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Introduction | A Personal View of the History of Interventional Radiology
Introduction | A Personal View of the History of Interventional Radiology
2017appointmentsAVIRcannulatedinterventionalloopmassmassachusettsprogramradiologicradiologysocietywaldman
Radiology in the Past - What Shaped Radiology | A Personal View of the History of Interventional Radiology
Radiology in the Past - What Shaped Radiology | A Personal View of the History of Interventional Radiology
2017arteriesAVIRcarotidchapterencephalopathyfull videogramsinternshipinterventionalintracranialneedlepneumoradiologistradiologysurgerytera
Changing Environment for Hospitals | A Personal View of the History of Interventional Radiology
Changing Environment for Hospitals | A Personal View of the History of Interventional Radiology
2017AVIRchangingchapterfull videohospitalmedicarephysiciansradiologistsradiology
Boston 60's | A Personal View of the History of Interventional Radiology
Boston 60's | A Personal View of the History of Interventional Radiology
2017angioAVIRbostoncadaverchaptercystsdacronfull videograduallymaterialsseldingervessels
Sven Seldinger | A Personal View of the History of Interventional Radiology
Sven Seldinger | A Personal View of the History of Interventional Radiology
2017aortaarteriesarteriographyarteryascendingAVIRbrachialcardiologistscathetercatheterizechaptercoronaryfull videointerventionaljudkinsmajorpersistedradiologisttechniqueventriclevessels
My Introduction to Vascular MGH 1971 | A Personal View of the History of Interventional Radiology
My Introduction to Vascular MGH 1971 | A Personal View of the History of Interventional Radiology
2017AVIRcathetercatheterschapterdarkfilmfilmsfrenchfull videomaterialspicturespullshapeshapessterilewires
Early Interactions with Manufacturers - Cook Inc and Meditech Inc | A Personal View of the History of Interventional Radiology
Early Interactions with Manufacturers - Cook Inc and Meditech Inc | A Personal View of the History of Interventional Radiology
2017AVIRbillarycathetercatheterschaptercholecystectomycookdesignductfloatingfull videoguidewireinterventionalmoveoregonproductproductsradiologistrigidrsnarunoffsequentiallystartedwirewires
Procedures in Filming | A Personal View of the History of Interventional Radiology
Procedures in Filming | A Personal View of the History of Interventional Radiology
2017aneurysmsAVIRchapterdiseasefull videopancreaticpatientsperipheralrenaltumorsultrasoundvascular
Diagnostic Arteriography - 1971 MGH GI Bleeding | A Personal View of the History of Interventional Radiology
Diagnostic Arteriography - 1971 MGH GI Bleeding | A Personal View of the History of Interventional Radiology
2017armyarteriesAVIRbleedingbloodcatheterschapterduodenumembolizationfoamfull videoiliacjournalpatientspelvisphiladelphiavasoconstrictorsvasopressinvessels
Formation of SCVIR - 1972 | A Personal View of the History of Interventional Radiology
Formation of SCVIR - 1972 | A Personal View of the History of Interventional Radiology
2017alcoholAVIRblockschapterchemocommunicationscompressibledesignsembolisationembolizationfull videoinfusedinterventionalliquidmaterialsmichiganocclusionpolyvinylradiologyradiopaquesizesspongetexasvascularwires
Embolization - 1973 | A Personal View of the History of Interventional Radiology
Embolization - 1973 | A Personal View of the History of Interventional Radiology
2017anticoagulatedatheromaAVIRcavalchapteremboliembolusfilterfrenchfull videopatientpulmonaryradiologistsurgeonsvena
1st Patient in OR with Surgical Attendance - 1974 | A Personal View of the History of Interventional Radiology
1st Patient in OR with Surgical Attendance - 1974 | A Personal View of the History of Interventional Radiology
2017aneurysmaneurysmsangioplastyarteriesarteryAVIRballoonchapterdesignfemoralfull videokindslargerstenosissuperficialsurgerysurgicalvascularvessels
Non-Vascular Interventions | A Personal View of the History of Interventional Radiology
Non-Vascular Interventions | A Personal View of the History of Interventional Radiology
2017AVIRcatheterschaptercryotherapyfluoroscopyfull videogastrointestinalintestinalmanagenonvascularperitonealtracttumorsultrasoundurinary
Transhepatic PortoSystemic Shunts | A Personal View of the History of Interventional Radiology
Transhepatic PortoSystemic Shunts | A Personal View of the History of Interventional Radiology
2017AVIRchaptercomplicatedfull videoHypertensionoregonpatientsportalshuntssystemicvariceal
Thrombolysis | A Personal View of the History of Interventional Radiology
Thrombolysis | A Personal View of the History of Interventional Radiology
2017activatorAVIRbasalchapterchronicemboliembolicfull videoiliaclysisocclusionsplasminogenpulmonarystreptokinasethrombosisultrasoundvenavenousvessels
IVC Filters | A Personal View of the History of Interventional Radiology
IVC Filters | A Personal View of the History of Interventional Radiology
2017AVIRchapterfragmentfull videopatientsremoveretroperitoneum
Vascular Grafts | A Personal View of the History of Interventional Radiology
Vascular Grafts | A Personal View of the History of Interventional Radiology
2017aneurysmAVIRcardiologychaptercollaborationfull videoiliacpatientspercutaneouslystenosissurgerysurgicaltherapythoracic
1973 - 1980 | A Personal View of the History of Interventional Radiology
1973 - 1980 | A Personal View of the History of Interventional Radiology
2017AVIRchapterdollarsexpandedfull videoinitiallyjournal
IR Physicians become Clinicians | A Personal View of the History of Interventional Radiology
IR Physicians become Clinicians | A Personal View of the History of Interventional Radiology
2017AVIRchapterclinicianfull videogoogleinterventionalistoncologiconcologypatientpatientstechnologist
Transcript

