England Society for Vascular Surgery. Dr Gross, at that point some 85 years old, commented on Dr Darling's innovation in terms of noninvasive diagnosis! In 1958, appointment to the Super Chief Resident was the aspiration of all MGH surgical residents. However, Dr Edward Churchill, his Chief, “with a wink in his eye,” said Dr Darling was “too good technically to be the Chief Resident,” and appointed George Zuidema to this position. This was, in fact, fortuitous, because Churchill called one Michael DeBakey, facilitating the appointment of Dr Darling as Chief Resident in Thoracic and Cardiovascular Surgery under DeBakey in Houston from 1958 to 1960. This, of course, was the proverbial “golden opportunity,” because Darling worked directly with DeBakey, Cooley, and E. Stanley Crawford. who had recently joined DeBakey's faculty after completing the Chief Residency at the MGH in 1955. The era was apocryphal, being the virtual origin of direct arterial reconstruction, in particular, for aortic disease. Thereafter, Dr Darling joined Linton in practice in 1960, and the rest, as they say, is history. Perhaps a useful outline to detail Dr Darling's important contributions across the spectrum of vascular surgery can be found in the announcement of the Commemorative Surgical Grand Rounds that was held in his honor at the MGH a few months after his death, and as we stand here this morning, almost exactly a decade ago (Fig 2). Important contributions and landmark publications were produced by Dr Darling in aortic aneurysm disease, lower extremity occlusive disease, noninvasive diagnosis, arterial embolism, renovascular surgery, and the long-term results after vascular surgical procedures. By 1961, Linton had reported in no less a prestigious forum than the New England Journal of Medicine, a series of 150 elective AAA repairs with a 10% mortality.4Gryska P.F. Wheeler G. Linton R.R. A review of seven years' experience with excision and graft replacement in 150 ruptured and unruptured aneurysms of the abdominal aorta.N Engl J Med. 1961; 264: 639Crossref PubMed Scopus (13) Google Scholar It remained for Darling to detail the next two decades of aneurysm surgery at the MGH in the context of his own prodigious experience: he treated more than 500 elective patients for AAA in the 1970s, with an operative mortality of 1.7%.5Darling R.C. Brewster D.C. Elective treatment of abdominal aortic aneurysms.World J Surg. 1980; 4: 661-667Crossref PubMed Scopus (50) Google Scholar I should like to remind the younger members of the audience that there were no Persantine-thallium scans, there were no pulmonary artery catheters, every patient got a tube gastrostomy with intermittent clamping beginning on the fifth postoperative day, and no one cared too much about length of stay! The secret to these superb results was Darling's rigid adherence to Linton's simple, yet quintessential principle of vascular surgery: “it must be done right.” Shown in Fig 3, made from one of Dr Darling's original manuscripts, is his advocacy of an interrupted suture technique for the proximal aortic anastomosis. This is a lesson we continue to teach our fellows today; namely, in the circumstance of a bad or fragile aorta, go to the interrupted pledgeted technique. Although Linton began aortic surgery at the MGH, Darling perfected it, enabling his pupils with a practice perspective to subsequently mature both EVAR and complicated central aortic surgery.Fig 3Interrupted, pledgetted technique for proximal aortic anastomosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Published in Circulation in 1977 was one of Dr Darling's most famous and widely quoted contributions to aortic aneurysm disease. In this autopsy study of nearly 500 patients who died with unrepaired AAAs, 25% died of rupture. The provocative finding from this study was the finding of rupture in something other than truly large aneurysms. In addition, the anatomy of rupture and survival after symptom onset were carefully detailed, as shown in the Figure (Fig 4) from his manuscript.6Darling R.C. Messina C.R. Brewster D.C. Ottinger L.W. Autopsy study of unoperated abdominal aortic aneurysms: the case for early resection.Circulation. 