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Interviews with pioneers of vascular

James S. T. Yao, MD, PhD,a Roger T. Gregory, MD,b and Norman M. Rich, MD,c Chicago, Ill; Norfolk, Va; and Bethesda, Md

History is defined as the discovery, documentation, one of direct surgery on arteries. A breakthrough occurred collection, organization, and presentation of information in the decade of the 1950s when Kunlin5 introduced the about past events, usually in written format. Jesse Thomp- femoral-popliteal vein bypass graft for limb ischemia. Du- son, past President of the Society for bost used homograft for replacement of abdominal aortic (SVS), often quoted the great historian Thomas Carlyle as ,6 and was first performed saying, “history is the essence of innumerable biographies.” by DeBakey as a procedure to prevent stroke.7 In this era, Thompson also said, “The basis for today’s modern vascu- the SVS was formed and began to take a leadership role to lar surgery rests on achievements from the past.”1 In an develop vascular surgery. With the aid of catheter arteriog- effort to preserve the history of the SVS and vascular raphy and heparin, bypass graft using autogenous vein or surgery as a distinct specialty, the leadership of the SVS prosthetic graft was now extended to almost any part of the launched a new initiative to collect the oral history of body. As such, the era of reconstructive surgery began. An vascular surgery by conducting interviews of significant extra-anatomical concept for bypass evolved for use when a leaders and contributors in vascular surgery. This article normal pathway was not suitable for arterial bypass. The attempts to familiarize SVS members with this oral history growth of operative surgery continued until 1989, when and its importance in our surgical heritage. Juan Parodi successfully applied the endovascular graft In the history of vascular surgery, there are three eras. technique for a patient with abdominal .8 The first era began with the repair of a brachial artery by This innovation heralded the third era, one of catheter- 2 Hallowell in 1759 (reported by Lambert in 1761), follow- based endovascular techniques for vascular lesions. Balloon ing the development of an understanding of the pathophys- angioplasty, with or without stent placement, is now a iology of arteriovenous fistulas with the 1757 observations common procedure for the treatment of stenotic lesions of 3 of William Hunter, older brother of John Hunter. This era carotid, visceral, and infrainguinal arteries. For venous was a period of indirect surgery, and many surgeons were problems, endovenous ablation and laser are now common working on arterial anastomosis. Treatment of procedures for treatment of varicose veins. As endovascular was often by ligation, and lumbar sympathectomy was procedures proliferated, open procedures began to decline. often performed to improve limb blood flow. The first era In recent years, there has been a marked increase in the ended with the discovery of thromboendarterectomy for an number of endovascular procedures in the United States 4 occluded artery by dos Santos in 1946. The second era was with more than 69% increase per capita.9 Endovascular procedures are minimally invasive. Many patients who are From the Division of Vascular Surgery, Northwestern University Feinberg poor surgical candidates now can undergo a vascular pro- a School of Medicine, Chicago ; the Department of Surgery, Eastern Vir- cedure with eventual success. ginia Medical School, Norfolk (retired)b; and the Norman M. Rich Department of Surgery, F. Edward Hebert School of Medicine, Uni- With continued refinement of endovascular technol- formed Services University of the Health Sciences, Bethesda.c ogy, the practice and training of vascular surgeons has History Project Work Group of Society for Vascular Surgery: James S. T. changed dramatically. Vascular surgery has become a hy- Yao, MD, PhD (Chair); Roger T. Gregory, MD; Norman M. Rich, MD; brid specialty: vascular surgeons must be equipped to treat Peter F. Lawrence, MD; Walter J. McCarthy, MD; Mark K. Eskandari, MD; Melina R. Kibbe, MD; William H. Baker, MD; and Calvin B. Ernst, patients with either standard open procedures or endovas- MD. cular techniques. To accommodate the training of endo- Author conflict of interest: none. vascular procedures, the length of vascular training was Reprint requests: James S. T. Yao, MD, PhD, Division of Vascular Surgery, extended to 2 years in addition to the 5-year general Northwestern University Feinberg School of Medicine, 676 N. St. Clair, #650, Chicago, IL 60611 (e-mail: [email protected]). surgery residency training. During this period, trainees are The editors and reviewers of this article have no relevant financial relation- expected to fulfill four components in their training curric- ships to disclose per the JVS policy that requires reviewers to decline ulum: open procedures, endovascular techniques, vascular review of any manuscript for which they may have a conflict of interest. laboratory, and medical knowledge, including critical care. J Vasc Surg 2012;56:e52-7 A training option is now available to shorten the entire 0741-5214/$36.00 Copyright © 2012 by the Society for Vascular Surgery. training period (general surgery and vascular surgery) to 5 http://dx.doi.org/10.1016/j.jvs.2012.04.065 years. Also, a primary general surgery certificate is no longer e52 JOURNAL OF VASCULAR SURGERY Volume 56, Number 3 Yao et al e53