I dr. Waldman you know became quite famous for a technique he probably all heard of which is the waltons loop which is the cannulated to provide the guy so we have a program that's basically love the loop back in Mass General so let me introduce dr. Waldman attended medical

school at the University of Pennsylvania his radiology residency there completed his fellowship at Massachusetts General Hospital through his tenure dr. Waldman hold many appointments including the chief of the section for a number of

years appointment in the United States Army Harvard University Mass General Hospital he told numerous countless board appointments including the ACR the Massachusetts radiologic society the sio would think with interventional society

come he was a gold medalist in any president I can't even tell you the countless amount of fellows that he helped inductees the program director the secretary the president president-elect chairman all of these

positions as you can see dr. Waldman is held in been such a huge influence on our society so please join me in welcoming my dear friend dr. Waldman good morning most of you will have had some sort of presentation or read

something about interventional radiology I'm going to just sort of give you my personal walk through a good bit of the life of interventional radiology today and the past so let's get started with

why did we get interventional radiology

and what was radiology like back in the 50s and 60s basically radiology was a diagnostic world and major procedures were barium studies I vp's we didn't have ultrasound we didn't have cts and we didn't have mr and nuclear medicine

was like a bad storm with a lot of pictures of dots and not at all sophisticated the way it is today our tera grams were performed mostly by surgery and they use needles it was very much grew out of Portugal and Spain with

a almost a similar type of a needle shape as the people used to make that final punjon of bull in the stadium but I remember in my residency seeing patients with meals placed in their carotid arteries taped to their chest

and on a table to get our Terra grams of the carotid arteries and the intracranial not vessels trans lumbar protests were we got into the lung the aorta and femoral arteries and that was pretty much what was available

now as far as radiologists doing anything occasionally they would be involved in myelography but they didn't do the needle puncture and they didn't instill the contrast similarly pneumo encephalopathy yet I don't think anyone

in this room has ever seen a new moon Seth Legrand oh all right and they didn't do that those punches or and put the carbon dioxide in the either so pretty much just a hands off of patients and my father wanted me to go into

