P&S Medical Review: Oct 1994, Vol.2, No.1
Arthur B. Voorhees, Jr., M.D., P&S '46 A Vascular Surgical Pioneer and His Legacy

ALAN I. BENVENISTY, M.D., P&S '78
Department of Surgery, Columbia University College of Physicians and Surgeons, New York, N.Y.

Modern vascular surgery is a field that literally did not exist when Arthur B. Voorhees commenced his training as a surgical intern at The Presbyterian Hospital in the City of New York in 1946, but it is one whose shape and character was dramatically alte red as a result of this man's research effort. The brief scientific paper reprinted herein, based on Dr. Voorhees's work as a junior resident and junior research associate in the Department of Surgery at the College of Physicians and Surgeons, is probably the greatest landmark in the progress of vascular surgery in the twentieth century, both heralding and spawning the growth of modern vascular reconstructive surgery as it exists today.

Arthur Voorhees never imagined the role he would play in defining the specialty now known as vascular surgery. At that point in surgical history, there were precious few operations that could be performed on human arteries. Most abdominal aneurysms, if d iagnosed before rupture, could not be treated. When treatment was attempted, it was aimed at the induction of thrombosis by the introduction of hundreds of feet of wire percutaneously in a time-consuming, painstaking fashion often complicated by high rate s of infection. Most patients with limb-threatening atherosclerosis were treated by amputation. No one had yet conceived that removing atherosclerotic plaque from the carotid artery could prevent strokes in certain patients. In contrast, the contemporary vascular surgeon concerns himself with stroke prevention surgery, the resection of life-threatening aortic aneurysms, and abdominal and infrainguinal vascular reconstructions not even dreamed of in the 1940's and 50's. All of these are being performed on a daily basis, with morbidity and mortality rates a fraction of what they had been in the past, in large part due to the contributions of this great surgical pioneer.

Up until the late 1800's, the only vascular operations were ligations. Although Eck2 reported the successful anastomosis between the portal vein and the vena cava in dogs, this was not attempted for quite some time in humans. Successful arterial anastomos is was described by Jassinowsky in 18913 but he dared not pass the silk suture through all layers of the arterial wall fearing thrombosis if the suture passed into the blood stream. It is curious and surprising that soon after this report, Dorfler4 accomp lished arterial suture by passing suture through all layers of the arterial wall and observed that the suture soon became covered with a glistening membrane. The vast significance of this observation was not realized until Voorhees's reflections more than 50 years later. In the early 1900's, Alexis Carrel, a medical student in France, spent several years developing and describing all of the basic techniques that would be used by his successors in the performance of vascular surgery. This included many dif ferent types of arterial anastomoses: direct end to end, end to side, and the now famous "Carrel patch;" a myriad of organ transplants in several different animal species; and vessel grafts-truly, a great leap forward.5,6 It is curious that these techniq ues would not be used clinically for decades, but are now the mainstay of "the vascular tool chest." In 1951, Dubost reported the first successful resection of an abdominal aortic aneurysm7 with a preserved human arterial homograft, a conduit which had b een in use for several years. Unfortunately, these homografts degenerated and became aneurysmal themselves, making them unacceptable long-term vascular substitutes.