necessary to sit for the vascular board examination. The 0 ϩ ety.10,11 The history of vascular surgery is often mixed with 5 vascular training program is now the most competitive that of general surgery,12,13 and there are few books de- surgical training program in the United States. voted to vascular surgery alone. Those texts that do focus The development of vascular surgery is not confined to solely on vascular surgery include CLIO Chirurgica: The the technical part of the operative procedure alone. Other Arteries by Wiley Barker,14 and A History of Vascular disciplines often are involved with vascular surgery. These Surgery by Steven Friedman.2 There is only one oral history include radiology, to provide catheter arteriography, and (transcribed into text) in vascular surgery–Band of Brothers: imaging techniques, such as computed tomography (CT) Creators of Modern Vascular Surgery by Andrew Dale.15 scan and magnetic resonance imaging (MRI). In recent The other major history book in vascular surgery is The years, the 3D CT scan has helped to depict the aneurysm Classics of Vascular Surgery. The author, Charles Rob, configuration more accurately and has helped to avoid selected 27 articles considered to be classics in the litera- endoleaks. Vascular surgeons have developed a noninvasive ture.16 The history of vascular trauma is covered extensively test that uses Doppler to record flow velocity and ankle in Vascular Trauma by Rich and Spencer, which the SVS systolic pressure. In more recent years, the duplex ultra- has “adopted.”17 The SVS currently anticipates the third sound scan of arteries and veins has emerged as a useful edition of Vascular Trauma to be completed by Todd diagnostic test for carotid artery stenosis, as well as for the Rasmussen and Nigel Tai of the United States and United diagnosis of deep vein . These tests have led to Kingdom militaries, respectively, supplementing the sec- the establishment of the noninvasive vascular laboratory, ond edition with their recent allied experiences in Afghan- which is now an integral part of diagnostic services in most istan and Iraq. hospitals. Vascular surgeons must also work closely with Oral history is the oldest type of historical inquiry, as hematologists. Hematologists provide expertise on various well as one of the most modern. The modern concept of types of heparin, as well as newer antithrombotic and oral history was developed in 1940 by Allan Nevins of thrombolytic agents. Surgical research has evolved from Columbia University. Nevins used a tape recorder, but the using large animal studies primarily, to practicing molecular technique has progressed with time to high-definition dig- biology and gene-based techniques in the study of the basic ital videography (DVD).18 Oral history collects memories pathogenesis of vascular disease. Translational research and personal commentaries of historical significance (“from bench to bedside”) is now a common theme in through recorded interviews. It has been said that “oral many surgical research laboratories. In recent decades, the history is history comes alive.”19 The discipline came into development of critical care as a specialty has been recog- its own in the 1960s and early 1970s when inexpensive tape nized, and many elderly patients who were not candidates recorders became available to document social movements for surgery now can undergo surgery safely. The SVS, too, (ie, civil rights, feminism, the Vietnam War protest). Many has recognized the importance of critical care and has made writers employed oral history in their books, which are the specialty the fourth component in the training curricu- largely based on interviews. One example is the book on lum of vascular surgeons. President Truman, Plain Speaking: an Oral Biography of Harry S. Truman.19 The author, Merle Miller, spoke ORAL HISTORY OF SVS AND VASCULAR frankly with Truman for hundreds of hours, spanning many SURGERY months in the early 1960s, which he recorded in tapes and At present, we are blessed with modern communica- notes. He also interviewed many of those close to Truman. tion devices such as cell phones, computers, the Internet, An oral history interview generally consists of the inter- and a journal dedicated to vascular surgery (Journal of viewer questioning the interviewee on a well-researched, Vascular Surgery,orJVS). This, however, was not the case specific topic, while also recording their exchange in audio in the early stages of development of vascular surgery. and/or video format. Unlike audio recording alone, the Despite attempts