surgery in the most important way and that come work with him and I sort of decided that I tried surgery looked at surgery did an internship in surgical environment and I said this isn't for me and I have had some exposure to

radiology and I applied and was accepted and went into radiology and then some years later when I gave a lecture to our county medical society in Pennsylvania he said you're a surgeon you're not when I think it was a radiologist so what

shaped what happened to radiology well oops oh this money hospital started

changing and they changed very quickly with the passage of Medicare Medicare meant that radiologists were paid for the procedures separately from the

hospital and that meant that we had to Bill's hospital and the physicians component and that the monies that that they collected allowed those people who are in charge of radiology departments of a physician's to acquire additional

people in some cases equipment and personnel so it freed up radiology from the domination of whatever interest the hospital had in managing their their lives we then have what's been changing

in that timeframe in the 50s and in the

60s we had a real war was called the police action in Korea and a lot of patience a lot of soldiers were injured survived but they had major injuries to vessels and they lost their limbs and what was necessary was to create a

[Music] bypass of some sort and surgeons were trying to use veins but if you have damages to both legs you really don't have a lot of good selections to go with to put a vein in these things and they

were trying all kinds of different materials that do graphs and they had some of the new woven materials coming out of the Second World War and Dacron and rayon and nylon etc that gradually became part of the thing Teflon was

another particle another material in addition they also used cadaver vessels that they irradiated to knock out as much of the immune system as possible and when a transplanted material it worked in some cases even for aortic

transplants and they needed additional ways of getting more information now the problem was that of people and also facilities that could allow you to do this we had a group of radiologists in Boston who got together

they were trying to do these procedures and they wanted to learn the seldinger technique and a fella from New York by the name of Bosniak some of you may have heard of him as a category of classifying cysts and kidneys would come

up and bring materials with him and show them what they could do and make new studies any of these groups in New York Boston Chicago Philadelphia Baltimore Washington and gradually they would have annual meetings pulling together

different groups and became the beginnings of something called the eastern and western angio societies that you may have heard of before dr. Seliger

was a major inventor and it was such a common sense type thing but it took

somebody to do something that was against sort of what his Chiefs are told him to do and which is the user sharp needle with a it was Hollow then when it got my blood spurt were fluid he could slip on the guide wire in piano wires

were the best at the beginning and then pull that out and then you can slide another catheter and over that and that whole process introduced all cognitive advantages to the forwarding of interventional management even years

later cardiology persisted in using a process that was developed by the sun's technique out of a Cleveland Clinic which is a to do a cut down on the brachial artery and then class a catheter retrograde up the brachial

artery into the ascending aorta to catheterize the vessels there that that technique when you've finished you had to then remove any traumas that was present and so Apple vessel and most of the cardiologists doing this were not

sophisticated in their technique and had to go through a number of emergency trips to the o.r to have a vascular surgeon do the repair of the vessels was a major problem but then we had doctors Judkins and Amplats who were

radiologists and we're very much interested in the heart and the coronary arteries and they developed a whole series of catheter shapes and designed to facilitate the performance of coronary arteriography and well

evaluation of the ascending aorta and eventually procedures to get into the ventricle and do pressures across the aortic valve thing that irritates the gnosis major step forward and we had these parallel ways of managing patients

coming from the radiologist and the femoral arteries coming from the cardiologists with the surgery on the brachial artery to do access to the coronary arteries and it persisted until it became very obvious that it was a

much easier and safer and faster technique than the sun's technique I

arrived in Boston after coming out of the Army in 71 and I arrived to a facility that had a whole slew of different imaging systems image take

techniques filling capabilities and we had limited guide wires catheters nothing was sort of very very little was available in pre-designed thing so that we had to work on making catheters the an afternoon for the fellows every

week where we would all sit down and make up catheter shapes punch holes in them if we wanted to make a pigtail catheter we had to shape the tip and then we had to flare the end so that we could put on a sort of metal

arrangements we didn't have plastic materials to be the fittings and connections to the injectors injectors had gone through a series of improvements they originally were systems where you stood on a pedal and