The time was ripe and the milieu rich for Dr. Voorhees's discovery. The supply of homografts was insufficient for the number of aortic aneurysms that required resection and an appropriate substitute was needed. Numerous patients with atherosclerosis faced limb loss or permanent disability as there were no means to adequately reconstruct the blood vessels. The use of heparin was becoming popular to avoid thrombosis at the junction of two freshly apposed blood vessels. Many investigators at the time were se eking an appropriate substitute for the homograft. "The discouraging early results of the rigid glass and metal tubes of Carrel, Guthrie, and Touffier turned surgeons' attention to some new products of the spawning plastics industry."8 In 1948, Dr. Arthu r Voorhees had just finished his internship and was spending one year as a research fellow in the laboratory of Dr. Arthur Blakemore, a faculty member of the Department of Surgery at P & S. While performing experiments trying to develop a novel mitral val ve mechanism, Dr. Voorhees placed an errant silk suture across the ventricular cavity of one of his experimental animals. Knowing that the suture could not be revised, he left it in, but when it was time to sacrifice the animal months later, he took great pains to find the misplaced suture. To his surprise, it was coated with what grossly appeared to be endocardium.9 Dr. Voorhees wondered if "a piece of cloth might react in a similar way...[he] speculated that a cloth tube, acting as a lattice work of th reads, might indeed serve as an arterial prosthesis."9,10 First experimenting with a silk handkerchief, then moving on to Army Air Corp Nylon parachute cloth,8 the young investigator gradually drew up a "wish list" of characteristics that his textile pro sthesis would possess. Another young investigator, Dr. James W. Blunt, Jr., working on an artificial tendon project in the Department of Orthopedic Surgery at the College of Physicians and Surgeons, suggested that the spinnaker cloth, Vinyon "N", would pr obably meet Dr. Voorhees's requirements. He was able to procure a bolt of it from the Union Carbide Company and experiments began. Fabric was cut into squares and a longitudinal suture line was made on Mrs. Voorhees's sewing machine at home. The ends were rolled back so as to prevent fraying at the suture lines. These tubes were grafted into the abdominal aortas of dogs. With almost no experience in vascular technique, Dr. Voorhees noted that " a great feature of blood vessel surgery for the trainee is th e immediacy with which one's technical errors become apparent."9 However, with his characteristic tenacity, persistence and strict attention to detail, he persevered, dealing with the vicissitudes of pioneering research. With the assistance of fellow sur gical resident Dr. Alfred Jaretzki, III, pathologists Nathan Lane and Raffaele Lattes, and the guidance of his mentor, Dr. Arthur Blakemore, the project developed momentum. The project was supported by the Fund for the Advancement of Blood Vessel Surgery and the report that is reprinted here was submitted for publication in mid-1951.

Its impact resounded throughout the surgical community. Dr. W. Andrew Dale, an eminent vascular surgeon, wrote,

My own worst illusion occurred in 1951 when I did not follow the suggestion of my teacher and friend, W.J. Merle Scott, himself an innovator, that I should go to hear Arthur Voorhees present his then new study of the fabric Vinyon-N to replace the can ine aorta. I dismissed as far-fetched one of the most important papers ever presented to the surgical world. The significance of synthetic graft replacement of the dog's aorta escaped me at the time, yet proved to be the seminal discovery that launched th e rapid evolution of arterial replacement. By the time this dog had carried such a graft for 7 years, vascular replacement had become widely accepted.11

Implantations commenced in humans soon after animal models demonstrated that the grafts were durable and could remain patent. The first implantation was in a patient whose abdominal aortic aneurysm ruptured when no homografts were available in the aortic bank. Dr. Voorhees left the OR, fashioned a prosthesis, returned to the OR where Dr. Blakemore had the aorta crossclamped, and then sutured into place the Vinyon "N" graft.12 By 1954, Drs. Voorhees and Blakemore had already used the prosthesis in the res ection of 17 abdominal aortic aneurysms, thus inaugurating a new era in Clinical Surgery. The work was presented to The American Surgical Association in 1954.13 The surgical literature soon exploded with research in this newborn field, which often looked more like technical treatises of the plastic and textile science than surgery. Surgeon/scientists became fixated on this newly discovered phenomenon of textile tubes that conducted blood in the human circulation. They wondered: why didn't patients exsang uinate through the pores of the textile? How could a cellular matrix be so quickly laid down in the textile? Why didn't clots form when the grafts came in contact with unheparinized blood? A whole new vocabulary entered into the surgical community. Wor ds like weaves, knits, taffeta, braid, denier, calendaring, now entered the lexicon of the surgeon who performed vascular reconstructions.

