Historical Account: Cardiovascular

Interventional Radiology 2
Josef Rösch and Frederick S. Keller

Contents 2.1 Birth of Interventional Vascular

2.1 Birth of Interventional Vascular
Radiology......................................................
2.2 Origins of Interventional
Vascular Procedures ....................................
2.2.1 PTA with Coaxial Catheters ..........................
2.2.2 PTA with Balloon Catheters ..........................
2.2.3 Vascular Stenting ...........................................
2.2.4 Endovascular Stent-Grafting .........................
2.2.5 Selective Thrombolysis .................................
2.2.6 Therapeutic Vascular Occlusion ....................
2.2.7 Transjugular Intrahepatic
Portosystemic Shunt (TIPS) ..........................
References .................................................................
Radiology
15
The modern area of vascular radiology started in
16 1953 with introduction of the percutaneous trans-
16 femoral catheterization method by Seldinger. For
17 the first 10 years, the angiographic catheter’s use
18
21
was limited exclusively to diagnostic angiography
22 in order to define in detail pathologic lesions of
23 vessels or organs so that the proper therapy, usu-
ally surgery, could be undertaken. Charles Dotter
25
26
changed this mindset in June 1963 at the
Czechoslovak Radiologic Congress in Karlovy
Vary (Fig. 2.1). During his presentation, he stated
that “the diagnostic catheter can be more than a

J. Rösch, M.D. (*) • F.S. Keller, M.D.

Dotter Interventional Institute,
Oregon Health & Science University,
3181 SW Sam Jackson Park Road, L342,
Portland, OR 97239, USA Fig. 2.1 Charles Dotter lecturing at the Czechoslovak
e-mail: roschj@ohsu.edu; kellerf@ohsu.edu Radiological Congress in Karlovy Vary on June 10, 1963

P. Lanzer (ed.), Catheter-Based Cardiovascular Interventions, 15

DOI 10.1007/978-3-642-27676-7_2, © Springer-Verlag Berlin Heidelberg 2013
16 J. Rösch and F.S. Keller

Fig. 2.2 The first percutane-

ous transluminal angioplasty a b c
performed on January 16,
1964 (Reprinted with
permission from Dotter and
Judkins [2]). (a) Initial
angiogram reveals tight
stenosis of the distal
superficial femoral artery.
(b) Coaxial catheters used for
stenosis dilation.
(c) Follow-up angiogram
shows well-patent artery