you push down with your foot and reject contrast into the catheter to actual powered machines that will give you a given rate of flow at a given pressure and volume we had film changers that worked by I remember hearing somebody

says shoot you know becoming out of the army I turned around to see what the hell we were talking about and there was a young RT pulling a frame of film down at little trash there was a tube leaded compartment and a stack of films and in

there just that and she would pull the first one at a place they'd get a a blank picture or picture without any contrast and injection would start they pull fire pull that out next one pull it next one pull it and she were all that

apron but I don't know how much radiation she got I just remember they got pictures for one early one did one light of the head in another room I watched them working with a changer that I knew that had developed in

Philadelphia all the Franklin changer and it was a box and you had a 50-foot roll of film the 14 inches long s wife and the film wait for 50 feet and you pull sheet out put it across the area where your

screens were put it on a take-up tank and then close everything up you fire away and do whatever protocol you hadn't taken sposi and cut that out have that film off and then put it in this dark room and put it through a processor and

you get this long roll of pictures Ricky somebody then had to mark them as to when they were thought they were exposed the big advantage that we had we had a brand new room that had from Siemens that had swedish design of film that

contained 14 inch square sheets of film in little holders and you put this in this box and you'd sell it in a dark room and then you come out put it into a holder close it up and it was open up the box and we take out the films and so

forth well what all this means is that you don't make pictures you do a run and then you had a wait for somebody to feed the films through a dark room across from the doctrine through a processor and it come out and you get one another

stone another film and then you just have a whole wall of few boxes that you put these things up that was just sort of a very convenient 10 minute delay between runs left- whatever you would do in terms of manipulations changing the

position of the patients whatever we had circumstances where we you had to move the patient pull them put them up on a block and get them positioned so you had to have people that were willing to lift two and three hundred pound patients and

get them into position often we would also modify catheters in the room they were sterile appreciate length catheters that we would shape in the room we had Bunsen burners of oiling steam cold water sterile water and we would shape

our own pastors catheter materials were came from various sources that were sort of bulk would get 15 feet or 20 feet or meters depending on whether you're getting things from Sweden or from the united states and different sizes we had

a French seven French and six French and five french catheter materials based on color kiva and we would use these raw materials guide wires what you got was what you got we had one size 35 thousandths of an inch diameter and then

quartus company some of you may still be working with who had developed a preformed polyurethane catheter that came in 78 French sizes and blue and one of the shapes that they had was this thing that we called the situ or t1 or

t3 and when somebody wrote that describe how these catheters worked and one of the reviewers recommended that they change the title for the thing in call this catheter Cobra because when the catheter

came up to a vessel in the side of the aorta it strike though they were snakes by making a bite now I'm going to see if

I can get where I want to be a year cook cook was a company that started in a garage their major product that got them

started with the design of a shot glass of whiskey at the bottom of which had a young lady with no clumps and your goal was to empty the glass and then look didn't make a whole lot of money but he had heard about something that was

happening in the in the local communities that said that maybe he should be considering getting into guide wires and catheters and he hired a young man from high school who designed a system where they would dip then if

you've not taken guidewire part the traditional guide wires there soldered at either end and in between is a little thin metal connection safety wire and then you have the coil spring but inside that is a rigid metal structure that is

the stiffness of the catheter the what guideline and at what you he did was he would dip them in nitric acid and had these things that look like the soap flamingos dipping and he just dissed them and they how long and how deep into

this nitric acid he would get different lengths and different thinness of the tip of the wire so that you had a transition zone from floppy to Surat gradually to more rigid in its design bill Polk is a good friend of

interventional radiology and I remember him telling me the story that he went to the rsna it was held in the hotel the palmer house in Chicago every late fall early winter and people were moving up and down stairs and passing exhibitors

and the exhibitors consisted of people who would bring their products on a like a suitcase it opened it up and put it on a platform and then then show you what they had it wears a radiologist among many radiologists came walking by and

