Born to Russian immigrants, Victor M. Bernhard was the oldest of three children, all raised in Milwaukee, Wisconsin. After graduation from Northwestern University (BS 1946, MD 1950), he entered the surgical training program at Northwestern, under the leadership of Dr Loyal Davis. Determined to be a vascular surgeon, Bernhard worked in the laboratory of Harold Laufman, where he learned about graft fabrics and other vascular devices. After residency, he returned to Milwaukee to join his father's small clinic and the clinical staff at the Medical College of Wisconsin (MCW). Bernhard then completed a vascular fellowship under the direction of Michael DeBakey at Baylor College of Medicine (1964-1965). He served as professor of surgery and the first chief of vascular surgery at MCW, then as vice chair of surgery at Albert Einstein Medical Center and Temple University, and, finally, as chief of vascular surgery at the University of Arizona Medical School. He volunteered as an emeritus lecturer at the University of Chicago School of Medicine. One of the most significant changes in Bernhard's career was his recruitment to Endovascular Technologies as vice president of medical affairs, in charge of the endovascular graft trial. It was Bernhard's idea to learn from the commercial side via clinical trials to improve the product. In his nearly 50-year career, he made significant contributions to vascular surgery. At the invitation of Robert Rutherford, he joined the editorial team of the textbook, Vascular Surgery, as associate editor. He recruited Dr Frank Maddison, a radiologist, to MCW to introduce the technique of catheter arteriography. The relationship eventually developed into an interventional radiology program, which replaced translumbar aortography to diagnose lesions in the profunda femoral artery in patients with ischemia of the lower limbs. With his MCW partner, Jonathan Towne, Dr Bernhard sponsored two symposia on vascular complications, a subject often avoided by surgeons. The symposia were successful, and a compendium book from each symposium was published. As recorder for the Society for Vascular Surgery, Bernhard served as chair of the publications committee; during his tenure, Dr Michael DeBakey negotiated with CV Mosby Company for a journal. Along with Dr John Ochsner and other members of the publication committee, the Journal of Vascular Surgery was first published in January 1984. Victor and his wife, Suzan, loved to travel, and they enjoyed many tours on all seven continents. A pilot, Bernhard flew a small plane and fully enjoyed the blue skies. His sense of humor and calmness, even in a storm, will be greatly missed. On July 21, 2020, Dr Victor M. Bernhard died peacefully at 93 years of age in his home in Port Charlotte, Florida, attended by his wife and immediate family.

Dr J. Leonel Villavicencio was one of the first vascular surgeons who advocated equal attention to all components of the circulation—arterial, venous, and lymphatic. Yet, the “Mexican Maestro” was careful not to criticize those who focused only on arterial diseases, even though he thought that an understanding of the interaction between arterial, venous, and lymphatic systems was a key to the care of patients.

He is the quintessential surgical teacher first by example (as one of the finest surgeons of his generation), but also through the high standards he set for the scores of individuals who had the honor of working with him. At his widely renowned morbidity and mortality conferences, Dr Spencer stressed thoughtful analysis and introspection as fundamental to achieving surgical competence. He viewed compassion and professionalism as important as technical perfection in providing quality care to our patients. Still today, generations of former students, residents, and colleagues view Dr Spencer as their most memorable teacher.—Dr Tom Riles, longtime colleague Frank Cole Spencer, a prototypical West Texas farm boy, was born in 1925 in Haskell, Texas. He rode his pony bareback to and from the two-room schoolhouse where he was taught and rose to become an icon of American surgery. He attended North Texas State College at age 15 but was rejected from medical school in Texas because of his young age of 17 years. He was subsequently accepted at Vanderbilt and graduated at the top of his class. He had early intern contact with Dr Alfred Blalock (1947-1948) at Johns Hopkins, and this exposure provided the basic preparation to learn arterial repair. He then spent 2 years at UCLA under Drs Longmire and Muller. Midway through his surgical training, he was drafted into military service. He was aware of the 1946 report by DeBakey and Simeone of the poor results with ligation in treating arterial trauma. Operating in a tentlike hospital during the 1953 Korean Conflict, he was also aware that military regulations mandated all vascular trauma be treated by ligation. For the first time, surgical units were positioned close to combat zones, and helicopters were available for routine evacuation. Thus, the opportunity arose to perform early vascular repair, and he made the clear choice to perform repair instead of ligation. He knew that he would either be “court marshalled or get a medal” for this patient-oriented decision. In 1954, he was awarded the Legion of Merit for his work in the Korean War. Dr Spencer finished his formal training at Johns Hopkins, where he rose to Associate Professor by 1961. Although offered other opportunities, he refused to consider any future position that did not involve teaching. He then spent 5 years at a new medical school in Kentucky, moving to NYU in 1966, where he served as chair for 30 years. Perhaps Dr Spencer's primary impact was his insistence on deductive reasoning and consideration for proper time management. In these areas, he influenced a generation of surgeons. He always went back to his “cookbook notes” written after each operation in search of a better way to perform the next procedure. A genius for organization of academic records for subsequent reporting and for teaching others to follow his example, he believed that “with a good mind and hard work, anything could be accomplished." Dr Spencer served as president of the American College of Surgeons, the American Surgical Association, the International Society for Cardiovascular Surgery, and the American Association of Thoracic Surgeons. He was the recipient of the Michael DeBakey Award. When asked what kept him coming to work long into his 80s, Dr Spencer said it was “the excitement of learning.” A complete interview with Dr Spencer is available from the Society for Vascular Surgery's Audio Visual History Archive at https://vascular.org/about-svs/history.

Dr John Lockwood Ochsner will be remembered as a charismatic physician, a dedicated teacher, a loving father, and a role model for the hundreds of surgeons he trained. He was revered as an innovative, energetic, and talented surgeon, performing over 12,000 operations, including the first cardiac transplant in the Gulf South. He always said he was happiest in the operating room and loved teaching young resident surgeons. He believed that “surgery is an art as much as a science. You have to improvise almost every case – no two cases are the same – and that's where the fun of surgery comes in, making something new that particular moment that you've never seen before … It's like opening up a package; it's always a little different.”—Dr Larry H. Hollier, LSU Health Sciences Center, July 2018 John Lockwood Ochsner was born in 1927 in Madison, Wisconsin, was raised in New Orleans, and attended college at Tulane. He was surrounded by giants of surgery during his childhood,1Gregory R.T. Childhood memories of giants in vascular surgery: Matas, DeBakey, de Takas, Ochsner: an interview with John Ochsner.J Cardiovasc Surg. 2003; 11: 407-411Crossref Google Scholar including his father, Alton, who founded the Ochsner Clinic in 1946 and, in 1947, became the first President of the Society for Vascular Surgery. John and his siblings never considered any other profession but medicine. He received his MD from Tulane and finished residency at Michigan and Baylor. He then returned to Baylor for extended cardiovascular training under Dr Michael DeBakey, who had been his childhood babysitter. In 1961, he returned to the Ochsner Clinic, and in 1966 he became the Chairman of the Department of Surgery, a position he held for 22 years. He built the Clinic from a small group of visionary surgeons to a huge, world-class educational and clinical institution. He devoted time to scores of public service activities, serving on boards and charitable organizations too numerous to recount. He is the only person to receive both the Cooley and DeBakey awards. His mentors included his father, Dr DeBakey, and Dr Denton Cooley, who influenced both his personal and professional life and contributed to his success. All cardiac surgeons at that time were first vascular surgeons, and Dr Ochsner's training in both arenas equipped him to become a pioneer in cardiac surgery in Louisiana with multiple firsts (including organ transplantations of heart, liver, and lung). Simultaneously, he had a profound impact on vascular surgery, performing successful repair of thoracoabdominal aneurysms, which at that time was breaking new surgical ground. His scholarly activities were staggering, with >300 publications. Nearly 40% of these publications addressed vascular issues. He served as president of 10 surgical associations, including the International Society for Cardiovascular Surgery and the American Association of Thoracic Surgeons. In 1990, he was elected Rex, king of the Carnival in New Orleans. Among his many personal highlights, perhaps the most important was meeting his wife in Ann Arbor when he was an intern at the University of Michigan. Dr Ochsner credits Dr DeBakey with the idea for the Journal of Vascular Surgery, yet he was clearly responsible for bringing the Journal to life, chairing the committee that did the formal groundwork. Dr John Ochsner was on the ground floor in the development of vascular surgery as a specialty. His understanding of people, political awareness, organizational skills, and leadership made him an amazing force in the development of all phases of American surgery. John is clearly a hero in American surgery and a model for achievement for all to emulate. To learn more about John Ochsner, go to www.vascularweb.org (click the About SVS tab, then choose the history link).

