Dubost performed the first open aortic aneurysm repair in 1952. While vascular surgeons refined this technique over time, significant blood loss, cardiovascular stress from cross-clamping, and invasive abdominal surgery limited its suitability for older patients or those with comorbidities.1 The origins of endovascular aneurysm repair (EVAR) in the aorta recall two seminal figures: the late leading vascular surgeon in the Soviet Union, Nicolai L. Volodos, of Kharkiv, Ukraine, and Argentinian vascular surgeon Juan C. Parodi, MD, of Buenos Aires. The former was the first to treat a thoracic aortic aneurysm with a stent graft and the latter performed the first EVAR on an abdominal aortic aneurysm (AAA).2 Dr. Parodi performed the first EVAR in Argentina, but conceived the idea during his fellowship tenure at The Cleveland Clinic in the mid-1970s. After witnessing patient deaths from open repair, he proposed excluding aneurysms by deploying a compressed graft with a metal framework endoluminally, aiming to decrease morbidity and mortality.3 He continued his research work at the Cleveland Clinic, but further fruition only took place once he returned back home to Argentina and met Dr. Palmaz, a fellow countryman and a radiologist in 1988 at a conference, where he was presenting his work on balloon expandable stents. Dr. Parodi in conjunction with Dr. Palmaz modified the use of a Palmaz balloon expandable stent with a straight tubular polyester stent graft, with the balloon expandable part being used as approximal fixation device. He also worked with a bioengineer named Mr Hector Barone to fine tune the devices and eventually with Johnson and Johnson to manufacture the stent grafts with sizes up to 30 mm. After many years experimenting on dogs and animals, Dr. Parodi finally got permission to implant these in humans with a rider that these cases should have been refused by at least two institutions.4 Serendipitously, the first case was the cousin of the President of Argentina, who had severe back pain, a 6-cm aneurysm and severe COPD, which prevented him from proceeding for an open repair. Dr. Palmaz assisted him for the case and the first device was very simple. It consisted of a stent graft, extra-large Palmaz stents, a Teflon sheath, and a valvuloplasty balloon. The case was uneventful and the patient was eating food in a couple of hours. Incidentally, there was another patient who underwent an open repair and was still intubated for a couple of days after the procedure. Seeing the difference in the postoperative condition of the patients, only encouraged Dr. Parodi to perform these cases on more patients. The index case presented with a distal endoleaks after 3 months, which was subsequently managed by an aorta uni-iliac device, occlusion of the contralateral iliac artery, and a femoro-femoral bypass. The patient did well for 9 years and eventually succumbed to pancreatic cancer. The first five successful cases with straight tubular grafts were published in the Annals of Vascular Surgery in 1991. This ushered the dawn of the endograft era of treatment of aortic aneurysms.5 Dr. Parodi delivered many lectures and also performed these procedures at his own center and other centers of excellence elsewhere. In the USA, the first stent graft for an AAA was performed in 1992 in New York by Dr. Frank Veith and his team, which further paved the way for this innovation and technology to be adopted by others all over the world and now EVAR is a standard of care treatment. The EVAR technology we now know today, is a testament to the hard work, innovative skills and the never say die attitude of the early pioneers. Their willingness to think out of the box and persevere in spite of multiple road blocks, has led to lifesaving and patient-friendly implants and procedures. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Pranay Pawar (Thu,) studied this question.