sort of looked at his products and fiddled with some of them and then disappeared and he came back later one of things that sort of diminished and everybody went off to cocktails and dinner and talked with it mr. cook about

making design changes fixing things for him the position so he could do things and would he will do this for him with out a lot of issues and then he took the whole display with him so off to Oregon it was Charles daughter and I was the

beginning of a long very successful relationship between cook and daughter in terms of creating new products and getting things started and that's about the time that we started buying cook product as well

meditech the small company that started in Boston was in a basement of a house in Watertown and they had one product it was a catheter that had a little for wire attachment inside the cancer to a platform in the tip near the tip of the

catheter and it came down and then you could hook these wires to a disc that you could manipulate so that you could move as the catheter tip that had it flex and move to get into different places it eventually gained founded real

success in managing retained gallstones in the billary common bile duct and baskets and all kinds of things take take them out and this is a way of evaluating post cholecystectomy patients fluoroscopy imaging it was initially

very frustrating you had a tower and off of that tower were two rods in a mirror and you'd look at in the mirror and every time you moved you how to move yourself you didn't have floating tables and if you wanted to move on page metope

drags back and forth and shoved back and forth to get their major invention was a floating far away tabletop so we had these images and we didn't have a remote monitors so that we could we were wandering all over the place it was

difficult we had processes where we were doing runoff and we could do it if you did four separate injections when you move the patient takes the pelvis move down get the thigh moving down at the knees down and get the lower leg and

then we got moving tables that would move sequentially and time it gets ohms we had ten 11-foot ceilings so we couldn't get them really high ones that some people had in their in their facilities where they could put a single

actually shave up in the ceiling and cover a four-foot length of the film which was one way of handling it and then they had four of these assets that would be initial one second third and fourth times and perfectly

okay most of the things that we were doing were should we say diagnostic we were working up patients with aneurysms patients with peripheral vascular disease renal tumors were a huge problem because ultrasound wasn't sufficient to

give us a good look at the contents and we didn't have CT scanning that team about a decade later and so we were constantly doing all kinds of question marks and picked filming of of different things and evaluating patients for renal

masses as I said aneurysms peripheral vascular disease liver pancreatic disease cleans etc and then early in my

time at follow Stanley bomb was our my mentor and teacher initially I was going to be with him in Philadelphia and he

called me up one day while I was in the Army on the army line I had no idea how the hell he did that the Army has their own telephone system that is separate for her safety and also command structure but he got on it somehow and

he said he wasn't gonna be a Philadelphia in the spring and I said I'll and then he said I'm going to be going to Boston alright then he said I'm going to ask general and I'd like to you to come along so I said fantastic so we

met and we were busily getting this one room going and we were busy working on diagnostic studies and he gave a lecture to the residence and this lecture was that he had come up with this technique of used

selective infusion of vasopressin in the arteries at the control arterial bleeding and it wasn't so good in the duodenum we thinks because of the multiple blood supplies are those duodenum and that it involved an altar

and penetrates the wall and wall is part of the muscle contraction Tristram there pinches off the vessel think that's off the blood supply so we started treating these patients and we were very successful and we started to get

patients and many of the icu's in the hospital we'd have one follow-up came to me and he said I can't believe it we have every I see you in the hospital filled with one of our patients when they go around the season and won

laughter noon were there standing around sort of doing things and one of the surgeons came down from the ohh our trauma surgeon and he said he had a patient who has just kicked by a cab and she was dying because of the bleeding in

her pelvis and would we do something so he said sure and we saw bleeding in the pelvis some of the major vessels branches of the internal iliac arteries and then we said well how do we stop this and we tried vasoconstrictors and

they didn't work they sort of increased all the high resistance in the vessels that were intact and it shot out the other ones and draws the priestly so then we said well how about something we could throw in in and we all scratch

their heads and anybody seen anything in the literature recently it says anything that we should do and so we took some blood from the patient he did it so it coagulates and took fragments of this put it in a syringe and injected it stop