Dr Denton Arthur Cooley, MD, was an iconic pioneer from the dawn through the explosion of cardiovascular surgery. Along the way, he was a prolific researcher, the inventor of many instruments and procedures, and educated innumerable vascular and thoracic surgeons. His clinical productivity is almost incalculable, having carried out over 140,000 cardiovascular and vascular procedures, all with humor and a quick wit, sometimes very appropriately referred to as a surgical athlete. He was a humanitarian of the first order, and the number of lives that he saved and impacted is beyond calculation.—Dr Joseph S. Coselli, Baylor College of Medicine, December 2016Denton A. Cooley will always be remembered as perhaps the finest technical cardiac and vascular surgeon at the modern dawn of these two specialties. A native of Houston, Texas, whose grandfather was a real estate developer and father a dentist, Dr Cooley attended the University of Texas in Austin. At 6 feet 4 inches tall, he played basketball for the Longhorns as a forward and sometimes center. His zoology major led to medical school at the University of Texas, Galveston and to a transfer to Johns Hopkins to complete his medical degree in 1944. This began his relationship with Alfred Blalock, Chairman of Surgery at Hopkins, who Dr Cooley considered one of his primary surgical mentors. As a surgical trainee at Hopkins, Dr Cooley said he was “an intern down at the foot of the table” when Dr Blalock performed the first “blue baby” operation in November 1944. After 2 years in the military, Dr Cooley returned to Johns Hopkins to complete his surgical residency in 1950. He then spent 1 year in London with Russell Brock, who he described as the most prominent thoracic surgeon in the United Kingdom. In 1951, Dr Cooley returned to his hometown of Houston to be an associate professor of surgery at the Baylor College of Medicine and to work at Methodist Hospital with Dr Michael DeBakey. There followed collaboration with early fundamental work on cardiopulmonary bypass, artificial cardiac valve surgery, aortic surgery, and coronary artery bypass grafting. Dr Cooley moved his practice to St. Luke's Episcopal Hospital in 1960 and founded the Texas Heart Institute in 1962. In 1969, Dr Cooley is credited with implanting the first artificial heart, which functioned for 3 days and was followed by a heart transplant. This led to a decades-long dispute with Dr DeBakey, who had been the principal investigator of the implantable heart. The two surgeons reconciled their differences publicly in 2007 when Dr DeBakey was 99 years old and Dr Cooley 87. Dr Cooley is credited with the first successful heart transplantation in the United States. He also performed congenital heart surgery regularly. His experience with aortocoronary bypass and valve surgery is unparalleled, as outlined in his recent autobiography, 100,000 Hearts–A Surgeon's Memoir.1Cooley D.A. 100,000 hearts: a surgeon's memoir. Dolph Briscoe Center for American History, Austin, TX2012Google Scholar He also estimated that about 20% of his practice was aortic and other vascular surgery. A 1986 atlas of aortic surgery, which he authored,2Cooley D.A. Surgical treatment of aortic aneurysms. W.B. Saunders Co, Philadelphia1986Crossref Google Scholar remains to this day an outstanding reference for this work. Dr Cooley received many awards, including the Presidential Medal of Freedom from Ronald Reagan in 1984 and the Renee Leriche Prize in 1967 as the “most valuable surgeon of the heart and blood vessels anywhere in the world.” Married for 67 years, he wed Louise Thomas, RN, in 1949 in Baltimore, where she was a head nurse at Johns Hopkins. Mrs Cooley died on October 21, 2016. The couple raised five daughters. Throughout his life, he played tennis and golf and he also played the double bass in a swing band. Denton A. Cooley died at home November 18, 2016 at the age of 96.

Dr Edward B. Dietrich, MD, was an extraordinary cardiovascular surgeon, a maverick innovator, and a visionary leader of the endovascular revolution, who introduced new techniques and procedures well before his peers. He challenged the status quo, disregarded conventional wisdom, pushed boundaries, and innovated vascular therapy and surgical education by organizing live telecasts and highly successful meetings. He established a journal, an international society, a translational research center, and a foundation dedicated to cardiovascular care. His transforming impact on the practice and science of vascular surgery was recognized by the Society for Vascular Surgery by awarding him the distinguished Medal of Innovation.–Dr Peter Gloviczki, Mayo Clinic, Rochester, Minn, March 2017Internationally recognized as a brilliant cardiovascular surgeon, Edward (Ted) B. Diethrich, MD, died on February 23, 2017. He was a DeBakey-trained cardiovascular surgeon with a magnetic personality who loved music and sports. He once owned a football team (the Arizona Wranglers) and befriended the team's famous coach, George Allen. Sports Illustrated featured him in a story about frontenis, and LIFE Magazine followed him for a week and noted that his support team coined the sobriquet “Ted Terrific.” Indeed, he was terrific. On many occasions, he moved too fast for his colleagues to catch up, and his thinking was often ahead of others. He was one of the first surgeons to advertise his practice. At that time, medical marketing was forbidden fruit, and he was soundly criticized. Ted took a different view, and today it is routine to see full-page ads in major newspapers touting various medical centers. As in many areas, he was ahead of his time. Dr Diethrich was a native of a small town in Michigan (Hillsdale) near the University of Michigan, where he attended college and medical school. He was a natural athlete and musician, and his interest in medicine was encouraged by his mother, who was an operating room nurse. His surgical training included residency at St. Joseph Mercy Hospital, followed by a rotation with the legendary Emerick Szilagyi at Henry Ford Hospital. He went for advanced cardiovascular training with Dr Michael DeBakey at Baylor College of Medicine. He was responsible for the first multiorgan transplant while in Houston. Always driving himself, he simply could not “wait his turn,” which led to his leaving Houston and moving to Phoenix to found the Arizona Heart Institute (AHI) in 1971. Under his leadership, the AHI emerged as an international organization. When endovascular technology was first introduced, Ted immersed himself in the “endovascular explosion.” His annual endovascular conference (this conference was first called the “International Congress on Endovascular Interventions” and later “iCON”) showcased new ideas in endovascular surgery and attracted surgeons from around the world. He was also coeditor with Tom Fogarty of the Journal of Endovascular Surgery, now called the Journal of Endovascular Therapy. He was a frequent speaker and participant in worldwide surgical meetings and was, indeed, an international ambassador for vascular and endovascular surgery. Ted first tasted innovative success in 1962 and is given credit for invention of the sternal saw for opening the sternum. He later established the first outpatient cardiac catheterization laboratories and established one of the first ultrasound companies. He introduced one of the first endovascular grafts in the U.S. Later in his career, he had three companies to pursue research related to translational research, endoluminal graft development, and prevention and management of cardiovascular disease. He was generous in sharing and teaching his skills, particularly with young surgeons and nurses. His generosity extended to establishment of the Diethrich Professorship in Biomedical Engineering and Vascular Surgery on May 18, 2015, at the University of Michigan. Ted felt strongly that radiation exposure led to increased risk of certain medical problems, including brain tumor, cataracts, and carotid occlusive disease – all of which he had contracted. He pushed hard for better protective measures. When asked to characterize Ted before his Society for Vascular Surgery (SVS) interview, his wife, Gloria, said, “He was always looking for a better way.” The recipient of many awards and honors, perhaps his most cherished was the SVS Medal for Innovation in 2013, which brought tears to his eyes. He recently recounted his life in an autobiography “SLED – the Serendipitous Life of Edward Diethrich,” completed while his brain tumor was in remission. SLED is a fascinating story of his successful life as a cardiovascular surgeon. Ted had also played a role in fictional books, including the very popular “HEARTS,” which reflected some of his time in Houston. Ted was committed to his family and loved them deeply. He is survived by his wife, Gloria, of 61 years, son Tad, daughter Lynne, son-in-law Joe Jackson, daughter-in-law Terri Diethrich, and many grandchildren that were the pride of his life. Ted Diethrich was a tremendous innovator, consummate surgeon, and benefactor. He lived his life in line with his belief in the “Power of Three – To Care, To Teach, To Pioneer.” He was a great man and will be missed.