1977; 56: 161-164Google Scholar Thus, the preponderance of retroperitoneal rupture (being some 80%) and its obvious implications for both the potential of surgical salvage and certain technical considerations (eg, venous injury) were clearly established. This report was cited for some 20 years as the definitive work demonstrating that small aneurysms can and do rupture, and was for the world of vascular surgery an important work in justifying an aggressive posture towards even modest-sized aortic aneurysms. Although his study was not the first to suggest familial and genetic factors in certain AAA patients, Dr Darling's was the largest series systematically analyzed in this regard. In an article published 20 years ago in Journal of Vascular Surgery and with his son, Clem, as first author, Dr Darling presented prospectively gathered data on more than 500 AAA resections. He established the incidence (15%) of familial aneurysm, the fact that anatomic extent was no different vs nonfamilial lesions, and most importantly, the greatly increased rupture risk for familial aneurysms, especially in women.7Darling III, R.C. Brewster D.C. Darling R.C. LaMuraglia G.M. Moncure A.C. Cambria R.C. Abbott W.M. Are familial abdominal aortic aneurysms different?.J Vasc Surg. 1989; 10: 39-43PubMed Scopus (153) Google Scholar The hypothesis of this important article emphasizing the morbid history of aortic aneurysm in women with familial aneurysm has now been verified in large prospective and population studies for both thoracic and abdominal aortic aneurysms.8Greenhalgh R.M. The U.K. small aneurysm trial participants with Louise C. Brown and Janet T. Powell Risk factors for aneurysm rupture in patients kept under ultrasound surveillance.Ann Surg. 1999; 230: 289Crossref PubMed Scopus (534) Google Scholar, 9Clouse W.D. Hallett Jr, J.W. Schaff H.V. Gayari M.M. Ilstrup D.M. Melton 3rd, L.J. Improved prognosis of thoracic aortic aneurysms: a population-based study.JAMA. 1998; 280: 1926-1929Crossref PubMed Scopus (355) Google Scholar, 10Juvonen T. Ergin M.A. Galla J.D. Lansman S.L. Nguyen K.H. McCullough J.N. et al.Prospective study of the natural history of thoracic aortic aneurysms.Ann Thorac Surg. 1997; 63: 1533-1545Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar Other widely quoted scholarly works would come from Dr Darling's pen. These would review the effect of Fogarty's catheter on the treatment of arterial embolism,11Darling R.C. Austen W.G. Linton R.R. Arterial embolism: review of 27 years experience at the Massachusetts General Hospital.Surg Gynecol Obstet. 1967; 124: 106-114PubMed Google Scholar this being a follow-up study to an MGH series initially published in 1948,12Warren R. Linton R.R. The treatment of arterial embolism.N Engl J Med. 1948; 238: 421-429Crossref PubMed Scopus (16) Google Scholar a full 15 years before the advent of catheter embolectomy!13Fogarty T.J. Cranley J.J. Kraisse R.J. Strasser E.S. Hafner C.D. A method for extraction of arterial emboli and thrombi.Surg Gynecol Obstet. 1963; 116: 241-244PubMed Google Scholar In a review article for the New England Journal of Medicine, Darling noted that in the interval of 1963 to 1969 “approximately 1,200 articles pertaining to the surgery of peripheral vessels have been published” and that his review was “an analysis of progress.”14Darling R.C. Medical progress: peripheral arterial surgery, part I.N Engl J Med. 1969; 280: 26-30Crossref PubMed Scopus (10) Google Scholar He was not the first to describe extra-anatomic bypasses for renal artery reconstruction, but Darling reported one of the initial large series in this regard and this topic is the subject of the very last citation on his curriculum vitae written with this pupil and confirming the durability of extra-anatomic renal artery reconstruction.15Cambria R.P. Brewster D.C. L'Italien G.J. Moncure A.C. Darling Jr, R.C. Gertler J.P. et al.The durability of different reconstructive techniques for atherosclerotic renal artery disease.J Vasc Surg. 1994; 20: 76-87Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar In the realm of lower extremity arterial occlusive disease, it remained for Dr Darling to carry on and mature the experience that Linton