the bleeding and got her under control and certainly after that we had a couple more occasions like this he said we have to find something better and someone said well what about gel foam and we wandered

in the gel foam so that was the beginning of managing patients in terms of embolization least for us and got a little article in our local State Journal the New England Journal and a lot of people picked it up and started

doing things and we heard a lot of people doing other materials that they were injecting on relief through the catheters in the pensions one afternoon

a bunch of people whose names I had only heard of arrived from cleveland and

chicago and michigan and Philadelphia New York and met in me in a room and they were very quiet talking about things and it was beginning of the formation of the Society of vascular radiology cardiovascular radiology and

so we've gone through a series of iterations was SCV are and then we after a few years added interventional and about ten years ago we converted to SI r which is what you know today some people wanted to make it SI but that gets

infused with Sports Illustrated [Music] so am going back to embolisation we went from gel foam to a whole series of other plastics particle materials including polyvinyl alcohol sponge and then

designs people started having all kinds of great designs in the manufacturing world I when I my first alcohol sponge experience I read about an article that amplats associates had written up about a compressible material because of the

sponge and we were we went and got it from a supplier in North Carolina turned out to be a furniture manufacturing facility and they had blocks of his stuff and how much you went for math I dollars so we had a couple of blocks mmm

and now in manufacturers start turning it out on the quote-unquote graded sizes and making it radiopaque or not ready okay and charging 160 dollars a bottle for a couple of grams it's just entirely different but then that's all led to

different materials and balton beads that were made beez it could hold things inside them and leap let them leach out things that had things attached to the surface they were either rough and so the structure so they would stick to

each other or they would pass by as smooth balls all of these things are great and they brought on a whole business of chemotherapy with embolization with the particles actually being the chemo therapeutic delivery

system or y 90 and radioactive materials liquid agents also were very much interested pure alcohol and liquid tissue adhesives or ways of dealing with high flow vascular systems that were complex and

not easily managed group in Texas led by Sidney Wallace and the work of inventive individual from University of Illinois c├ęsar G interco who developed Texas coil and it had a little string of cotton on it it caused rapid thrombosis

and it was a good solid formosus but somebody found that there were some reactive cells in the tissues where these things have been placed and they said that it was causing a reaction and is going to cause problems in cancer so

now we have also of different types of coils you I'm sure where the sizes of the wires of thickness of the wires with shapes that they have that Orton torpedoes tornados etc all of these things to facilitate occlusion and

management of bleeding sites or communications that you don't want and then the last one is the amplats plug that was developed to deal with very large communications that your hands in the vascular system between the arteries

and veins we at one point tried the

daughter technique that dr. elm had read about and finally got a patient referred to us and we I don't know if you've ever tried doing the original daughter kept lunch kaithar system where you slide a

14 or 16 French Teflon tube over an eight or ten French catheter and sort of he put it like stepping on snow with your foot it packs it down packs down the salton atheroma the problem with it was was it's easy to get

in it's hard to get out you have a 14 or 16 in French hole in a anticoagulated patient and takes a lot of beef and a lot of luck and blood losses can be surprising and that was the last two of those we did I went to Lexington

Kentucky the nearish Kentucky we're movin udine was holding regular courses for people interested in policing inferior vena caval filters and his design was a diaphragm with holes in it that you displayed from a 24 26 french

metal sheet and placed from the jugular vein and most of the people at this meeting were surgeons I was the only radiologist there at that time and brought back the idea talked it up and the community wanted some way of

protecting patients from having pulmonary emboli when they already had additional or fatal pulmonary embolus and the problem was that the surgeons didn't want to come and work during the day they wanted to do it at the end of

the day or whenever it was convenient and we would have the patience wait until we could get access the filter was such a major problem because it caused an enormous amount of thrombosis above and below the filter

and we needed something different I had

the opportunity of visiting dr. zeitler in Nuremberg and a dr andreas grunting and search forensic was working with a balloon technology to do peripheral valve that's all angioplasty and sounded