to hold national meetings to exchange addition of video makes the interview a dynamic experi- ideas, the isolation of time and space led to several separate ence. The reaction of the interviewee to questioning, in “schools of thought” in the development of vascular sur- his/her facial expressions and body language, is clearly gery. Centers in Houston, San Francisco, Chicago, New visible when videotape is added. It is a powerful tool for York, New Orleans, Cleveland, and Rochester, Minnesota documenting historical events. Oral history is now an ac- as well as the US military developed, each offering a fasci- cepted part of history-collecting methods, and there are nating story of its development. Of interest is the manner in many oral history associations. In addition, many universi- which the same disease was approached in different ways ties have academic programs in oral history. according to the “school” involved (eg, endarterectomy vs Andrew Dale interviewed 36 vascular surgeons, as well bypass for aortoiliac disease). Yet, despite their isolation, as one owner and engineer of a prosthetic graft manufac- there was considerable commonality in thought regarding turer for Band of Brothers (Fig).15 Unfortunately, Dale died diagnosis and indication for intervention. The current in- of leukemia on September 22, 1990, and the book was terviews with more senior surgeons will offer interesting completed by his trusted friends, Drs George Johnson and insights into the beginnings of vascular surgery. James DeWeese. Dale had been interested in learning The SVS was founded in 1946. Several publications about the early training and experiences that led to the have documented the birth and the progress of the Soci- interviewees’ lives in vascular surgery, rather than of their JOURNAL OF VASCULAR SURGERY e54 Yao et al September 2012

Fig. Band of Brothers: Creators of Modern Vascular Surgery by W. Andrew Dale, MD, 1996. Reproduced with permission from Dale.15 contributions, which were considered common knowl- During the 50th anniversary celebration of the SVS, edge. Dale called this group, “Creators of Modern Vascular the Society sponsored VHS tape interviews of the only Surgery,” and wrote the foreword in January 1989. At that two remaining survivors of the 31 founders: Michael time, most of the interviewees had already been President DeBakey and Harris Shumacker, Jr. Part of the interview of either the SVS or the International Society of Cardiovas- of DeBakey was transcribed and published in the Journal cular Surgery, North American Chapter (ISCVS-NA). Four of Vascular Surgery in 1996.20 Both interviews have been of those who had not been elected—Malcolm Perry, James converted to DVD and are now accessible via the SVS S. T. Yao, Thomas Fogarty, and Frank Veith—were all Web site (http://www.vascularweb.org). The interview elected to president in the years subsequent to the inter- with DeBakey is more than 1 hour long and provides views. Of the 37 individuals interviewed, only eight were detailed stories on how he built the Department of not elected to the presidency of either the SVS or ISCVS- Surgery at Baylor College of Medicine into a major, NA. As was Dale’s intention, the book was completed by world-renown cardiovascular center. The interview of Johnson and DeWeese to detail the life and times of these Shumacker recalled the premier days of the SVS, when he surgical leaders. would collect membership fees and luncheon expenses JOURNAL OF VASCULAR SURGERY Volume 56, Number 3 Yao et al e55 by passing a hat around to the few members attending A committee called History Project Work Group the meetings. (Work Group) has been formed. Yao chairs this group, with Other VHS tapes recently acquired by the SVS include Rich and Gregory as members and Calvin Ernst as consul- (1) Frank J. Veith, The Origin of a Species & Future of a tant. After the first several interviews were conducted, the Specialty (VHS); (2) Michael E. DeBakey, Rudolph Matas: committee expanded to include younger SVS members: How I Remember Him (VHS); and (3) John L. Ochsner, Peter Lawrence, Mark Eskandari, Melina Kibbe, Walter Giants in Vascular Surgery–Childhood Memories (VHS). McCarthy, and William Baker. The Work Group is charged These three VHS oral histories were conducted by Roger (1) to develop a series of interviews with leaders in vascular Gregory, who has generously donated them to the Society, surgery, by using standard definition videography (DVD); and have been converted to DVD for Internet release. The and (2) to acquire VHS interview tapes and convert them to SVS has received three additional DVDs of interviews with DVDs. After these two charges are accomplished, all DVDs Charles Rob, Emerick Szilagyi, and Harris Shumacker, Jr. will be uploaded to the SVS Web site for Internet access by The interview by Norman Rich of Charles Rob, “Reflec- members. The following are the steps taken by the Work tions of Charles G. Rob: Early Years and Vascular Years,” Group: centers on Rob’s military experience. Of