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The Seldinger technique: 50 years on

Z C J Higgs, D A L Macafee, B D Braithwaite, C A Maxwell-Armstrong

Lancet 2005; 366: 1407–09 Case presentation Published online July 20, 2005 8 years after saphenofemoral ligation and multiple avulsions DOI:10.1016/S0140-6736(05) 66878-X of varicose , a 39-year-old woman re-presented with Division of Gastrointestinal symptomatic . Duplex ultrasound of her venous Surgery (Z C J Higgs BMBS, system confirmed bilaterally incompetent long saphenous D A L Macafee MRCS, veins and showed a blood supply secondary to C A Maxwell-Armstrong neovascularisation from the previously ligated DM FRCS), and Division of saphenofemoral junction. Her symptoms warranted surgery (B D Braithwaite MChir FRCS), and she agreed to take part in a randomised trial. Queen’s Medical Centre, Conventional redo groin surgery and stripping of the left long Nottingham NG7 2UH, UK saphenous was done, and endoluminal thermal ablation Correspondence to: of the right vein was undertaken. Endoluminal thermal Mr David Macafee david.macafee@nottingham. ablation entails intraoperative ultrasound location of the ac.uk long saphenous vein at the ankle. With the Seldinger technique, a 6 F sheath is inserted into the vein (figures 1 and Figure 1: Percutaneous puncture of the long saphenous vein 2). The treatment is then passed through the sheath to the proximal end of the long saphenous vein (figure 3). The vein is then heated to more than 85ºC. Both procedures are well tolerated but considerably less bruising happens with ablation than conventional surgery after 7 days (figure 4).

2003 marked the 50th anniversary of Seldinger’s seminal work on percutaneous catheterisation1 and provided an opportunity to reflect on the influence his investigations had on modern medicine, and especially interventional . We emphasise the role of several of the clinicians who were influential in developing diagnostic and therapeutic percutaneous techniques, and provide a brief history of Seldinger’s life, his role as a radiological pioneer, and discuss why his technique was such an important discovery. Figure 2: Removal of cannulating needle after insertion of a 6 F sheath over Development of the technique the guidewire By 1953, by needle puncture was an established procedure. However, a refined technique, using a catheter (threaded through the needle), had potential benefits including: a reduction in the risk of extravasation of contrast media; maintenance of during film development; more flexibility in patient’s positioning; and injection of the media at any level within the vessel.1 Although Farinas, Radner,2,3 and others had done many arterial catheterisations, arterial ligation or after surgical exposure were still needed in some patients. Percutaneous use of a catheter was not, however, without its problems. Before Seldinger, the procedure needed a large bore needle (through which a narrower bore catheter was threaded), which restricted its use to larger arteries and made vessel puncture more difficult. The hole in the artery was large, so the risks of Figure 3: Endoluminal thermal ablation catheter and sheath in place through haemorrhage and arterial wall damage were high. Also, skin and into vein www.thelancet.com Vol 366 October 15, 2005 1407 Eponym

no suitable flexible, thin-walled catheter of sufficient bore to undertake angiography was available, especially for larger vessels. In 1951, Pierce2 discovered and successfully used a polyethylene catheter to do percutaneous , and this new flexible catheter allowed Seldinger to develop his technique. Seldinger’s technique was unique because of the addition of a flexible, round-ended, metal leader (guidewire). The sequence was needle puncture, guidewire through needle, needle removed, flexible catheter threaded over guidewire, and guidewire removed. This process enabled a catheter of the same bore as the needle to be inserted percutaneously, rather than needing surgical exposure or a large bore needle. The original diagram published in 1953 by Acta Radiologica is shown in figure 5.1 Today, the additional use of ultrasound for vessel localisation has further improved the safety profile of the Seldinger technique. This combined approach is recommended by the National Institute for Clinical Excellence. Seldinger’s work showed that all arteries in the body could be reached from the femoral route, and he used the parathyroid and renal arteries as examples. Subclavian arteriography was done, with one exposure showing a mediastinal adenoma that an earlier operative exploration had not identified. Surprisingly, Seldinger’s chief at the Department of Radiology thought that his ingenious invention and its obvious potential were not enough to form the basis of a thesis. Further investigation and a series of publications followed, all examining the use of the technique within angiography. Figure 4: Results at 7 days Seldinger eventually submitted his thesis on percuta- Left leg has undergone conventional redo long saphenous vein surgery, right leg has undergone endoluminal thermal ablation. Reduction in bruising with new neous cholangiography 13 years later. The table provides technique is marked. an overview of the range of applications and medical specialties that benefit from the Seldinger technique, which are usually done by interventional radiologists and cardiologists.