exciting and it is even more encouraging that he was considering doing renal arteries and then coronary arteries and I said well if he's going to do those we certainly consider doing superficial femoral arteries and alien vessels grad

it a few products and went home and the first patient we were given was from the chief of vascular surgery who was guaranteed that we were going to cause all kinds of problems and he has the far end of a common femoral art I mean

superficial femoral artery open so he could catch the blood and the debris that came out of a vessel when we did an angioplasty of a stenosis and me in a superficial femoral artery nothing happened it's also repaired that he did

opened up it was patient then how many more symptoms so all kinds of interest was coming in the younger members of the vascular surgery department I was very fortunate to have dr. forensic visit me and stay in my house and I took him to

various conferences that he made presentations to cardiology vascular surgery radiology etc and eventually we got him to come to the meeting that we had in New Orleans the and this his design was a real problem

in the sense that it was a coat of coding outside of a catheter in the hole that you could connect to the balloon as you inflated it the balloon didn't always expand the same amount it progressively got larger and larger and

larger and would not collapse completely and it was a major design flaw and all the manufacturers in united states were visually coming up with improvements on this design I went to the New York surgical society deliver paper on

abdominal aortic aneurysms that recommended a routine evaluation of the aneurysm before surgical intervention and I was before they had dinner and it was a room crowd bigger than this and I I'm glad they hadn't put the soap

flatware out because there weren't two sides one side said yes with the great thing to do and know ahead of time what you're going to hit another group said I don't need that I just can go do whatever I want forget about it and then

they start I didn't I had answered one question and that was it they just yelled at each other they did settle down I did have dinner it did have a couple of drinks the presenter afterwards the full of real person for

the evening was Charles daughter and he has a film if you've never seen it I would recommend that you have your cooked representatives give you this little video sequence that he's put together

doing angioplasty but in it he has bombs bursting plumbing equipment drills and all kinds of things and he says we went we aren't doing that we're just going in there and doing it very delicate and intelligent way of managing the vessels

and I couldn't believe it the place has been that they didn't have a question for him they just quietly left as I said

before the mobo new dean felt there was the one Felder we've had and it's always like the one-eyed man in the kingdom of

the blind is King followed by the name lazer Greenfield a surgeon was in Oklahoma and he saw these things called pigs that are used to clean and filter out the sludge that comes in the oil pipelines and Lissa's it looks just like

his filter that they designed and made and he assembled and he's brought it to meditech News Boston Scientific and put that company on the map forever we the initial design is again a big capsule to deliver it but everybody wanted to be

able to do it without having to have a surgical team come and give you access to the major veins so that you could put this thing in and all kinds of people started putting these things in from the femoral

approach and there were some damage to the iliac and femoral veins that is pretty dramatic but they that was a led to a whole slew of downsizing delivery systems and all kinds of inventive designs of the filters and off we went

everybody was putting in solders the

nonvascular world the same time is starting to find CT scans IV contrast injections and fluoroscopy and ultrasound that allow them to do all kinds of things in placement of

catheters do biopsies and manage the gastrointestinal tract in the urinary tract and the solid organs for tumors etc now we have RF a microwave and cryotherapy management primary and secondary tumors and it it's just

phenomenal what can be a complex additionally they do peritoneal dialysis they can do manage patients with the sightings they can do tube feeding issues and management in the denser intestinal tract and it just exploded

sanjib had exported systemic shunts originally was tried in dogs with dr. Roshan Oregon and tombo Sperry quickly the problem was to find a better standing arrangement and get good passage flow from the portal to the

systemic system and gradually we took over a lot of patients with portal hypertension variceal bleeding a very complicated group of patients and complicated problems of the management

dr. daughter seems to be eminent and a

lot of this stuff he designed the start using streptokinase as the means of doing therapy for thrombosis and for emboli the problem with specific kinase was that it was sort of a mixture of different proteins and it was hard to

know quite how to manage it and use it more sophisticated product was a tissue plasminogen activator that was developed and in variations on that and other agents that work for lysis and just opened up management of patients with