tool for passive means for diagnostic observation;
used with imagination, the catheter can become an
important therapeutic tool and replace the surgical
scalpel” [1]. None of us in the audience realized or
even dreamed that Dotter’s words will soon
become reality and eventually lead to a new spe-
cialty. About 7 months later, Dotter performed the
first catheter-based radiologic intervention – per-
cutaneous transluminal angioplasty (PTA). This
was the birth of interventional vascular radiology.
2.2 Origins of Interventional
Vascular Procedures
2.2.1 PTA with Coaxial Catheters
On January 16, 1964, Dotter percutaneously
dilated a tight, localized stenosis of the superficial
femoral artery (SFA) in an 82-year-old woman
with painful leg ischemia and gangrene who
refused a recommended leg amputation (Fig. 2.2).
After successful dilation of the stenosis with a
guide wire and coaxial 9F and 15F Teflon cathe-
ters, circulation returned to her leg and her rest
pain ceased. The patient started walking soon
afterward. She left the hospital on her feet – both
of them. The dilated artery stayed open until her
death from pneumonia 2.5 years later.
Encouraged by this success, Dotter not only
continued to dilate SFA stenoses but also began
treating SFA occlusions. Dotter’s first paper on
PTA with coauthor Melvin Judkins was published
in Circulation, November 1964. It described the
technique and summarized their 5-month experi-
ence with PTA of 11 extremities in nine patients
[2]. In describing the technique, Dotter recom-
mended “passing guide wires through the lesions
more by the application of judgment than of
force, even when both are often needed for subse-
quent dilation.” Force was indeed often necessary
when passing the 15F outer diameter dilation
2 Historical Account: Cardiovascular Interventional Radiology
catheters over the first 9-F catheter. But soon,
Dotter refined his technique and decreased the
size of coaxial dilation catheters to 8F and 12F
and improved the taper of their tips. In 1968,
4 years after his first case, he reported on 217
dilations of 153 lesions in 127 patients. Dotter
considered himself a “body plumber,” and to
avoid reference to his technique as “reaming out,”
he drew and published a picture of his concept of
the basic mechanism of transluminal dilation in
which nothing is removed except for the
obstruction.
Dotter’s referrals were mainly from general
practitioners. Surgeons, at that time, were not
interested in percutaneous endovascular treat-
ment of atheromatous disease and, in fact, were
adamantly opposed to PTA. However, Dotter’s
articles in local newspapers and his radio and
TV interviews were effective in attracting
patients interested in this new procedure. These
patients were admitted to the hospital on the
radiology service under Dotter’s name. Radiology
residents or fellows, with varying degrees of
enthusiasm, worked them up and prepared for
the procedure.
However, general recognition of PTA pro-
gressed slowly. In particular, acceptance in the
USA stalled for a long time. Even though Dotter
published 17 papers on PTA in the first 4 years,
PTA procedures in the USA were performed
almost exclusively in Portland. Angiographers at
other US institutions did not share Dotter’s idea of
“catheter therapy.” They continued to concentrate
only on diagnosis. However, European angiogra-
phers were more progressive and demonstrated a
desire to change and expand their work. Werner
Porstmann, a good friend of Dotter’s from Berlin,
started performing PTA in the mid-1960s and
published his first experience in 1967. Gerardus
van Andel from the Netherlands modified the
dilation catheters and published his monograph
on PTA in 1976. However, the greatest credit for
disseminating PTA throughout Europe belongs to
Eberhart Zeitler from Germany. He published
15 papers and, in 1973, summarized experience
with 570 procedures in 498 patients [3]. After this,
many European angiographers accepted PTA and
began “Dottering” diseased arteries.
17
Fig. 2.3 From left to right: Eberhardt Zeitler, Andreas
Grüntzig, and Charles Dotter in 1975 discussing angio-
plasty techniques at the symposium in Cologne, Germany
(Reprinted with permission from Rösch et al. [6])
2.2.2 PTA with Balloon Catheters
To improve angioplasty of larger arteries, Dotter
in 1966 fabricated a “reinforced balloon-dilating
catheter” in which a woven fiberglass sheath sur-
rounded a simple balloon catheter. However,
because of feared thrombogenicity, he did not use
it in patients. In 1973, Porstmann introduced a
“Korsett Balloonkatheter” consisting of an 8-F
outer Teflon catheter with four longitudinal slits.
A latex balloon catheter inflated inside the slits
permitted dilation up to 9 mm, sufficient to treat
iliac artery lesions. Dotter improved Porstmann’s
device and used the “caged balloon-dilating cath-
eter” for successful treatment of iliac artery
obstructions in 48 patients. Early failures with
thrombosis, however, complicated use of this
dilating catheter and neither of these balloon
catheters ever found its way into wider practice.