particular note in Selection criteria for candidacy for interview. The this interview, Rob declares that the greatest invention in first task of the committee was to develop selection criteria vascular surgery since World War II is the Fogarty balloon for interview candidates. After a conference call, the follow- catheter. (Judging from what we have seen with current ing selection criteria were adopted. endovascular technology, he is absolutely correct in that (1) Must be a member of the SVS or the International statement–Fogarty deserves the credit for the current en- Society for Cardiovascular Surgery, North American dovascular revolution in vascular surgery.) The interview Chapter. with Szilagyi, which focuses on the management of aortic AND aneurysms, was conducted at Henry Ford Hospital and (2) Must have served as president of the SVS, the Interna- contains the first aneurysm surgery to be performed live on tional Society for Cardiovascular Surgery, North screen. The subtitle of the interview reflects Szilagyi’s well- American Chapter, or a regional vascular society. known reputation: The Conscience of Vascular Surgery. The OR DVD of Shumacker, in which he is interviewed by Rich, is (3) Must be nationally and internationally known as a split into two parts: Shumacker’s early years and his vascular contributor to the development of peripheral vascular years. Both DVDs on Rob and Shumacker were given to surgery (local recognition, large number of cases, or the SVS courtesy of Rich. Both are in the Military Surgical newspaper fame is not counted) (Adapted from Dale, Heritage Series, produced by the Uniformed Services Uni- WA. Band of Brothers). versity of the Health Sciences (USUHS). Although the OR archive of oral history of the Society is somewhat small, the (4) Must be an inventor of an operative procedure or a impact on history of the SVS clearly shows. The SVS medical device. members hope that, by the time the planned interviews OR with leaders in vascular surgery are completed, there will be (5) Must have distinguished service to a vascular surgical sufficient materials to fully reconstruct the history of the society. SVS. OR The Journal of Vascular Surgery, owned by the SVS, (6) Must be considered and universally acknowledged as has offered a companion effort. “Historical Vascular Vi- an ultimate authority on a vascular disorder or surgical gnettes” have augmented and complemented the current procedure. method to collect oral and written histories regarding vascular surgery. Co-chief editors, Tony Sidawy and Bruce While selection criteria are important, the Work Group Perler, with Rich as Section Editor, have encouraged the will look at the total picture of the specialty to make sure all reconstruction of the history of SVS since 2009. Yao pre- facets of vascular surgery are covered. As stated previously, sented the first “Historical Vascular Vignettes” (published the development of vascular surgery involves multiple dis- March 2010), which brings the history of the SVS up to ciplines, and we will strive to show this in our project. In the date.21 The challenge continues, however, and all who have last several decades, we have witnessed the struggle of an interest in the history of vascular surgery are invited to vascular surgery to be recognized as an independent surgi- contribute to this section of JVS. cal specialty. In order to reassert vascular surgery’s unique position in medicine, as well as preserve an accurate history, we will interview those who were involved in the process, DVD INTERVIEWS WITH LEADERS IN including former officials from the American Board of VASCULAR SURGERY: A NEW INITIATIVE Surgery and the American Board of Medical Specialties. The SVS, under the current leadership of Richard Cam- Important events, such as the change of the name of bria and Peter Gloviczki, has decided to sponsor a series of ISCVS-NA to American Association for Vascular Surgery audiovisual interviews to feature the outstanding leaders (AAVS), the eventual merger of ISCVS-NA/AAVS into and contributors to the specialty of vascular surgery. the SVS, and the impact of endovascular surgery on train- JOURNAL OF VASCULAR SURGERY e56 Yao et al September 2012

ing and practice, must be kept in our surgical heritage. In Lessons learned from the interviews. After experi- recent years, several leaders in vascular surgery have become encing many interviews with leaders in vascular surgery, the deans of medical schools, and a few have moved up to author (Gregory) has the following impressions of these become CEOs of their own institutions. All of these indi- leaders. Interestingly, there were many common character- viduals may provide valuable information on how vascular istics that all of these surgical giants shared: surgeons should place themselves in the current tough economic situation. Finally, we have no desire to turn the (1) All were intelligent. This is essentially a given in view interview project into a senior endeavor. The members of of the rigors of medical school. the