The news of the death of Dr Denton Cooley on November 18, 2016, and the long obituary in the New York Times1Dr. Denton Cooley, heart surgery pioneer who set off a 40-year feud, dies at 96. New York Times Obituaries, November 19, 2016, D6.Google Scholar have brought back many memories of America's best technical surgeon, whose surgical skills were, by all accounts, simply magical. As John Ochsner said about Denton Cooley, “He operated with great speed and that saved patient time on the pump, and the end result is faster recovery” (John Ochsner, MD, personal communication. November 18, 2016). It is appropriate that the Society for Vascular Surgery (SVS) History Project Work Group recognize some of its discoveries in the history of Dr Cooley. In 2011, the SVS leadership initiated an oral history program by audiovisual recording of interviews using high definition digital video disc (DVD). The first surgeon chosen for interview was Dr Denton Cooley. On September 26, 2011, Roger Gregory interviewed Cooley. Cooley was in good form, alert, with a great sense of humor. His story about the use of muscle flap to stop bleeding of a thoracic false aneurysm was fascinating. At the time of this incident, he was just a surgical resident at Johns Hopkins. It is little wonder he was universally recognized as the best technical surgeon in America, whose extraordinary vision led to courageous solutions of seemingly impossible situations. But it is no surprise that Cooley chose Houston, The Texas Medical Center, Baylor College of Medicine, and working with Dr Michael E. DeBakey to expand his visions in cardiac and vascular surgery. If Europe was the cradle for vascular surgery, then America has been the “growing up venue” for youth in vascular surgery, and for decades, Houston was the epicenter of that development. DeBakey and Cooley both spent time in Europe—DeBakey with Leriche in France and Cooley with Lord Brock in England. Shortly after World War II, 31 general surgeons with interest in vascular surgery founded the SVS. American ingenuity then went to work, and America emerged as the leader in vascular surgery. Leading this evolution was none other than Michael DeBakey. After he took over as the Chair of Surgery at Baylor College of Medicine in 1948 and 1949, one of his earliest recruits was Denton Cooley as one of his faculty and partners. Together, they mastered the surgical treatment of aneurysms of the thoracic and abdominal aorta and of cerebrovascular revascularization. They then expanded surgical treatment to every part of the body. Dr Cooley was also an expert pediatric cardiac surgeon. They wrote together, both expertly and extensively. The name Denton Cooley is inextricably linked to Michael DeBakey. DeBakey and Cooley were both recognized as expert cardiac surgeons. In April 1969, Cooley performed the first human implantation of an artificial heart without approval of DeBakey or authorization by the research protocol review panels, both internal and external to Baylor College. The subsequent findings and recommendations led to Dr Cooley's resignation from Baylor. Undaunted, Dr Cooley founded the Texas Heart Institute and continued his clinical, teaching, and research work there. The separation attracted considerable media attention. Instead of writing about the extraordinary contributions of these two pioneers in vascular surgery, most press writings were sensationalized accounts of the split. In addition, little attention by media was given to three important events. First, when in October 2007, DeBakey received the Congressional Gold Medal, Dr Cooley was in the selected audience at DeBakey's invitation. Second, later the same week, Cooley presented DeBakey with the Lifetime Achievement Award from the Cooley Surgical Society. When they met, Cooley told DeBakey that he was glad they were together again and the feud was over. DeBakey replied, “Denton, there has never been a feud. That was in the minds of others.” A short time later, at a meeting of the Michael E. DeBakey International Society, Dr DeBakey presented a similar recognition to Dr Cooley. Clearly, their estrangement had ended. In the recent Cooley obituary, the “feud” between Cooley and his mentor, DeBakey, was revisited. Interestingly, when we learned of the death of Denton Cooley, the SVS History Project Work Group had just returned from Houston after visiting the DeBakey museum, followed by a meeting with three DeBakey-trained vascular surgeons (Drs Ken Mattox, Charles McCollum, and George Noon). The purpose of the meeting was for the SVS History Project Work Group and the DeBakey International Surgical Society to jointly produce a DVD on the life and work of Michael E. DeBakey. With renewed attention on the feud between DeBakey and Cooley, the question posed to Drs Mattox, McCollum, and Noon was whether we should revisit this issue again. The spontaneous, simultaneous, instantaneous answer from these three Houston second-generation vascular surgeons was “No, the ‘feud’ is over and has been for years, if, indeed, it ever did exist.” Regardless of the terminology used, it was actually a fierce, healthy competition that contributed in no small part to the development of the amazing Texas Medical Center. During the time of the competition, Mattox, McCollum, and Noon, who interacted with both Cooley and DeBakey, emphasized that neither was ever heard to say a derogatory word about the other to them or anyone else—ever. When they reunited, at a table of 12 people, Drs DeBakey and Cooley were deep in conversation between just the two of them, both talking at the same time. They were like two golfers at the end of the 18th hole, talking about their good shots and the ones that could have been better (Fig). The loss of these two pioneers has closed a chapter in the history of American surgery. For more than a century, manual dexterity played the central role of surgical skills in vascular surgery. Advances in surgery, as Francis Moore said, now reside largely in the growth of effective technology.2Moore F.D. Clinical surgery and biological science.Ann Surg. 1963; 158: 785-798Crossref PubMed Scopus (5) Google Scholar In the endovascular era, which is technology-dependent, surgery is performed within the lumen of the artery from a remote site. We are now in a new chapter of American surgery, and we must adapt to this new order to provide better service for our patients.

I am honored and humbled to be cited in the article “The role of immigrants to United States of America in the development of cardiovascular surgery” in the May issue of Journal of Vascular Surgery.1Sterpetti A.V. Ventura M. The role of immigrants to United States of America in the development of cardiovascular surgery.J Vasc Surg. 2017; 65: 1528-1530Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The article listed a number of immigrants who helped to develop cardiovascular surgery in America. However, there is one notable omission: Dr Geza de Takats of Hungary. Dr de Takats first came to America on a traveling fellowship supported by the Rockefeller Foundation in 1924-1925 and was assigned to Columbia University Medical School under Dr Allen O. Whipple. He observed the specialty-oriented clinics, such as a spleen clinic and a liver clinic, that were established by Dr Whipple as an effective way to provide advanced patient care. This experience formed the basis of his creating a vein clinic when he was offered a faculty position at Northwestern in 1930 as a half-time surgical fellow. This enabled Dr de Takats to combine teaching and research with patient care, and with the encouragement of Dr Allen B. Kanavel, then Chair of the Department of Surgery, de Takats opened a vein clinic. The clinic used injection treatment for varicose veins and also recognized problems with deep venous insufficiency. In 1935, de Takats moved to University of Illinois, where a peripheral circulatory clinic was created, providing care to both artery and lymphatic disorders. He was able to gather a group of aggressive and talented physiologists, internists, neurologists, and, later, a coagulationist, all of whom converged on the clinic two times a week instead of the patients limping from one clinic to another. Noninvasive tests like plethysmography and ergography as well as skin temperature and galvanic resistance measurements were used. The setting, with the exception of our modern ultrasound instrumentation, was similar to the current vascular laboratory.2de Takats G. Symposium on venous problem: introductory remarks.in: Bergan J.J. Yao J.S. Venous problems. Year Book Medical Publishers, Chicago1978: 1-2Google Scholar Another difference is that the current vascular laboratory is a fee-for-service laboratory. de Takats presided over two eras of the development of vascular surgery. During the first era of indirect surgery, the practice was primarily concerned with venous problems, sympathectomy, Raynaud phenomenon, and causalgia. The second era, direct arterial surgery, began with the thromboendarterectomy by dos Santos of Portugal.3dos Santos J.C. Sur la désobstruction des thromboses artérielles anciennes.Mem Acad Chir (Paris). 1947; 73: 409-411PubMed Google Scholar At the same time, the Society for Vascular Surgery was founded by 31 general surgeons, including de Takats, with special interest in vascular surgery.4Yao J.S. Society for Vascular Surgery (SVS)—the beginning.J Vasc Surg. 2010; 51: 776-779Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar It was during this era that the use of prosthetic graft and homograft expanded the growth of direct surgery. Geza de Takats was a friend to every surgeon in Chicago, and it was because of his leadership and respect from others that he was asked to take charge of an artery bank in Chicago. The artery bank was supported and used by all surgeons in Chicago. In its 3 years of existence, the citywide Chicago Artery Bank implanted 364 grafts in patients with aortic aneurysm.5Weinberg Jr., M. Fell E.H. de Takats G. McElwaine N. Use of homografts dispensed by Central Artery Bank of Chicago Heart Association.JAMA. 1959; 170: 2132-2134Crossref Scopus (1) Google Scholar The use of homograft kept direct arterial surgery evolving until the introduction of prosthetic graft by Voorhees of the Columbia group. de Takats also practiced the wiring technique for treatment of thoracic or abdominal aortic aneurysm. He wrote extensively on sympathectomy, causalgia, and venous thromboembolism. He had special interest in heparin and was the first to advocate the use of low-dose heparin for prevention of deep venous thrombosis.6de Takats G. The subcutaneous use of heparin. A summary of observations.Circulation. 1950; 2: 837-844Crossref PubMed Scopus (4) Google Scholar He was a great leader and supporter of vascular surgery's growth into a specialty surgery. In the Archives of Internal Medicine, he published a monthly summary of the achievements in vascular surgery.7Scupham G.W. de Takats G. Van Dellen T.R. Marcus P.L. Vascular diseases: eighth annual review.Arch Intern Med (Chic). 1942; 70: 444-510Crossref Scopus (1) Google Scholar He was elected locally as president of the Chicago Surgical Society and the Chicago Heart Association and, nationally, as president of the Society for Vascular Surgery in 1953 and the North American Chapter of the International Society for Cardiovascular Surgery in 1954. de Takats was a great writer and was a member of the Chicago Literary Club. He wrote several short stories, including A Breach of Etiquette, which became very popular.8de Takats G. Breach of etiquette and other short stories.1971Google Scholar In medical writing, his textbook, Vascular Surgery, published in 1959, was the best in the field of vascular surgery. In the last part of the book (pages 553 to 663), there were beautiful illustrations of surgical procedures.9de Takats G. Vascular surgery. WB Saunders, Philadelphia1959Google Scholar When I first joined Bergan in the practice of vascular surgery, I received a phone call from de Takats. I had never met him, but of course, I knew his reputation. The call was an invitation to have lunch with him—what a pleasant surprise! He took me to his exclusive private club, which at that time was well known for three-martini lunches for CEOs. We had a great time and I learned what I needed to become an academic vascular surgeon. After that meeting, we kept in touch. One unique way he kept in touch was by postcard. If he heard an interesting presentation, he would send me a postcard describing it. The practice of lunch with younger colleagues was so unique that I decided to do the same with younger surgeons who landed in Chicago. In addition to those mentioned in the article and Geza de Takats, there remain quite a few immigrant vascular surgeons who helped the development of vascular surgery in America. These are Henry Haimovici (Romania-France), Leonel Villavicencio (Mexico), Hassan Najafi (Iran), Ramon Berguer (Spain), Enrico Ascher (Brazil), Anton Sidawy (Syria), Christopher Zarins (Latvia), Robert Linton (Scotland), and Charles Rob (United Kingdom). Each of these has made significant contributions to vascular surgery. It has been said that immigrants make up America and it is the land of opportunities. We all are fortunate to have been given the opportunity to develop vascular surgery in America. We succeed because of the rich resources, the strong support, and, most important, the generosity of Americans. The role of immigrants to United States of America in the development of cardiovascular surgeryJournal of Vascular SurgeryVol. 65Issue 5PreviewThe migration from one part of the world to another is a common finding in nature and among human beings. Immigration has many advantages as well as many problems. Full-Text PDF Open Archive