Balloon PTA finally took off in 1974 when
Andreas Grüntzig introduced his double-lumen
balloon catheter made of polyvinyl chloride
(PVC). Grüntzig, a German-born cardiologist
working in Zurich, learned coaxial catheter PTA
from Zeitler and published his experience with
the first 25 patients in 1973. However, he was not
satisfied with the coaxial technique (Fig. 2.3).
Always thinking of PTA’s application to coronary
arteries, Grüntzig started working on the design
of a balloon catheter in his kitchen with help from
his wife, Michaela, his assistant Maria Schlumpf,
and her husband, Walter. They explored several
types of materials and settled on PVC suggested
18
by chemistry professor, H. Hopff. Grüntzig con-
structed the final prototypes and used it for PTA
in 15 patients including 6 patients with iliac artery
stenoses. With Walter Schlumpf making the dila-
tion catheters, the number of Grüntzig’s patients
grew rapidly. In January 1976, his group treated
115 patients with balloon PTA [4]. Realizing the
potential of dilation balloons, medical device
manufacturers began producing them and balloon
PTA took off.
Favorable experience with balloon catheters
in peripheral and iliac arteries opened the way for
balloon PTA of other vessels including the coro-
nary arteries. After exploration of dilation of
experimentally constricted coronary arteries in
dogs, Grüntzig first successfully used balloon
PTA clinically on September 16, 1977, to treat a
patient with severe stenosis of the left anterior
descending artery. Despite initial resistance of
some cardiologists, Grüntzig carefully collected
and summarized his experience with the first
50 patients in July 1979 [5]. Grüntzig also was
the first physician to balloon dilate the renal
artery stenosis in 1978, thus, starting interven-
tional treatment of renovascular hypertension.
Balloon dilation of carotid artery stenoses was
first explored experimentally in dogs in 1977 and
introduced clinically by Klaus Matthias.
Success of the balloon PTA in Europe ignited
the interest of a new generation of angiographers
in the USA. Some went to Europe to see Grüntzig
at work in live case demonstrations he organized.
Some even stayed with him for fellowships. Upon
returning to the USA, they brought the latest
improvements in PTA back to the USA, the coun-
try where it originated approximately 15 years
earlier. Their enthusiasm resulted in rapid dis-
semination of the PTA in the USA where it soon
became the most commonly performed interven-
tional procedure.
2.2.3 Vascular Stenting
Percutaneous vascular stenting was first explored
by Dotter in dogs in the late 1960s to find ways
for improving results of coaxial PTA. From vari-
ous types of prostheses, a short uncoated coil
J. Rösch and F.S. Keller
spring had the best results. Two of three coil
springs remained patent over 2 years in the dog’s
popliteal arteries. The “coil spring endarterial
tube grafts,” as Dotter called them, were not
expandable and, therefore, because of the need
for large introducer sheaths, were not used in
clinical work. Dotter, however, suggested ways to
create an expandable stent: “Coilsprings, either
stretched out or wound up and hooked to a con-
trolling mandrel, could be reduced in diameter
favoring easy introduction and placement. Upon
their release from the mandrel, they automati-
cally expanded for a larger lumen and improved
anchoring at the site of placement.”
However, it took more than 10 years before
Dotter’s idea of endovascular stent placement
became established in interventionalists’ minds.
But afterwards, rapid progress followed. Andrew
Cragg, Charles Dotter, Cesare Gianturco, Dierk
Mass, Julio Palmaz, and Hans Wallsten were the
first stent pioneers [6]. In the early and mid-
1980s, they introduced a variety of expandable
metallic stents. These were either self- or bal-
loon-expandable stents made primarily of stain-
less steel alloys or thermal memory stents made
of nitinol, an alloy of nickel and titanium. They
were tested in animals, and most of them or their
modifications were eventually used in clinical
practice. Early on, many of them were handmade
and used with local institutional review board
approval. Later on, when companies obtained
approval for their use of the biliary system, they
were placed intravascularly on an off-label basis.
In the USA, more than 30 years after Dotter’s
original experiments, only a small number of
stents have been approved by the Food and Drug
Administration for intravascular use.
The Maass self-expandable spiral coils and
double-helix stents, introduced in 1982, were first
studied in animals. They were later used in clini-
cal practice, mainly for relieving inferior vena
cava obstructions, and occasionally, in aortic dis-
sections. These devices, however, never gained
widespread acceptance mainly because their large
introducing sheaths required arterial cut down.
Nitinol stents were introduced in 1983 when
Dotter and colleagues and Cragg and col-
leagues simultaneously published results of their
2 Historical Account: Cardiovascular Interventional Radiology 19