began by performing the first femoropopliteal vein graft at the MGH in 1950 for a popliteal aneurysm. By 1961, Linton and Darling were reporting clinical series of femoropopliteal bypass grafts at the Society for Vascular Surgery (SVS). The initial direct surgical repairs of aortoiliac and femoropopliteal occlusive disease were long-segment endarterectomies, often closed with a venous or Linton patch. Careful and scrupulous follow-up end results after such procedures eventually indicated that endarterectomy would yield to bypass grafting both for aortoiliac inflow disease and superficial femoral artery disease. A variety of Dr Darling's landmark publications would profoundly influence the practice of vascular surgery in occlusive disease management for the next several decades. In a sentinel report before the SVS in 1966, saphenous vein femoropopliteal bypass grafting was established as the gold standard for revascularization of infrainguinal occlusive disease, and life-table analysis of such results was reported for the first time. Dr Darling gathered nearly 300 such cases performed by he and Dr Linton and reported a 73% actuarial 5-year patency.16Darling R.C. Linton R.R. Razzuk M.A. Saphenous vein bypass grafts for femoropopliteal occlusive disease: a reappraisal.Surgery. 1967; 61: 31-40PubMed Google Scholar Of interest is that John Mannick, MD, another Bostonian, also presented data at the same SVS meeting championing the saphenous vein as the preferred conduit. However, in discussing Darling's paper, Dr E. Stanley Crawford of Houston allowed that 8-mm Dacron, in his experience, produced equivalent results. History has shown the Bostonians to be correct! In a follow-up study presented to the New England Surgical Society in 1971, Darling demonstrated the superiority of venous autograft bypass vs endarterectomy for femoropopliteal occlusive disease in a series of 565 femoropopliteal reconstructions performed from 1955 to 1967 and only including patients with a minimum of 3 years of follow-up. Endarterectomy would pass into the history books for the treatment of superficial femoral artery disease.17Darling R.C. Linton R.R. Durability of femoropopliteal reconstructions: endarterectomy versus vein bypass graft.Am J Surg. 1972; 123: 472-479Abstract Full Text PDF PubMed Scopus (151) Google Scholar Similarly, Dr Darling's personal experience with aortoiliac reconstruction established the superiority of aortofemoral prosthetic bypass grafting—as opposed to endarterectomy—for inflow disease. In a landmark paper and report to the SVS in 1978 with his new partner, David Brewster, MD, as first author, they detailed nearly 600 patients treated by Dr Darling for aortoiliac disease from 1963 to 1977. Superior procedural morbidity and durability (with the now-often quoted 5-year patency of 91%) was established for aortobifemoral bypass grafting, and remains the gold standard more than 30 years later.18Brewster D.C. Darling R.C. Optimal methods of aortoiliac reconstruction.Surgery. 1978; 84: 739-748PubMed Google Scholar Other surgical nuances such as discerning different patterns of aortoiliac occlusive disease, the importance of profunda femoris reconstruction, and the preference for end-to-end proximal aortic anastomosis as reported in that article have been surgical dogma in aortoiliac reconstruction for more than 30 years. Perhaps less known, but arguably of greater overall impact in the world of vascular disease management, were Dr Darling's contributions in the realm of noninvasive diagnosis for peripheral arterial occlusive disease. Linton had assembled a surfeit of pioneers in vascular disease at the MGH Vascular Clinic, originally established as the very first clinic of its kind in 1928 under Arthur Allen, MD, and subsequently directed by Robert Linton as of 1946. Linton charged one Fiorindo Simeone, MD, the fourth President of the New England Society for Vascular Surgery, with the establishment of a laboratory dedicated to the study of peripheral vascular disease in 1946. Jimmy Yao, MD, in his Presidential Address to the Midwestern Vascular Society in 1986, credited Linton and Simeone with the establishment of the very first noninvasive vascular laboratory