pulmonary emboli management of venous thrombosis in the lower extremities and the patients was chronic or a long term occlusions the sort of that we started dealing with ways to break up the more saliva or causes the break-up basal this

such as ultrasound or just going in and mechanically fragmenting it in small vessels with small fresh embolic material we used mechanical aspiration to remove some of them I think it could also pluck them out a little bit and

we've just expanded in not only that the peripheral venous night but the pulmonary arteries cerebral vessels and inferior vena cave and iliac veins to manage these things and it just changed people's lives not have chronic

obstructive inefficient

meanwhile our filters come back to us again this time we now have 10 your experience with these things and we're starting to see some of the designs breaking up in private we have fragments

that have gone to the pulmonary arteries via fragment city in the art fragment city in the retroperitoneum and we have struts that are sticking into the spine stuck into the aorta sticking in the bowel and the question is are we going

to have infections or nerve injuries patients sometimes complain that they have back pains that they're back and they're having sciatica or is it actually something result of these well-struck sticking out and then people

started developing all kinds of ways to remove these things and they are highly successful but it's a real undertakings in some circumstances and then the question comes when do you want to remove them how soon after you put one

in you want to take it out who's responsible for making that decision who's tracking the patients who's doing you know whole management issue of patients who have had this we haven't settled that various people have

different ideas of how they should do it and how it should be done there was the

development of immigrants and covered Catholic sensed all of which opened up the possibility of repair of peripheral vascular disease and iliac stenosis but

then we had a or defender grass and that opened up a whole new bag of tricks it was us we could do it more easily in a non-operative fashion and get patients discharged from hospital that wouldn't have survived standard surgical

management as a result we had patients getting any risen therapy management of thoracic aortic aneurysm therapy and it's mind boggling what they plan to do with these technologies I wish them well in terms of getting it lined up for the

all the branches off of the aorta hasn't gone so well for the renal arteries in a number of circumstances the collaboration between the radiology and surgery has been so so in a lot of places but the combination can give you

some real collaboration that is very successful cardiology similarly has been working with surgery and been placing percutaneously a Ortiz valves and that has been mad at dramatic improvement and for patients who are older and very

frail and can't take the business of a thoracic surgical procedure meanwhile as

cbi SC vir as I said became as cv ir and when it did that sort of it took up all the people who were now very interested in coming to the

meetings but we're having difficulty wanted to be members and were actually clinically important in their communities in some cases were doing research that was very vital so I remember this day we opened it up and

looked up in a large number of people expanded the society opened it up for everybody and in a matter of a year we were went from hundreds of 150 people in the societies of 2000 we had initially we had small numbers of display people

coming again with suitcases with little displays and materials and now you go to the stands meeting across and you look at it and you go oh my god these are you know several thousand dollars or tens of thousands of dollars displays and real

sophistication in marketing we've been expanded education in the measure way and we also added a journal of the JV I are initially it was published as part of a supplement in radiology but then became a separate one and we have had

four very strong editors in chief of the Society of the journal okay this is

become clinician I get the hook all right basically physicians are have to become more than just diagnosticians or Clint

interventionalist do the catheter work and they have to be in the office seeing patients getting into patient management this is particularly true for those who are in oncology the management of patients with oncologic issue and it

really sort of says that we're going to go into a sub specialization promise in addition the number of personnel that are involved in it if I started out we had a total of seven people supporting one room and today we have a former that

we have in technologist range of about hundreds and detect the nursing area about a hundred fifty and some office practice capabilities and staffing and we have just expanded everywhere in the institution that last thing is it causes

the things that we did we showed clinicians that patients can be managed with small afters small wires needles lots of things can be accomplished without having to go through the major things that we did in terms of surgical

receptions of the Google of body major parts of the body and treating people like size of beef I really have to say last thing I really owe a lot to our technologists and our nurses who work long hard difficult circumstances

patients trying to stay patient Ethan going and make things safe for patients I can only say that a lot of these people are still my friends I think very highly thank you [Applause]

[Applause]

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