a b

Fig. 2.4 Expandable stent pioneers and their stents (Reprinted with permission from Rösch et al. [6]). (a) Andrew
Cragg with his nitinol stent. (b) Julio Palmaz with his balloon-expandable stent

experimental studies. With Dotter’s nitinol spiral
stent, saline solution heated to 60°C was needed
for rapid radial stent expansion after its placement.
In the Cragg’s stent (Fig. 2.4), body-temperature-
activated nitinol coil grafts for expansion and it
required flushing with cool saline solution during
introduction. These complex introduction systems,
together with significant intimal proliferation,
were drawbacks to the use of nitinol stents in the
USA at that time. In Russia, Josef Rabkin intro-
duced a widely spaced nitinol spiral stent that was
easy to introduce and expand at body temperature.
After experimental animal testing, he used it in
clinical practice beginning in 1985. In the early
1990s, he reported successful results in treatment
of obstructions in vascular and nonvascular sys-
tems in 268 patients.
Three stents were introduced in 1985: the
Gianturco Z stent, Palmaz stent, and Wallstent.
The self-expandable Gianturco Z stent made
from stainless steel wire bent into a zigzag pattern
with connected ends had a strong expansile force
(Fig. 2.5). To prevent overexpansion of the stent-
implanted structures and to maintain the desired
diameter, we modified the original Z stent by
suturing its bent “eyes” with monofilament. This
also allowed us to form multi-segmental stents
and facilitate their placement. It was easy to make
both the original and modified Z stents by hand.
Many interventionalists made them at home
before they became available from manufactur-
ers. The modified Z stents were the first expand-
able stents approved by the Food and Drug
Administration for use in biliary system in April
1989. We often used modified Z stents for relief
of obstructions of large veins, particularly the
superior and inferior vena cava. One of our
patients with massive edema due to occlusion of
the inferior vena cava and common iliac veins
was treated with stent placement in 1990. He has
20 J. Rösch and F.S. Keller

a b

Fig. 2.5 Expandable stent pioneers and their stents (Reprinted with permission from Rösch et al. [6]). (a) Cesare
Gianturco with his self-expandable Z stent. (b) Hans Wallsten with his self-expanding meshwork stent

not had recurrence of edema for 19 years
(Fig. 2.6). The simple zigzag pattern of the Z
stent has been incorporated into frames of several
types of aortic stent-grafts.
Palmaz made his original balloon-expandable
stent (Fig. 2.4) under a low-power microscope by
weaving stainless steel wire into a crisscrossed
tubular pattern and then electro-polishing it. The
crossover points were soldered to keep the stent
expanded after balloon inflation. Soon, however,
the process was modified for easier fabrication,
and his final stent design became a single stainless
steel tube with parallel staggered slots in the wall.
Palmaz did excellent research work with his stents
and their use in the arterial system including
peripheral, renal, and coronary arteries. His stent
was the first and, for a long time, the only stent
approved by the Food and Drug Administration
for vascular use. It was approved in August 1994
for coronary arteries and in May 1996 for iliac
arteries. Palmaz also studied biomechanical and
hemodynamic effects of stents in various arteries
and contributed significantly to our understanding
of arterial stent placement.
The self-expanding spring-loaded meshwork
stent known now as the Wallstent was developed
by engineer Hans Wallsten (Fig. 2.5) at his Swiss
company, Medinvent. By using the technique
developed for other applications such as braiding
catheters or coaxial cable shielding, Wallsten
spun 16–20 alloy spring filaments into a tubular,
flexible, self-expanding braid configuration. The
stent was then constrained on a small-diameter
catheter by a rolling membrane for easy vascular
introduction. For stent placement, the membrane
was withdrawn, freeing it and allowing stent
expansion. After Schneider Europe started man-
ufacturing the Wallstent with a simplified
unsheathing delivery system and markers, the
Wallstent became very popular in Europe and
was used not only in vascular systems, including
coronary arteries, but also in nonvascular appli-
2 Historical Account: Cardiovascular Interventional Radiology
a b
Fig. 2.6 Reconstruction of occluded inferior vena cava
and common iliac veins with multiple Z stents in a
55-year-old patient with retroperitoneal fibrosis. (a)
Occluded inferior vena cava and common iliac veins. (b)
cations. Good results in Europe with the Wallstent
brought it to the USA. Thanks to several clinical
investigators including the interventional team at
the University of California, San Francisco,
Wallstents were soon approved for biliary use
(December 1989) and later for vascular applica-
tions (December 2003).
The work of these pioneers generated significant
enthusiasm not only for interventionalists but also
for device manufacturers. The original stents were
improved, and new types of stent were developed.
Some of these new stents not only mechanically
expanded vascular stenoses, but bioactive com-
pounds that prevented vascular restenosis from
occurring were incorporated in them.
2.2.4 Endovascular Stent-Grafting
The stent-graft is a synonym for both the stents
fully covered by a graft material and the vascular
graft conduit structurally supported by non-con-
nected stents. Experimental work on stent-grafts
started soon after introduction of bare stents.
Interventional radiologists played important role
in this research. The first experimental work was
published in 1986 by a surgical group led by
21
c d
Severe irregular IVC narrowing is present after 28 h of
selective urokinase infusion. (c) After multiple stent
placements. (d) Five-month follow-up venogram
Alexander Balko (Fig. 2.7). They used a sinusoi-
dally curved nitinol stent covered with a polyure-
thane sleeve for successful exclusion of surgically
created abdominal aortic aneurysm in sheep.
In the late 1980s, the radiology research group
from M.D. Anderson Hospital in Houston pub-
lished results of their three research projects in
canines on stent-grafts. They used the original
Gianturco Z stent as a frame to support the graft
material. David Lawrence used polyester (Dacron)
for stent covering. His stent-grafts implanted in
normal abdominal or thoracic aorta remained pat-
ent up to 35 week (Fig. 2.7). However, occurrence
of graft stenosis due to folding or kinking of the
inelastic Dacron fabric led them to explore
another material. Expandable nylon mesh showed
great promise. It was effective and remained pat-
ent when introduced into the normal canine
abdominal aorta (Tetsuya Yoshioka – 1988). It
also excluded experimentally created aneurysms
(David Mirich – 1989) [7]. However, because
nylon mesh had not been approved for intravascu-
lar use, further exploration was not continued.
Julio Palmaz from the University of Texas SA
collaborating with Argentine surgeon Juan Parodi
introduced stent-grafts into clinical practice. In
canines, they explored Dacron graft supported at
22 J. Rösch and F.S. Keller