Advice is defined as "recommendation regarding a decision or course of conduct."1Merriam-Webster dictionary. Available at: http://www.merriam-webster.com/dictionary/advice. Accessed November 9, 2015.Google Scholar This suggests or implies a request or need for direction. Advice from old to young is not always welcome, yet in today's complex world of medical practice, there has never been a time when advice is more needed by young surgeons emerging into the medical environment. The enormous changes in the practice of vascular surgery—from open surgery to endovascular surgery, from hand-written hospital notes to electronic medical records, and from various private third party carriers to the Affordable Care Act—all represent staggering upheavals in the everyday practice of medicine. Further, many couples are two-career families, which puts extra demands of time on both, leading to added stress. Thus, when the History Project Work Group of the Society for Vascular Surgery (SVS) conducted interviews over the past few years, advice was considered to be an important topic for discussion. In 2009, the SVS, under the leadership of Richard Cambria and Peter Gloviczki, initiated a project to preserve the history of the SVS, including the merger with the American Association for Vascular Surgery (AAVS; originally the International Society for Cardiovascular Surgery, North American Chapter), and of vascular surgery as a surgical specialty via audiovisual DVD recordings of interviews with leaders and contributors of vascular surgery. A committee called the History Project Work Group was formed. The structure and functions of the nine-member committee previously have been described in detail.2Yao J.S. Gregory R.T. Rich N.M. Interviews with pioneers of vascular surgery.J Vasc Surg. 2012; 56: 352-357Abstract Full Text Full Text PDF Scopus (4) Google Scholar It soon became apparent that the information we collected has not only historical value but educational value as well. Lessons we learned from the interview program have been reported recently.3Yao J.S. Gregory R.T. Rich N.M. the History Project Work Group of the Society for Vascular SurgeryInterviews of leaders and contributors in vascular surgery: a new initiative sponsored by SVS.in: Eskandari M.K. Pearce W.H. Yao J.S. Current vascular surgery 2012. People's Medical Publishing House-USA, Shelton, CT2013: 1-8Google Scholar, 4Gregory R.T. Yao J.S. Rich N.M. the History Project Work Group of the Society for Vascular SurgeryInterviews with pioneers of vascular surgery: observations and lessons learned.in: Eskandari M.K. Pearce W.H. Yao J.S. Current vascular surgery 2013. People's Medical Publishing House-USA, Shelton, CT2014: 1-9Google Scholar, 5Yao J.S. Gregory R.T. Rich N.M. the History Project Work Group of the Society for Vascular SurgeryInterviews with leaders and contributors of vascular surgery: a summation.in: Eskandari M.K. Pearce W.H. Yao J.S. Current vascular surgery 2014. People's Medical Publishing House-USA, Shelton, CT2015: xxxi-xxxixGoogle Scholar Beginning in 2011, the History Project Work Group conducted 80 interviews. The Table shows the numbers of interviews in four categories. Unfortunately, several former presidents were unable to grant an audiovisual interview because of their neurological condition. At the conclusion of each interview, the question "What advice would you like to give to the young vascular surgeons?" was posed. Some of the best individual answers follow.TableNumber of interviews according to category of candidatesCategoryNo.Living past presidents of SVS, AAVS, or ISCVS-NA40Recipients of awards from SVS5Honorary members20Highly selected contributors chosen by the work group15Total80AAVS, American Association for Vascular Surgery; ISCVS-NA, International Society for Cardiovascular Surgery, North American Chapter; SVS, Society for Vascular Surgery. Open table in a new tab AAVS, American Association for Vascular Surgery; ISCVS-NA, International Society for Cardiovascular Surgery, North American Chapter; SVS, Society for Vascular Surgery. Robert B. Smith III, MD, Atlanta, Ga (President, AAVS 1997) I have a lecture I have given several times with that exact title. In the closing comments I have mentioned:1.Attention to the family. Because vascular surgery is an all-consuming profession you can get too locked into it if you are not careful. So, spend as much time as possible with your family. Art Voorhees told me when I left his program that he never knew of any surgeon who said on his death bed that he wished he had done more aneurysms!2.Personal integrity. This is paramount to success especially if you are a vascular surgeon and the patient's welfare is your prime concern.3.Other attributes:a.Perseveranceb.Dedication to the specialtyc.Patience when things aren't going well. I sometimes tell my colleagues to offer the surgeon's prayer, "God, if you'll just get me out of this this time, I will never do this again!" Professor Roger Greenhalgh, London, England (Honorary Member, Selected Contributor) Enjoy what you are doing. Do what you love to do and it will not seem to be work. And get paid for it! A feeling of genuine warmth comes from that combination! Thomas J. Fogarty, MD, PhD, Portola Valley, Calif (President, SVS 1995) You must be persistent. Ignore what others think. And forget committees—if you want to do something, just do it! Don't horse around trying to see how to do something. When you jump into a project or activity, then you become familiar with the details and can move ahead. So you want more specific advice? Always be patient-centric in your focus. Your obligation as a physician is not to government or to an institution. Your focus should always be on caring for patients. Christopher K. Zarins, MD, Stanford, Calif (President, SVS 1999) Remember that it is a privilege to be a surgeon. Not everyone gets that opportunity. It must be earned every day. You must be committed—that is how it is earned. And for those with academic interests, try to integrate that interest with your clinical activities. Larry H. Hollier, MD, New Orleans, La (Distinguished Fellow, Selected Contributor) Do what excites you. Is this fun? Do what interests you. And hope your wife supports you! Alexander W. Clowes, MD, Seattle, Wash (Distinguished Fellow, Selected Contributor) You must do vascular surgery if you like pipes. Remember that the heart is only a pump. The pipes are the important part of the circuit, and it is the pipes that do everything important. As vascular surgeons, you get to work on these pipes. And the tool box is huge! There is open surgery, endovascular, diagnostics, research, and many areas to utilize. There are still many challenges to address. Anthony M. Imparato, MD, New York, NY (President, SVS 1985) Learn how to operate! Norman M. Rich, MD, Bethesda, Md (President, AAVS 1990) Recognize that you have an exciting future ahead. The opportunity to innovate and contribute has never been better. And mentors are important. Our medical students are involved in "capstone" projects. They are challenged to choose and work on an area of interest for all 4 years, mostly in their spare time. In the fourth year, they are given 3 months to complete the project. One of my students is working with me on updating the Vietnam Vascular Registry. I have become really excited about this project as well! Thus, choose mentors who are excited about what you are doing! Kenneth L. Mattox, MD, Houston, Tex (Distinguished Fellow, Selected Contributor) Remember that the volume of medical knowledge doubles every 7 years—maybe every 5 years now! So, you must work hard to keep up! Never be satisfied with what you have. Always question your elders' dogma of "the only way" of doing things. Leave the world a better place by building on the past. Base your activities on science, but never lose your humanity. Jimmy F. Howell, MD, Houston, Tex (Distinguished Fellow, Selected Contributor) If you really want to be a surgeon, you better like what you are doing because it's hard work! But very satisfying. You know, I wouldn't do anything else—ever! If I had to do it all over again, I'd do the same thing. Julie A. Fleischlag, MD, Sacramento, Calif (President, SVS 2014) You have to be a good surgeon. Get trained! You must be an excellent surgeon, both technically and emotionally. Take as much time as you need. Some areas will come easily and some do not. Reassess all the time—are you happy doing this? If not, readjust. You might need to find something else to do. There are many options: research, vein centers, etc. Is there different advice for women? Well, women seem to feel more overwhelmed or inadequate. Yet, a recent publication suggests that men feel exactly the same way, but it doesn't bother them.6Lautenberger D.M. Dandar V.M. Raezer C.L. Sloane R.A. The State of Women in Academic Medicine: The pipeline and pathways to leadership, 2013-2014. Association of American Medical Colleges, Washington, D.C.2014Google Scholar, 7Pololi L.H. Civian J.T. Brennan R.T. Dottolo A.L. Krupat E. Experiencing the culture of academic medicine: gender matters, a national study.J Gen Int Med. 2013; 28: 201-207Crossref PubMed Scopus (184) Google Scholar, 8Kaatz A. Carnes M. Stuck in the out-group: Jennifer can't grow up, Jane's invisible, and Janet's over the hill.J Womens Health. 2014; 23: 481-484Crossref Scopus (40) Google Scholar Men just keep going. You know, men will apply for jobs that they are not qualified for! Women tend to wait longer. All of us feel the same way when faced with a ruptured aneurysm! Peter Lawrence, MD, Los Angeles, Calif (President, SVS 2015) I would tell them to pick something for which you have a passion. To be successful, one key component is "passion." This last year as President of SVS, people would say this must be a lot of work but I never have a minute that I don't realize this is a great honor. I have had the greatest time dealing with the Presidency as well as being President-elect and Vice-President because I have passion for doing it. Allan Callow, MD, Boston, Mass (President, AAVS 1975, SVS 1986) When asked about courage, John Wayne said, "Rough situations are going to come up. So what do you do? You just saddle up and ride out! And it usually works out OK." And so it is with medicine and surgery. You are going to encounter some rough situations. Just remember John Wayne—saddle up and ride out! And you'll be amazed at how most of the time it works out OK! Jock R. Wheeler, MD, Norfolk, Va (Distinguished Fellow, Selected Contributor) Medicine has changed so much from when I was in practice that it is difficult for me to give meaningful advice for today. With the change in the resident work week and all the government regulations, it is a different environment. Yet, with all these changes, dedication and honesty remain the keys to success. And it is hard to beat hard work! George P. Noon, MD, Houston, Tex (Distinguished Fellow, Selected Contributor) Stay current. You must stay up to date. For example, there are many that can do endovascular today: the radiologist, cardiologist, as well as the vascular surgeon. If you are not current and up to date, there will not be enough for you to do! James S.T. Yao, MD, PhD, Chicago, Ill (President, SVS 1993) You have a great future in vascular surgery. Work hard. Just shut up and do it! In reviewing these multiple statements and opinions from these and other interviews, three common themes emerged:1.Diligence: A successful career in vascular surgery without this is virtually impossible. Vascular surgery requires a commitment.2.Passion: You will not excel unless you have passion for your job.3.Balanced life: This might be the most difficult area to address. Vascular surgery requires a total commitment, yet so does family. Balancing the two without an occasional conflict can be difficult and, at times, impossible. Clearly, this is the challenge of the profession. Advice is a wonderful thing if offered honestly and received with an open mind. The Interviews with Leaders and Contributors program has not only historical value but also educational value. This SVS History Project Work Group interview program has allowed us to gather a host of thoughtful ideas valuable for the young and old. These ideas come straight from the innovators, contributors, and giants of vascular surgery.