Work Group feel strongly that the younger generation (2) All worked hard. This is a consistent, common thread. of leaders must be part of the interviews to allow an accurate Calvin Coolidge said, “. . . unrewarded genius is al- account of modern history of the SVS and the specialty. most a proverb.” Intelligence and talent is worthless America is led by young and vibrant leaders, and such without the added ingredient of hard work. Dr Den- tradition must be kept when the history of the SVS is ton Cooley observed, “The harder I worked, the recorded. luckier I got!” Preparation for interviews. The interviews take place (3) All were opportunistic. Good fortune and “luck” in a quiet room with two comfortable chairs facing each probably played a role in all of their careers; however, when opportunity arose, it was recognized and used other. Rooms near heavy traffic should be avoided. A to the fullest. standard definition 4 ϫ 3 video camera is used, and usually (4) All had mentors. These were teachers and role models we use the two-camera technique to capture the interviewer who were interested in their success and offered and the interviewee. The interview generally takes about 1 sound advice and direction. hour to 1 hour and 15 minutes. The interviewee is asked to (5) Most gravitated toward an academic career. This af- submit (1) a current curriculum vitae and a short biosketch forded maximum opportunity for teaching and re- of less than 150 words, (2) a headshot, (3) a signed consent search to complement a clinical practice that in all form approved by SVS legal counsel, and (4) no more than cases was vigorous. 10 photos of family, memorable events, prizes, and special (6) Most were multidimensional, some more than others. occasions. These photos will be inserted in the recorded This suggests an absence of “thought rigidity” and an interview to highlight the events. ability to “think out of the box.” Several were out- The interviewer prepares for the interview by reviewing standing athletes, musicians, or artists. the interviewee’s curriculum vitae, significant publications, (7) Disappointment and failure, a constant in the human usually the presidential address, and books edited or writ- condition, only inspired determination and persis- ten by the interviewee. When necessary, inquiry to his/her tence. colleagues may help to fashion the questioning. The inter- (8) All used deductive reasoning to recognize truth and view format used is somewhat fluid, allowing the interview reality. A blind alley was rarely pursued. to have considerable individual flexibility. Nonetheless, a (9) All had supportive families. basic review of the individual’s early years, family back- (10) All were ambitious and most were not arrogant. ground, and education is highlighted, with further atten- (11) All were likeable and attractive leaders, despite occa- tion to his/her surgical training, mentors, career highlights sional controversy. as well as low points, and his/her opinion of the reasons for (12) All truly loved their patients and exhibited a passion his/her success. A final segment focuses on the interview- for providing the best possible care for them. ee’s personal opinions of multiple topics. The interviewer is advised to develop a master list of questions, with impor- SUMMARY tant ones at the top. Members of the Work Group are encouraged to submit questions to the designated inter- The purpose of the SVS is not just to hold an annual viewer, and the designated interviewer will make the final meeting, but also to pursue social, financial, and political list of questions. The interviewer may show the questions to responsibilities. In addition, the Society leads in research, the interviewee prior to the interview. We believe an early training, education, and practice (ie, patient care). The acquaintance of the interviewer and interviewee adds value current leadership of the SVS is dedicated to preserving the to the event. history of the Society. The History Project Work Group After the completion of the interview and recording, will execute the orders of the Society to develop a series of editing of the tape is the final path to the product. Editing digital videography recorded interviews with leaders in is often a tedious process. Judicious use of photos to vascular surgery to be made available to our membership. highlight a memorable event or to illustrate an important The information collected will form the basis for a book on occasion improves the visual value of the DVD. Once the the history of the SVS. editing is complete, the Work Group will select a subtitle The authors thank Brigid Kelleher, Assistant to the for each of the DVDs. The DVD will be shown to the Chair, Department of Surgery, Uniformed Services Univer- interviewee for his or her final approval before being re- sity of the Health Sciences, for her help in preparation of leased to the public. the manuscript. JOURNAL OF VASCULAR SURGERY Volume 56, Number 3 Yao et al e57

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