Fig. 2.7 The first experimen-

tal stent-grafts (Reprinted with
a b c
permission of Journal of
Surgical Research and
Radiology). (a) Polyurethane-
covered nitinol stent-graft of
Alexander Balko.
(b) Dacron-covered Z
stent-graft of David Lawrence
(1987). (c) Nylon-
mesh-covered Z stent-graft of
David Mirich (1989)

both ends by balloon-expandable Palmaz stent
for exclusion of experimentally created abdomi-
nal aortic aneurysm. This work was quite suc-
cessful and transitioned to clinical practice quite
fast. Palmaz presented results of their experimen-
tal work in 1990, and Parodi published his expe-
rience with his first five patients of abdominal
aortic exclusion in 1991 [7].
The experimental studies and early clinical
results ignited the interest of the medical
industry and led to development of a variety of
endovascular graft prostheses. Most of them
have self-expanding stainless or nitinol stents
for support and Dacron or expanded PTFE as
graft material. Interventional radiologists and
endovascular surgeons often working as a team
are using stent-grafts for percutaneous treat-
ment of aneurysms and vascular trauma.
2.2.5 Selective Thrombolysis
The goals of selective or local thrombolysis are to
relieve an acute vascular obstruction by thrombus
and unmask the underlying pathology. Charles
Dotter started selective thrombolysis in 1972 to
treat complications of angiography and PTA.
Thrombotic occlusions occasionally occurred at
2 Historical Account: Cardiovascular Interventional Radiology
Fig. 2.8 One of the first cases
of selective thrombolysis a b
performed in June 1972
(Reprinted with permission of
Dotter et al. [8]). (a)
Post-catheterization thrombo-
sis of upper superficial
femoral artery. (b) After 24 h
of selective streptokinase
infusion, the artery is patent.
Minimal residual clots lysed
after further infusion
the catheter entrance or dilation sites because of
the large size of diagnostic coronary catheters
(8F) and coaxial dilation catheters (12F). Dotter
wanted to treat these complications with inter-
ventional techniques rather than have the patient
undergo surgery. In our department, we were
familiar with thrombolysis because of random-
ized studies comparing systemic application of
streptokinase (SK) and heparin for treatment of
pulmonary embolism and acute deep venous
thrombosis. In addition, we had extensive experi-
ence with local arterial infusion therapy, mainly
with vasopressin infusions for control of arterial
and variceal gastrointestinal bleeding and che-
motherapy infusions for treatment of tumors.
It was a natural beginning. As soon as the com-
plication was recognized, an end-hole catheter
was placed just above a short thrombus or a mul-
tiple-side-holed catheter was thrust into a long
thrombus in the angiography room. Continuous
SK infusion was then performed in the intensive
care unit. The dose of SK most often used was
5,000 U/h infused into the iliac or femoral arter-
ies, approximately 5% of the usual systemic dose.
Portable angiograms at 12- or 24-h intervals were
used to monitor the progress of fibrinolysis. In the
first six patients with acute thrombosis, 18- to
112-h infusions (mean 47 h) were needed for
23
complete clot lysis [8] (Fig. 2.8). Encouraged by
good results with acute thromboses, Dotter
explored local SK infusions for chronic arterial
occlusions, but found only minimal benefit for
this indication. Sometimes, thrombolysis was
used before PTA when there was clinical suspi-
cion of acute or subacute thrombosis superim-
posed on chronic arterial stenoses.
Our publication on this technique in April 1974
did not generate enthusiasm for local thromboly-
sis among interventionalists. The need for hospi-
talization in the intensive care unit, the antigenic
nature of SK, and some bleeding complications
were probably the main factors for the limited use
of this technique. Local thrombolysis became
accepted only after SK was replaced in the mid-
1980s by urokinase, a safer and more effective
fibrinolytic agent. It became a widely used inter-
ventional procedure in the 1990s and has contin-