In scientific investigation, “Who's on First” is often an ongoing debate when it comes to medical discoveries and scientific priority.1Markel H. “Who's on first?”- medical discoveries and scientific priority.N Engl J Med. 2004; 351: 2792-2794Crossref PubMed Scopus (10) Google Scholar Surgeons embrace the idea of being first to perform an operation, particularly if history later shines upon it a favorable light. Is it important to be first? The Olympic games initiated by ancient Greeks made heroes out of those who came in first in an event. In a presentation to the 25th Anniversary Veith Symposium on “Firsts” in Vascular Surgery: Who Did What “First,” Rich gave the subject an in-depth examination. He found that history is replete with claims of first. Many of these claims were associated with controversy.2Rich N. “Firsts” in vascular surgery: who did what “first.” Presented at the 25th Annual Symposium on “Current Critical Problems, New Horizons and Techniques in Vascular and Endovascular Surgery,” Annual Vascular Symposium, Albert Einstein College of Medicine - Montefiore Medical Center, New York, NY, November 19-22, 1998.Google Scholar Firsts in vascular surgery are numerous. It is generally acknowledged that William Harvey was the first to discover circulation. The Chinese, however, claimed they discovered the concept of blood circulation some 2000 years before Harvey.3Wan S. Yim A.P.C. The evolution of cardiovascular surgery in China.in: Wan S. Yim A.P.C. Cardiothoracic surgery in China: past, present and future. The Chinese University Press, Hong Kong2007: 80-112Google Scholar Similarly, coronary arteriosclerosis is often regarded as a Western disease, yet a recent report has found coronary arteriosclerotic disease existed in China >2200 years ago.4Cheng T.O. Coronary arteriosclerotic disease existed in Chinese over 2,200 years ago.Methodist DeBakeyCardiovasc J. 2012; 8: 47-48Crossref PubMed Scopus (4) Google Scholar Besides “first operations,” there are also “famous operations.” Harold Ellis, in his book Famous Operations, divided the “famous operation” into three types: type I is the breakthrough operation. A type II operation may be insignificant itself, but it marks the introduction of some important point in surgical technique. Finally, the type III operation depends entirely on the patient; the operation itself may be routine, but the patient is a famous person, thus an operation, an act between the surgeon and the patient, does carry extra meaning and significance.5Harold E. Famous operations. Harwal Publishing Company, Media, PA1984Google Scholar Among all first operations, none can surpass the “blue baby” operation by Blalock and Taussig, performed at the Johns Hopkins Hospital on November 29, 1944.6Blalock A. Taussig H.B. The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia.JAMA. 1945; 128: 189-202Crossref Scopus (564) Google Scholar To qualify as a first operation, DeBakey emphasized that the patient must survive the operation.7DeBakey M.E. Blaisdell F.W. The Society for Vascular Surgery: as I remember—an interview with Dr. Michael DeBakey.J Vasc Surg. 1996; 23: 1031-1034Abstract Full Text Full Text PDF Google Scholar One such example is the homograft replacement of an abdominal aortic aneurysm. Dubost of France did the operation on March 29, 1951. It was later known that Schafer and Dardin, of Kansas, did the same operation on March 2, 1951, 27 days before Dubost. However, their patient died 29 days after the operation, 1 day short of the magic 30 days to be counted as a “survival.”8Yao J.S. Commentary: surgical treatment of aortic aneurysm: 50-some years later.Cardiovasc Surg. 2003; 11: 413-415Crossref PubMed Scopus (2) Google Scholar Schafer and Dardin thus became just a footnote in the history of aneurysm surgery. A first operation also depends on the date of the report in the medical literature. The clearest example involves the most common open arterial operation, carotid endarterectomy, with multiple surgeons claiming to have been first to perform the procedure. Eastcott, Pickering, and Rob reported the first carotid surgery on May 19, 1954, and the report usually has been cited as the first operation. However, in a 19-year follow-up report by DeBakey in 1975, it appears that DeBakey did the procedure on August 7, 1953, some 9 months before Eastcott et al. In the quest for being the first in carotid endarterectomy, Dr Denton Cooley introduced his publication on the history of carotid endarterectomy with the quote by Ralph Waldo Emerson9Cooley D.A. Carotid endarterectomy: from first recorded case to present.Texas Heart Instit J. 1988; 15: 139-141PubMed Google Scholar: “Every child of the Saxon race is educated to wish to be first. It is our system.” Thus, the first Gore-Tex (W. L. Gore and Associates, Flagstaff, Ariz) femoral popliteal bypass reported here is both the product of a natural desire and an interesting and important landmark in surgical history. An elderly diabetic woman presented to our office in Norfolk, Virginia, with critical lower extremity ischemia <1 year after I entered clinical practice in 1974. She had the additional challenge of having had a ligation and stripping of bilateral lower extremity saphenous varicosities many years before. Angiography revealed an occluded superficial femoral artery, a patent popliteal artery segment below the knee, and limited runoff. The profunda was patent but small. My partner, Dr Jock Wheeler (later Dean of Eastern Virginia Medical School), and I had encountered this type of situation on several occasions, and it was always a dilemma. We had used an expanded polytetrafluoroethylene (PTFE) IMPRA graft (Impra Inc, Tempe, Ariz) for a femoral-tibial bypass several months earlier. The graft thrombosed in the early postoperative phase, and an attempt at thrombectomy with a Fogarty catheter resulted in a longitudinal split in the graft over its entire length. In view of this experience, we were not inclined to try another PTFE graft. And yet, our dilemma remained. We had heard that another new prosthetic graft made of PTFE had been produced by the W. L. Gore Company. The company was quickly contacted. They were aware of the problems with burst/hoop strength of the PTFE graft because a few of their sample grafts had developed graft aneurysms (personal communication, W. L. Gore Company, August 1975), later formally reported by Campbell et al.10Campbell C.D. Brooks D.H. Webster M.W. Bondi R.P. Lloyd J.C. Hynes M.F. et al.Aneurysm formation in expanded polytetrafluoroethylene prostheses.Surgery. 1976; 79: 491-493PubMed Google Scholar This had prompted them to recall all of their sample grafts. By July 31, 1975, the W. L. Gore Company had re-engineered the graft by reinforcement with a thin outer sheath, which resolved the issue of hoop strength. This activity predated the requirement for U.S. Food and Drug Administration approval of new devices; these changes were all in-house modifications. “When do you need it?” they replied when I asked to see the graft. “As soon as possible,” I said. Within a few days, Jack Hoover, a new associate with W. L. Gore, was in our office with unsterilized samples of the graft, which looked reasonable and handled well. We ordered six 6-mm reinforced grafts and two 7-mm to 4-mm grafts on August 25, 1975,11McElfresh P. First vascular graft sale commemorated: 20 years and 3.5 million implants later [internal newspaper]. W. L. Gore & Associates, Inc, Flagstaff, AZ1995Google Scholar which arrived 2 days later. On August 28, 1975, we performed a below-knee femoral-popliteal bypass with a 6-mm reinforced Gore-Tex graft, which was sterilized on site. The anastomoses were performed with 5-0 Prolene (Ethicon, Somerville, NJ) suture on an RB-1 taper needle. When the occlusive clamps were released, the anastomoses leaked through the needle holes like the sprinkler head on a watering pot. We had seen this with the IMPRA graft and were not overly alarmed. We quickly reversed the heparin given before anastomotic construction, sprinkled thrombin powder over the bleeding anastomoses, and applied careful pressure. Over the next 5 to 10 minutes, hemostasis was regained. The patient did well postoperatively, and limb salvage was achieved with a patent graft for several years. Hoover informed us later that this was the first use of the reinforced Gore-Tex graft: Ours had been their first order.11McElfresh P. First vascular graft sale commemorated: 20 years and 3.5 million implants later [internal newspaper]. W. L. Gore & Associates, Inc, Flagstaff, AZ1995Google Scholar In 1976, Campbell et al12Campbell C.D. Brooks D.H. Webster M.W. Bahnson H.T. The use of expanded microporous polytetrafluoroethylene for limb salvage: a preliminary report.Surgery. 