Vascular and Interventional Radiology: A Brief History

Vascular and Interventional RadiologyA Brief History

CURTIS W. BAKAL

Within months of Wilheim Roentgen’s discovery of the x-ray in 1895, Lindenthal produced the first
contrast-enhanced radiograph of the veins of the hand.1,2 Clinical application of contrast
angiography, however, would take more than two decades. From the 1920s through the 1950s,
arteriography was performed infrequently—and by the translumbar approach. Vascular surgery was
in its nascent stage, and diagnoses were made clinically without much diagnostic testing. For
example, in 1923, Leriche described a group of young men with decreased or absent femoral pulses,
bilateral claudication, and impotence, all on the basis of clinical findings and history. Leriche called
this entity aortitis terminalis and suggested the possibility of surgical intervention.3 Yet the
diagnostic arteriogram as a routine clinical tool was years away.

In 1953, Seldinger described a transfemoral arterial access technique that used a puncture needle
and guide-wire, which allowed selective catheterization.4 Coincidentally, the first use of a cloth
vascular bypass graft also had just been reported.5 During this decade, diagnostic arteriography of
the cardiac and peripheral circulations was increasingly being used and refined. In the 1960s,
radiologists began to develop “interventional” procedures. Many point to the landmark article that
first described percutaneous transluminal angioplasty (PTA) by Dotter and Judkins as the birth of
interventional radiology.6,7 Dotter and Judkins summarized their article by suggesting that there
would be “refinements of technique as well as further clarification” of the role of this attack on
arteriosclerotic obstructions.” The percutaneous transluminal treatment described in this article
became a basis for an emerging class of minimally invasive therapies.

In 1974, the Society of Cardiovascular Radiology was founded with a membership of about 30
academic angiographers. In addition to diagnostic angiography, members of this society were
beginning to expand their interventions: in addition to “Dottering” obstructive lesions, they were
beginning to treat gastrointestinal bleeding and pelvic trauma by pharmacologic infusion or
embolization.8–13 Techniques for nonsurgical splenectomy and intravascular foreign body attraction
soon were popularized.14 The Society was later renamed the Society of Cardiovascular and
Interventional Radiology.15 Gruentzig and others refined the Dotter angioplasty technique by using
an expandable balloon on a catheter shaft, which allowed smaller punctures to be made for arterial
access and larger vessels to be dilated.16,17 Real time ultrasound and computed tomography
scanning allowed nonvascular percutaneous interventions to be developed and refined, notably
intraabdominal abscess drainage.18,19 This revolutionized the care of many patients with abdominal
infections: Abdominal pus was no longer a surgical disease.

By 1985, small-vessel balloons and steerable guidewires became commercially available, allowing
PTA of the infrapopliteal vessels.20–23 Inferior vena cava filters, although still large in profile, were
being placed by vascular and interventional radiologists as well as by surgical cut-down.24 Within a
few years, low osmolar contrast agents were to be commonly used for peripheral arteriography,
increasing safety and patient comfort. Digital subtraction replaced cut film, and the multiplanar C-
arm became standard in angiography and interventional radiology suites; these two technical
advances allowed diagnostic and interventional procedures to proceed more rapidly, eliminating the
delays for processing cut films and for repositioning patients. The volume of studies that could be
performed in a working day now could be expanded because the time per study was shortened; the
interventional radiologists could expand their practices and push the envelope. The advent of
smaller-profile catheters and hydrophilic guidewires allowed more expedient selection of smaller
arteries for superselective embolization and infusion. The clinical use of thrombolytic agents began in
the late 1980s for acute arterial and venous occlusions. Renal angioplasty became a first line
technique.25