in the country at the MGH in the late 1940s.19Yao J.S.T. Presidential address: precision in vascular surgery.J Vasc Surg. 1986; 5: 535-543Google Scholar The laboratory was subsequently run by John Cranley for 2 years, before his departure to Cincinnati in 1952, whereupon the laboratory gradually petered out. A chance meeting in the late 1960s between Dr Darling and Jeffrey K. Raines, then a doctoral candidate in engineering at Massachusetts Institute of Technology, resulted in many hours of basic laboratory research to perfect what we know today as the pulse volume recorder. Results with this technique in some 1000 observations were presented to the SVS in 1971, and the fundamental concept of segmental pressures and pulse volume recordings was born as the cornerstone of peripheral vascular noninvasive diagnosis.20Darling R.C. Raines J.K. Brener B.J. Austen W.G. Quantitative segmental pulse volume recorder: a clinical tool.Surgery. 1972; 72: 873-887PubMed Google Scholar The manuscript, published in 1972 begins “A quantitative segmental pulse volume recorder (PVR) has been described which is 1) simple, reliable, and reproducible, 2) capable of standardization, 3) easily employed by paramedical personnel, and 4) adaptable to measurements taken after exercise.” This method for diagnosis of peripheral vascular disease would become and remains standard practice, including its use for intraoperative monitoring of arterial reconstructions.21O'Donnell T.F. Raines J.K. Darling R.C. Intraoperative monitoring using the pulse volume recorder.Surg Gynecol Obstet. 1977; 145: 252-254PubMed Google Scholar Dr Darling subsequently submitted a proposal to W. Gerald Austen, MD, then Chief of the Surgical Services, to establish a clinical laboratory, which was initially housed in our current fellows' sleep room adjacent to the Bigelow Amphitheater. With amusement, Darling related that the laboratory was “started with a budget of about $12,000, much of which was spent on removing a toilet and two wash basins.” The establishment of specific training in vascular surgery, or the Vascular Fellowship, was something very dear to Clem Darling's heart. Taking his lead from Linton, who apparently trained the very first Vascular Fellow in 1946,1Cutler B.S. Robert R. Linton, MD: a legacy of “doing it right.”.J Vasc Surg. 1994; 19: 951-963Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Dr Darling subsequently trained some 30 Vascular Fellows, at least 11 of whom went on to run vascular divisions of their own. Outstanding vascular surgeons with an enviable record of contribution to and leadership for our specialty were amongst Dr Darling's trainees. Among the names on this list are Cliff Buckley, Tom O'Donnell, Jeb Hallett, George Hamilton, Jay Robison, Bruce Perler, Patrick O'Hara, and Bruce Brenner. Dr Darling was no genteel teacher; rather, he was a demanding, intense surgeon accepting only of perfection. He might admonish a trainee with “I don't care if you do it slow and meticulous, or fast and sloppy, but do you have to do it slow and sloppy!” Other important contributions made by Dr Darling included some of the earliest applications of autotransfusion in aortic surgery; with his then Fellow, Bruce Brenner, the initial report of this strategy appeared in the literature in 1973.22Brener B.J. Raines J.K. Darling R.C. Intraoperative autotransfusion in abdominal aortic resections.Arch Surg. 1973; 107: 78-84Crossref PubMed Scopus (66) Google Scholar Although its popularity waned in these early years as blood banking came into its own, vascular surgeons today routinely apply the autotransfusion strategy in open aortic reconstruction. Finally, Dr Darling's interest in the physiology of aortic cross-clamp application, evident in an often-cited reference published in 1976 in Circulation,23Attia R.R. Murphy J.D. Snider M. Lappes D.G. Darling R.C. Lowenstein E. Myocardial ischemia due to infrarenal aortic cross clamping during aortic surgery in patients with severe coronary artery disease.Circulation. 1976; 53: 961-965Crossref PubMed Scopus (168) Google Scholar eventually led to his collaboration with a young cardiologist by
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