1976; 79: 485-491PubMed Google Scholar reported a small series of patients with femoral-popliteal Gore-Tex bypass grafts.12Campbell C.D. Brooks D.H. Webster M.W. Bahnson H.T. The use of expanded microporous polytetrafluoroethylene for limb salvage: a preliminary report.Surgery. 1976; 79: 485-491PubMed Google Scholar This prompted us to organize our experience. By 1977, we had a series of some 30 patients with reasonable short-term results. These results were submitted for publication, but rejected. Subsequently, the series was presented at the Virginia Surgical Society meeting (because we were the only full-time vascular surgeons in the state, there was no state vascular society at that time). After the presentation, there was only one question: “Are anticoagulants needed postoperatively?” Otherwise, there were no comments or discussion. The bypass principle, described by Jeger in 1913, was one of the most revolutionary concepts in the history of vascular surgery.13Yao J.S. Pearce W.H. The ischemic extremity. Appleton and Lange, Norwalk, CT1995Google Scholar Interestingly, Jeger never performed a bypass. This concept allowed vascular surgeons to aggressively attack segmental arterial occlusive disease. The discovery of a fabric graft material by Voorhees, in 1951, allowed the bypass principle to flourish.14Blakemore A.H. Voorhees Jr., A.B. The use of tubes constructed from vinyon N cloth in bridging arterial defects; experimental and clinical.Ann Surg. 1954; 140: 324-334Crossref PubMed Scopus (94) Google Scholar The DeBakey-led Baylor group used the Dacron graft (DuPont, Wilmington, Del) to replace aneurysms or to bypass occlusive disease in the aortoiliac position, which helped the growth of the era of reconstructive arterial surgery. However, the use of prosthetic grafts in limb salvage for critical ischemia secondary to severe infrainguinal arterial occlusive disease remained a serious issue because the results were not ideal. The development of femoral bypass dates back to the early 20th century, yet it was Kunlin, in 1948, who caught the attention of vascular surgeons internationally when he reported a femoral-popliteal bypass using a saphenous vein graft.13Yao J.S. Pearce W.H. The ischemic extremity. Appleton and Lange, Norwalk, CT1995Google Scholar The extension of the femoral bypass to the below-knee popliteal and tibial or peroneal arteries was slow to follow (Table). Improvement in technique was also very slow, although Cartier reported use of an in situ vein graft in 1960.15Samuels PB. The evolution of in-situ bypass. The Society for Clinical Vascular Surgery Annual Symposium, Scottsdale, AZ, March 1987.Google Scholar This technique failed to gain popularity until Leather et al16Leather R.P. Powers S.R. Karmody A.M. A reappraisal of the in situ saphenous vein arterial bypass: its use in limb salvage.Surgery. 1979; 86: 53-61Google Scholar reported their experience in 1979, including some technical refinements. Despite this progress, autogenous tissue was still viewed as the ideal bypass graft. The need for an off-the-shelf prosthetic graft for femoral-popliteal bypass to be used when autogenous tissue was not available or in certain high-risk patients was widely acknowledged.TableChronology of development of infrainguinal bypass since KunlinaModified from Yao JS, Pearce WH. Preface. In: Yao JS, Pearce WH, eds. The ischemic extremity: advances in treatment. East Norwalk, CT: Appleton & Lange; 1995.DateSurgeonDevelopment1951E. LowenbergSaphenous vein, lateral approach1958J. J. McCaughanDistal popliteal artery exposure1959G.C. MorrisPosterior approach—posterior tibial artery1959C. RobIn situ vein graft1960E. C. PalmaVein graft to posterior tibial artery1961J. J. McCaughanVein graft to posterior and anterior tibial artery, calf level1966J. J. McCaughanFemoral to posterior tibial (ankle) vein graft1966H. E. GarrettBypass to distal posterior tibial artery1967J. A. MannickBypass to isolated popliteal artery1967J. J. OchsnerDorsalis pedis1968H. E. GarrettTibial arteries at ankle level1969V. V. KakkarCephalic vein1971D. A. DeLaurentisSequential graft1972W. A. DaleComposite graft1975F. A. Reichle, R. TysonPeroneal artery1988E. Ascer, F. J. Veith, S.K. GuptaBypass to plantar arterya Modified from Yao JS, Pearce WH. Preface. In: Yao JS, Pearce WH, eds. The ischemic extremity: advances in treatment. East Norwalk, CT: Appleton & Lange; 1995. Open table in a new tab The expanded PTFE Gore-Tex tubular graft was first used as a venous prosthesis by Dr Ben Eiseman.17Yao J.S. Dr. Ben Eisman and the accidental discovery of the Gore-Tex graft.in: Eskandari M.K. Contemporary vascular surgery. PMPH-USA, Shelton, Conn2011: 1-7Google Scholar This is a fascinating story of serendipity, imagination, and friendship18Yao J.S. Eskandari M.K. Accidental discovery: the polytetrafluoroethylene graft.Surgery. 2012; 151: 126-128Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar that Chandler called a magical moment in vascular surgery.19Chandler JG. Magical moments in vascular surgery. Presented at the Rocky Mountain Vascular Surgical Society 31st Annual Meeting, Squaw Valley, CA, July 28-August 1, 2010.Google Scholar The accidental discovery of the Gore-Tex graft is of interest because it led to renewed hope that a suitable vascular prosthetic graft for femoral arterial bypass had been found. Several investigators began to report the successful use of the PTFE graft in the arterial circulation.20Kelly G.L. Eiseman B. Development of a new vascular prosthetic: lessons learned.Arch Surg. 1982; 117: 1367-1370Crossref PubMed Scopus (7) Google Scholar However, it was the multicenter randomized trial by Veith et al21Veith F.J. Gupta S.K. Ascer E. White-Flores S. Samson R.H. Sher L.A. et al.Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions.J Vasc Surg. 1986; 3: 104-114Abstract Full Text Full Text PDF PubMed Scopus (990) Google Scholar that firmly established the value of the PTFE graft in infrainguinal arterial reconstruction. Other substitutes for the saphenous vein graft have been tried, including the human umbilical cord vein, mandril grafts, bovine grafts, cryopreserved grafts, and composite grafts. These grafts garnered scattered use, but none received the attention and wide application that the Gore-Tex graft did. Although the first use of a Gore-Tex graft for a femoral-popliteal bypass in 1975 received little initial attention, this graft went on to international application in >5 million cases and underwent several improvements (thin walled, stretch, and ringed; personal communication, W. L. Gore Company, April 2012). The Gore-Tex graft is not yet the ideal replacement for an autogenous saphenous vein, but it has been a substantial step forward. On April 3, 1991, we implanted the first Gore-Tex Stretch graft in the aortobiiliac position (Fig), this time at the invitation of Don Lass, another W. L. Gore associate. The suture material for the anastomoses was 3-0 Gore-Tex, which offered a considerable improvement over the sutures used for the first femoral-popliteal bypass. Leaking after clamp release was minimal. This event, however, was not followed by the same explosive popularity as the Gore-Tex femoral-popliteal bypass graft placed 16 years earlier. We are fully aware that being first does not always mean being best. These first two cases are reported as a footnote to a graft that was discovered accidentally, followed by worldwide acceptance and widespread application.