Angiography Although Moniz and dos Santos of Lisbon led the development of clinical arteriography (cerebral and translumbar angiography) in the late-1920s, Forssmann of Berlin is remembered as the most influential and certainly the most controversial figure. In 1929, he was looking for a safer way to inject drugs for cardiac resuscitation. Convinced of his catheterisation idea, but prevented from using it by seniors, he inserted a urinary catheter into the right side of his heart by the left basilic vein before going to the radiograph room where he confirmed the catheter’s position.5 He also saw the potential for injection of a contrast agent through the catheter for imaging. As a result of his experiment, he was dismissed from his job and became a urologist.6 Despite initial rejection, Forssmann’s experiment Figure 5: The Seldinger technique gained acceptance and Cournard and Richards of New a) The artery punctured. The needle pushed upwards. b) The leader inserted. c) The needle withdrawn and the artery compressed. d) The catheter threaded onto the leader. e) The catheter inserted into the artery. f) the leader York worked together from the early 1930s, studying withdrawn. Reproduced with permission from Acta Radiol 1953; 39: 368–76. ways of measuring the output of the heart. With

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colleagues at Columbia University Chest Service, they Specialty Condition Procedure spent 4 years from 1941 to 1945 developing and testing Vascular cardiac catheterisation. In 1956, almost 30 years later, Arterial Atherosclerotic disease Angiography, balloon Forssmann, Cournard, and Richards were awarded the Cerebral aneurysm, trauma Embolisation Nobel Prize for Medicine for their work on heart Renal failure Vascular access for haemodialysis catheterisation and pathological changes in the Thoracic or abdominal Endovascular stenting Venous Total Central circulatory system. Portal hypertension Transjugular intrahepatic portosystemic shunt Although the diagnostic potential of the Seldinger Varicose veins Endoluminal thermal ablation technique continued to grow, Dotter, an American Cardiology radiologist, is credited with being the first to realise its Atherosclerotic disease Cardiac catheterisation, angioplasty, insertion Mitral valve stenosis Percutaneous transvenous mitral commissurotomy therapeutic potential. In 1963, he inadvertently did a Septal atrial defect Percutaneous closure transluminal recanalisation of an occluded iliac artery Patent ductus arteriosus Percutaneous closure while attempting retrograde aortography. Realising the Diagnostic Endomyocardial biopsy significance of this work, Dotter described percutaneous Oncology Diagnostic Needle biopsy 7 transluminal coronary angioplasty in 1964. Gruentzig Tumour treatment Embolisation, chemoembolisation, radiofrequency ablation then firmly established this method with the develop- Urology ment of transluminal dilatation using non-compliant Ureteric obstruction Percutaneous nephrostomy balloons introduced through .8 Surgery Jaundice Biliary drainage, imaging, and stenting Dotter also saw the need for combined technological Swallowing difficulties, nutrition Percutaneous gastrostomy advances in the form of equipment, so he initially Intra-abdominal abscess Percutaneous drainage designed the technology and ultimately established firm Table: Current diagnostic and therapeutic applications of Seldinger technique links with industry in the manufacture of these prototypes. This highly practical approach helped to ensure the subsequent success of the technique, and the of his technique and imagined the advances that have naming of the product (Seldinger catheters) probably been made in such a short time. In 1992, he was ensured Seldinger’s place in medical history. Since awarded, and remains the only recipient of, the Pioneer 1964, many technical advances have been made, for in award from the Society of example, introducer sheaths, bonded multiplayer Interventional Radiology. The next 50 years may yet be guiding catheters, thinner walled catheters to the most exciting, with further pioneers and many more accommodate new devices, and use of polyethylene applications. Seldinger died in 1998, aged 71, in his terephthalate to manufacture balloon catheters that home town of Mora. 9 permit higher inflation pressures. Dotter and Gruentzig References are widely regarded as the fathers of interventional 1 Seldinger SI. Catheter replacement of the needle in percutaneous radiology because of their earlier work. By 1995, half a arteriography; a new technique. Acta Radiol 1953; 39: 368–76. 2 Farinas PL. A new technique for the arteriographic examination of million patients worldwide had undergone percuta- the abdominal aorta and its branches. Am J Roentgenol 1941; 46: neous transluminal coronary angioplasty. 641. 3 Radner S. Intracranial angiography via the vetebral artery: preliminary report of a new technique. Acta Radiol 1947; 28: 838. Sven-Ivar Seldinger (1921-1998) 4 Pierce EC. Percutaneous femoral artery catheterisation in man Sven-Ivar Seldinger was born in the small town of Mora with special reference to aortography. Surg Gynaecol Obstet 1951; in Sweden in 1921. He was educated in local schools 93: 56. before studying medicine at the Karolinska Institute in 5 Forsmann W. Catheterization of the right heart. Klinische Wochenschrift 1929; 45: 2085–87. Stockholm (1940–48), where he was remembered for his 6 Luft FC. The birth of a common procedure. Ann Intern Med 1994; intelligence and independence.10 Seldinger took an early 120: 974. interest in radiology, and worked in the university clinic 7 Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic at the Karolinska Hospital where, in 1952, he had the obstruction. Description of a new technic and a preliminary report of its application. Circulation 1964; 30: 654–70. idea for the catheterisation technique. In 1967, he 8 Gruentzig AR. Percutaneous transluminal coronary angioplasty. returned to Mora to become chief of radiology at the Semin Roentgenol 1981; 16:152–53. local hospital, and remained there until his retirement. 9 O’Murchu B, Myler RK. Percutaneous transluminal coronary angioplasty: history, techniques, indications and complications, Modern medicine owes much to the simple technique 2nd edn. London: Martin Dunitz, 2002. established by Seldinger more than 50 years ago. One 10 Greitz T, Seldinger S-I. Am J Neuroradiol 1999; 20: 1180–81. wonders if Seldinger realised the potential applications

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