ued its growth with newer fibrinolytic agents such
as recombinant tissue plasminogen activators.
2.2.6 Therapeutic Vascular Occlusion
Therapeutic vascular occlusion started in 1931
when surgeon, Barney Brooks, treated a carotid
cavernous fistula at surgery by embolization of
24
Fig. 2.9 The first case of
a b
therapeutic arterial emboliza-
tion for gastrointestinal
bleeding performed in
November 1, 1970 (Reprinted
with permission of Rösch
et al. [9]). (a) Selective
gastroduodenal angiogram
reveals extravasation in gastric
antrum (arrow). (b) Follow-up
angiogram after blood clot
embolization shows occlusion
of the previously bleeding
gastroepiploic artery
muscle fragments introduced via arteriotomy.
Other surgeons occasionally used this “open
Brooks’ technique” to treat arteriovenous malfor-
mations or fistulas in head and neck by emboliza-
tion of muscle fragments, Gelfoam, porcelain
beads, inert plastic, or Silastic. Shoji Ishimore was
the first physician to embolize Gelfoam pieces
through a polyethylene tube inserted into the
exposed internal carotid artery. Neuroradiologists
John Doppman and Thomas Newton separately
were the first ones to perform embolization percu-
taneously. In the late 1960s, they concentrated on
embolization of spinal arteriovenous malforma-
tions. In their first case reports published in 1968,
they embolized lead or stainless steel pellets com-
plemented by the patients muscle fragments.
Embolizations were done using the percutaneous
femoral or axillary artery approach. In 1971,
Doppman also explored percutaneous emboliza-
tion of kidneys in dogs with silicone rubber and
published successful embolization of spinal cord
arteriovenous malformation in five patients. For
clinical embolization, he added Gelfoam to metal-
lic pellets and muscle fragments.
Therapeutic vascular embolization started for
us on November 1, 1970. We were asked to treat
acute hematemesis from a bleeding gastric ulcer
J. Rösch and F.S. Keller
in a 43-year-old woman with cirrhosis and hemo-
coagulation defect. The selective vasoconstric-
tive infusions that we used at that time for control
of acute gastrointestinal bleeding had only tem-
porary effect. As the patient was not a surgical
candidate, we decided after consultation with
her surgeons to treat her with vascular emboliza-
tion. We selectively catheterized the bleeding
gastroepiploic artery and occluded it with an
injection of 2 cc of autogenous clot that was held
in place by selective epinephrine infusion. The
embolization was successful, it occluded the
artery, and the bleeding stopped (Fig. 2.9).
Following this case, we performed an experi-
mental study in dogs and showed that selective
embolization of gastric arteries is safe and does
not result in ischemia because of rich collateral
circulation. Publication of these experiences
early in 1972 led to introduction of selective
arterial embolization into treatment of gastroin-
testinal bleeding [9].
In the early 1970s, interventional radiologists
were using transcatheter vascular embolization
mainly for control of acute arterial gastrointesti-
nal bleeding. Soon, however, embolization was
extended to control of traumatic arterial and gas-
troesophageal variceal bleeding. Obliteration of
2 Historical Account: Cardiovascular Interventional Radiology
a b
Fig. 2.10 Experimental TIPS in canines in 1969 (Reprinted
with permission of Rösch et al. [6]). (a) Working team
from left to right: Josef Rösch, Nancy Ross, William
arteriovenous fistulas and malformations, con-
trol of hemophysis, treatment of varicocele, and
ablation of tumors or organs was added to the
indications for embolization in the late 1970s
and early 1980s. Embolization agents also under-
went rapid development. The autologous natural
or modified blood clots were replaced by absorb-
able gelatin sponge (Gelfoam) or nonabsorbable
polyvinyl alcohol (Ivalon). Liquid and rapidly
solidifying polymers including cyanoacrylate
glue introduced in the 1970s became very effec-
tive embolization agents. Medical companies
also contributed to the burgeoning technique of