The purpose of the SVS is not just to hold an annual meeting, but also to pursue social, financial, and political responsibilities. In addition, the Society leads in research, training, education, and practice (ie, patient care). The current leadership of the SVS is dedicated to preserving the history of the Society. The History Project Work Group will execute the orders of the Society to develop a series of digital videography recorded interviews with leaders in vascular surgery to be made available to our membership. The information collected will form the basis for a book on the history of the SVS.

Dr. Edward B. Diethrich, a pioneer in endovascular surgery, discusses the evolution, maturation, and future of endovascular surgery from a personal perspective.

Autologous arteriovenous access is the key to long-term success with hemodialysis and is strongly supported by the National Kidney Foundation's Dialysis Outcomes Quality Initiative guidelines. Basilic vein transposition (BVT) fulfills the need for a durable conduit with high patency and maturation rates. This retrospective review examines a single group's experience with this procedure. All patients undergoing BVT for hemodialysis with available follow-up data were reviewed. Telephone interviews were used to supplement clinical data where needed. Functional assisted patency was used as the end point for this procedure, and if the access was never used for dialysis, then the patency was considered zero. Secondary interventions performed while the access remained patent and in use were not considered detrimental to the patency reported. One hundred seventy BVTs in 162 patients were performed between November 1992 and October 2001. There were 87 women (53.7%) and 112 black patients (69.1%); hypertension was present in 138 patients (85.2%) and diabetes in 89 patients (54.9%). Each year, an increasing incidence of BVT was performed in our dialysis population. The BVT was performed as the first access in that extremity in 73 of the procedures (42.9%). Functional patency (primary assisted) was achieved in 40.0% at 2 years and 15.2% at 5 years. The mean assisted patency was 14.6 months. To maintain BVT patency, 40 percutaneous secondary interventions (69.0%) and 18 surgical revisions (31.0%) occurred in 32 patients (19.0%). Ligation for swelling was necessary in 4 patients (2.5%), and steal syndrome occurred in 3 patients (1.9%). BVT is a useful autologous procedure for hemodialysis and the preferred access alternative in patients without an adequate cephalic vein. Although patencies remain poor relative to other conventional arterial vascular procedures, BVT is our most durable hemodialysis access procedure and is often the only available autologous conduit for hemodialysis.

Gregory: It has been my pleasure over the past few years to host a series of medical interviews highlighting pioneers in vascular surgery. The first of these interviews featured the legendary Michael E. DeBakey, who discussed Rudolf Matas. 1 Gregory RT Rudolph Matas—how I remember him: an interview with Michael E. DeBakey. J. Vasc. Surg. 2001; 34: 384-386 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar In the second interview, John Ochsner discussed his childhood memories of giants in vascular surgery. 2 Gregory RT Childhood memories of giants in vascular surgery: Matas, DeBakey, de Takats and Oschner: an interview with John Ochsner. Cardiovasc. Surg. 2003; 11: 407-411 Crossref PubMed Scopus (2) Google Scholar

Purpose: The purpose of this study was the demonstration of the value of color duplex ultrasound (CDU) scanning in the detection of type I endoleak (T1EL) and type II endoleak (T2EL), the correlation of Doppler scan waveform pattern to endoleak persistence or seal, and the description of the natural history of endoleak. Methods: The study was a retrospective review of 83 patients who underwent periodic CDU scan and computed tomographic (CT) scan surveillance of the endograft and aneurysm sac after insertion of an aortic endograft for abdominal aortic aneurysm (AAA). Forty-one patients (49%) with an endoleak at anytime in the follow-up period form the basis of this report. Results: T1EL was detected in all five patients with CDU and CT scans. T2EL was detected in 36 patients with CDU scan as compared with 18 patients with CT scan. With CT scan, endoleak was not detected when CDU scan showed no endoleak. Conversely, all CT scan–detected endoleaks were found with CDU scanning. The T2EL source artery was identified with CT scan in seven patients, whereas the source was identified in all 36 patients with CDU scan. Endoleak source did not correlate with outcome (seal or persistence). However, a to/fro Doppler scan waveform pattern was associated with spontaneous T2EL seal in seven of 12 patients, and a monophasic or biphasic waveform was associated with endoleak persistence in 14 of 17 patients (P =.023, with χ2 test). Thirteen of 36 T2ELs underwent spontaneous seal by 6.2 ± 2.8 months. T2ELs without increasing AAA diameter were observed. Eight patients with persistent T2EL present for more than 12 months did not undergo treatment. However, two patients underwent T2EL obliteration with coils because of AAA sac enlargement. T1EL of the distal attachment site was the initial endoleak identified in five patients, but seven patients harboring T2ELs had subsequent T1ELs develop. For the entire 83 patients, the combined T1EL and T2EL prevalence rate was 20% of patients at a 6-month follow-up period, but this rate increased to 50% after 24 months. The incidence rate of newly detected endoleaks and of spontaneous sealing was 24.4% at 12 months and 12.5% in longer-term follow-up period. Conclusion: CDU scan is effective in the identification of the type of endoleak, the delineation of the vessel involved, and the hemodynamic information not available with any other testing method. Endoleaks have a dynamic natural history characterized by a variable onset with changing branch vessel involvement and spectral flow patterns. Periodic long-term endograft surveillance with CDU scanning is necessary for following existing endoleaks and for detecting new ones. Corroboration of these findings in larger multicenter prospective trials will be needed to determine whether CDU scan analysis of endoleaks would be predictive of long-term success in endovascular AAA repair. (J Vasc Surg 2002;35:474-81.)

The incidence rate of treated end-stage renal disease in the united states is 180 per million and continues to rise at a rate of 7.8% per year. Arteriovenous hemodialysis access (AV access) creation and maintenance are two of the most difficult issues associated with the management of patients on hemodialysis. The 1-year complication rate of a primary prosthetic AV access for hemodialysis ranges from 33% to 99%. Various investigators report on patency and complications of AV access. However, it is rather difficult to compare outcomes because of the wide variety of access materials, configurations, locations, risk factors, and quality of inflow and outflow vessels. Although there have been reporting standards for dialysis access endovascular interventions and for central venous access placement, standards regarding surgical access placement and its revision are lacking. The "Dialysis Outcome Quality Initiative," published by the National Kidney Foundation, provides recommendations for optimal clinical practices aimed at improving dialysis outcome and patient survival. This reporting standards document is not meant to be a "practice guidelines" or "best practices" document. Rather, the purpose of this document is to provide standardized definitions related to AV access procedures and to recommend reporting standards for patency and complications, to be used by surgeons, nephrologists, and interventional radiologists, that will permit meaningful comparisons among AV access procedures. The terms, definitions, and categories featured in this article have been approved by the Committee on Reporting Standards of the Society for Vascular Surgery and the American Association for Vascular Surgery and should be observed in preparing manuscripts on AV accesses for submission to the Journal Of Vascular Surgery.

We're here today to talk with Dr DeBakey about Dr Rudolph Matas, who lived from 1860 to 1957, dying at age 97. Dr Matas has become the symbol of vascular surgery in the South and as such was chosen as a symbol for the Southern Association for Vascular Surgery where his profile is on the logo. He was a professor of surgery at Tulane from 1894 to 1927 and succeeded by Dr Alton Ochsner. The interview today regards Dr Matas and how you knew Dr Matas, Dr DeBakey, and your memories of him. How in fact did you meet Dr Matas? Well, I met him for the first time at his home at his invitation. I was a medical student at the time, and I would go to the library to get European journals, either in German or French. I did this as a means of translation for some of the faculty members who could not adequately read German or French. I could, and so it was a service that I provided. One day the librarian said to me that Dr Matas would like for me to go get the books myself, as these were located at his home, because he wanted to meet me. He wanted to know who this fellow was who was borrowing all of his journals. These books were in his home, in his library. As a matter of fact, his house was virtually a library, which I found out when I got there. And so when I arrived, he met me at the door, and I met a very portly gentleman, who had a goatee and graciously asked me to come in. He then asked me to sit down with him in one of the rooms that was part of his library. I later found out that almost all of the rooms had been converted into a library; in fact, they had to add additional foundational support to the house! We sat down and then he wanted to know all about me. He wanted to know who my parents were, where I was from, where I was born, and so on, and what my education was. Then he wanted to know why I was interested in his journals. He not only could read several languages, but spoke French and Spanish, of course, and German quite fluently. He was very interested that here was a medical student who could read these journals so well. And I explained to him what I was doing, that I was translating these for some of the faculty members. He offered me something to drink and he said, “Will you have a little glass of port with me?” He said, “I like port.” I had a little difficulty with that, but I made out like I was sipping it. I didn't, because I had grown up in a family that considered alcohol and tobacco a sin, so we didn't have any tobacco or alcohol in our family. But he didn't particularly notice that I was just sipping and not drinking his port. He was very gracious, so after that I had to go to his house to get the books, which was sometimes kind of a nuisance, because previously I could have someone go get them. I didn't have to do it myself. But it was nice to see him. I found out when I started assisting Dr Ochsner that he referred his patients to Dr Ochsner when they needed an operation. And he would follow the patients through. It was always interesting. For example, in those days most of the surgery was abdominal. There wasn't a great deal of thoracic surgery at that particular time, or even much later. He would like to come to the operating room after the patient was anesthetized so he could feel the abdomen, with the patient asleep and the abdominal wall pretty relaxed; that way he could get a better feel of things. It was very interesting. He was very thorough in the old-fashioned examination. I remember one occasion when we were getting ready to operate on a patient of his. He came after I had gone into the operating room and prepared the patient and then had to come out and scrub again. He was washing his hands because he was going to go in the operating room and sort of feel the abdomen. There was a swinging door between the scrub room and the operating room, and when he got to the swinging door, I noticed he took one finger and pushed that door open so he wouldn't get too contaminated. Except that was a little bit relative! He always invited me to his home on Mardi Gras, because when the parade went down St Charles Avenue, the King would stop and have a toast at certain houses on St Charles Avenue. When they got to his house, the King would stop and toast him. He was very nice to me, and when I got ready to leave New Orleans to come here, I wanted to say goodbye to him. And so I made an appointment and I went over to his home. He said, “You know I'm glad you came because I was going to call you. I want you to do something for me.” And I said, “Of course. I'd be glad to Dr Matas.” He said, “Come over here in the next room,” so we moved into another room where he had a lot of papers on the table and on a trunk, you know, one of these big steamer trunks. He opened his trunk and it was filled with papers. He said, “I'd like for you to take this trunk with you because I want you to finish what I've started.” He had been asked by the New Orleans Medical Society to prepare a history of the Louisiana Medical Association and medical activities of Louisiana, literally from its origin. And like everything he did, he couldn't do that without doing a history of medicine in the United States of America. So he had accumulated all the research reports that he had found about the history of medicine in America, and he hadn't yet finished the report. Now this was some 30 to 40 years after he was appointed chairman of a committee to do this. He hadn't completed it, and he said he was afraid that it might not be completed before he died. I had the opportunity of being at a couple of meetings where he attended. And I remember one of them was in Cleveland at a meeting of the American Surgical Association. But he got up to give a discussion of the man's paper, and he gave another paper, which was a much more thorough discussion of the subject than the man who gave the original paper. He was a great scholar, and, if you read his writings, you realize what a scholarly person he was. He had a very graceful way of expressing his prose, and you enjoyed reading it. About his surgical skill, I don't know really, other than what I heard. Did you see him operate? No, I never saw him operate. By the time I knew him he had stopped operating completely. He was still seeing patients, though, in his office, and whenever they needed an operation he would refer them to Dr Ochsner. One of the very interesting aspects of his interests in aneurysms and his description of his operative procedure is that he knew the history very thoroughly, and you can't help but wonder if it wasn't from that knowledge that he developed the procedure of endoaneurysmorrhaphy. The basic principles of his operation were pretty well described, except the procedure of endoaneurysmorrhaphy, where he sewed together the wall of the aneurysm after evacuating the sac. But the procedure of ligating the main artery above and below the aneurysm and opening it and then suturing the opening of the collateral vessel was well described by both Antyllus, who was a contemporary of Galen around the first or second century AD, and a fellow by the name of Aetius, some seven centuries after Antyllus. A very, very, detailed description is recorded that is exactly what Matas did, except Matas added the procedure of endoaneurysmorrhaphy, which was to completely collapse the wall by sewing all of the wall together. Now that was the real trick because that took care of any leakage that might occur from the collaterals. That procedure obliterated the aneurysm. Nobody at that time could resect or put a graft in. That didn't come about until much later. Dr Matas' procedure was done around 1880 something. Before that, in recorded history there was no consideration for resection and graft replacement so that concept was never described previously. Now isn't that interesting? It's fascinating. Why do you believe that Dr Matas was so innovative? He came up with ideas about intravenous fluids, about nasal gastric tubes, about endotracheal anesthesia, about using motion pictures for teaching. Why was this man so innovative—what was different about him? Well for one thing, he had a great sense of curiosity. Even when he was quizzing me about my life and family and so on, you could see the curiosity factor. And if you read his writings, you get that expression of curiosity, even about the etiology of diseases. He had a great sense of curiosity, and he was fascinated with the idea of maybe developing another new way of dealing with problems. When you think of what he did with his first endoaneurysmorrhaphy case that he had, he first operated on this patient by ligating both above and below. He said that the aneurysm was stilled, not pulsing anymore, yet to his amazement the next day when he came in to see the patient, the aneurysm was pulsing again. He was then curious as to why this happened. He couldn't believe that his ligature had opened. So he went back in and found that his ligatures were absolutely tight. There was nothing wrong with them, but the aneurysm was pulsating. He said the only way he was going to find out was by opening it up and that is when he found the collaterals. He said it became obvious, as it would to any surgeon, that the thing to do now was to oversew the opening of these collateral vessels in the aneurysm wall, and to bring the two walls together so as to obliterate it completely. That came to him as he was operating. It was innovative in a sense, but it was his curiosity that stimulated him to do that. What do you think his thought would be on endovascular surgery, specifically the aortic stent graft for aneurysm treatment? How would he react to that now? Well, I think his reaction would be reasonably positive. He didn't live long enough to see the full development of aortic surgery. Most of his surgery was peripheral with the exception of one case that he did, you remember, that was an abdominal aneurysm that he successfully ligated. In fact, he was the first one to do it successfully. Dr Matas actually ligated the aneurysm proximally, and it was successful. And he must have done 30 to 40 cases altogether after that which were successful, but he never replaced the aorta. The first aneurysm resection of the aorta with graft replacement was in 1952, so I don't think he was fully aware of that. I don't think he would understand the concept of graft replacement. He knew about graft replacement for a peripheral aneurysm, but not the aorta. His understanding (ie, his conceptual consideration for treatment of aneurysms) was to obliterate it. You remember, he had two types: one was the restorative endoaneurysmorrhaphy and the other one was obliterative. Restorative was mostly in what we call sacciform aneurysms, whereas obliterative procedures were used for fusiform. He was such a scholar, you know in surgery, that he would be open-minded about it and would be somewhat, I would say, surprised and maybe skeptical about the long-term value of endograft therapy, and he may be right! Professor, do you see similarities between Dr Matas and you? Both of you had a fascination with aneurysms, and both of you had a gigantic impact on the management of this problem. Do you see the obvious parallels here? Well, I feel honored to have any comparison with him because I admire him so much. I think he was one of the truly great figures in surgery of his time. Dr DeBakey, I appreciate your time today and remembering these fascinating aspects of Dr Rudolph Matas and the development of vascular surgery, particularly in the southern part of the United States. Thank you very much. It was a pleasure to be with you. Thank you!