therapeutic vascular occlusion by developing
very effective and easy to use occlusive devices
including embolization coils and detachable
balloons.
2.2.7 Transjugular Intrahepatic
Portosystemic Shunt (TIPS)
TIPS is a therapeutic connection between two
vascular systems – portal venous and systemic
venous – created inside the liver by percutaneous
interventional radiology techniques. Its goal is to
relieve portal hypertension caused by liver disease
25
Hanafee, and Harold Snow. (b) Well patent experimental
TIPS after placement of a covered coil tubing
and treat its symptoms, mainly bleeding from
gastroesophageal varices and ascites. It replaces
surgical portacaval shunts.
The TIPS technique was developed in the
early days of interventional radiology, in 1968
by Josef Rösch. It started by inadvertent entry
into intrahepatic portal branches during transjug-
ular cholangiography, done at that time to define
biliary obstructions. This ability to enter the por-
tal vein from the transjugular approach led us to
explore this technique for visualization of the
portal venous system. Catalyzed by Dotter’s con-
viction that any diagnostic catheter should be
considered a potential therapeutic tool; enlarging
the tract in the liver between the hepatic and por-
tal venous systems was the next step. Various
types of tubing to keep the shunts open were
explored in 40 dogs (Fig. 2.10). Covered coils
worked best. These shunts stayed patent for
approximately 2 weeks and then thrombosed
because of their small (4–6 mm) diameter and
slow flow through them in these dogs with nor-
mal portal pressure. In our final report, we con-
cluded that TIPS was a feasible technique.
Although we performed TIPS in cadavers and
human liver specimens, technology at that time
was not sufficiently advanced for TIPS to be
26
clinically applicable, as it would have required
the use of tubing too large to introduce percuta-
neously [10].
An important advancement in TIPS was made
by Oscar Gutierrez in the late 1970s. He used
repeated balloon dilation for shunt creation in
canines. In the early 1980s, Ronald Colapinto
performed the first clinical TIPS by continuous
12-h balloon dilation of the liver puncture tract.
Initially, he achieved significant portal decom-
pression and control of bleeding. However, recur-
rent bleeding in a majority of his 15 patients
demonstrated that simple balloon dilation was
not sufficient for prolonged portal decompres-
sion. In the mid-1980s, Palmaz made the final
step in TIPS evolution with introduction of his
balloon-expandable stents to keep the TIPS open.
The TIPS in most of his experimental dogs with
portal hypertension exhibited long-term primary
patency. In our experiments, we also had good
early results creating TIPS with use of modified
Z stents in young swine without portal hyperten-
sion. Unfortunately, liver parenchyma growth
through the stent interstices prevented long-term
patency.
The first clinical TIPS procedure with stents
was performed in January 1988 at Freiburg,
Germany, by Goetz Richter and associates using
Palmaz stents. The procedure was technically
successful, but the patient died later of acute
respiratory distress syndrome with a patent shunt.
They had much better results with their other
patients, and their success inspired many inter-
ventionalists to introduce TIPS procedures at
their hospitals. TIPS has become widely dissemi-
nated throughout the world and has been accepted
as a minimally invasive treatment of complica-
tions of portal hypertension.
Conclusion
We reviewed the birth of interventional vascu-
lar radiology and the origins of IR’s major
J. Rösch and F.S. Keller
interventional vascular procedures. After these
beginnings, many interventionalists contrib-
uted to further improvement or modifications
of these procedures. Medical companies then
developed new devices that enabled these pro-
cedures to be performed more effectively and
safely. Catheter-based vascular interventions
have become an indispensable part of modern
medical progress.
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