Dr. Voorhees commented that "...a consensus was reached on the essential elements of prosthetic arterial reconstruction: (1). The integrity of the anastomotic bond depended on the workability of the prosthesis end, the suture material used, and the subseq uent viability of the cut end of the artery including the adjacent soft tissue. (2) The prosthesis had to be ultimately blood-tight after interstitial closing, while allowing adequate pore size in order to permit at least some fibroblast reorganization to take place. (3) The prosthesis had to conform to tissues and be able to bend without buckling. (4) The prosthesis had to be made of a strong, stable, and relatively biologically inert material. (5) Finally, the prosthesis had to conform to surgical deman ds. It could not fray, ravel, bend needles, or pull out carefully placed sutures." 8

Innumerable experiments were launched worldwide in an attempt to optimize healing characteristics, improve durability, and minimize thrombogenicity. Soon Dupont's Dacron, either woven or knitted, emerged as the optimal graft material, and it remains so to day. In reality, there has not been much substantive improvement over Dr. Voorhees's original discovery. Many grafts now exist on the market, but it is important to note that Dr. Voorhees and his coworkers did not seek to patent or "protect" this discover y. They felt that it was much too important a discovery and wanted this information to rapidly cascade to benefit all people.14 This demonstrates Dr. Voorhees's benevolence and altruism. Dr. Smith comments, "He impressed young house officers as a master technical surgeon, bright intellect, and compassionate, ethical physician." 14

Dr. Voorhees, after attaining world notoriety in surgery, went on to become a distinguished member of our department, many of whom were already national leaders in surgery. Dr. Voorhees's career was best documented by his trainee, friend and colleague, Dr . Robert B. Smith III, in his presidential address to the Southern Surgical Association and beautifully illustrated and published in the Journal of Vascular Surgery.14 Dr. Voorhees went on to become the Director of the Vascular Service and a visionary lea der in the Department of Surgery. His clinical interest in the surgery of portal hypertension continued, and he remained a recognized world authority on this, as well as the science of vascular prostheses. As a clinical teacher, he was dedicated to the ca re of his patients and paid attention to all details. He taught by example and disclosed all "secrets". His technical skills and approach to vascular problems is still embodied in the vascular surgeons that he trained and that still practice at Columbia-P resbyterian. He established the vascular research laboratory as the Arthur H. Blakemore Laboratory, a place where many P & S students and Presbyterian residents have immersed themselves in research endeavors. He would be delighted to know that pioneering research in aortic prostheses continues. Dr. Timothy A. M. Chuter is currently developing, in Dr. Voorhees's laboratory, a revolutionary technique for percutaneous graft replacement of the aorta.

Dr. Voorhees established the Blakemore Award and Prize for excellence in research by surgical house staff and research fellows. The Association of the Alumni of the College of Physicians and Surgeons presented him with a medal honoring lifetime achievemen ts in Medicine.14 Many vascular surgeons have been nurtured by him, including Robert B. Smith, III, J.B. Price Jr., Joseph A. Buda, Howard Greisler, John V. White, James M. Chandler, Anthony D. Whittemore, Richard C. Britton, George Todd, Roman Nowygrod, Harry Bush, Peter Lawrence, Richard Gusberg, Leslie Kutcher, Paul DeMartini, Robert Collins, Steve Ruby, Carey Dolgin, and myself.

Unfortunately, because of failing health, Dr. Voorhees was forced to retire early in 1983 and died on May 12, 1992 at age 70. I find it particularly bittersweet to be able to recount the circumstances and impact of Dr. Voorhees's landmark contribution to the field of surgery, inasmuch as I had the honor of being his last clinical and research fellow in vascular surgery, and because my training with him was truncated by his early retirement in 1983. His legacy, however, continues to live on in the daily pr actice of vascular reconstructive surgery in operating rooms all over the world.

REFERENCES

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8. Voorhees AB. How it all began. In: Sawyer PN, Kaplitt MJ, eds. Vascular Grafts. New York: Appleton-Century-Crofts, 1978:3-4.
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10. Voorhees AB. The development of arterial prostheses: a personal view. Arch Surg 1985; 120:289-95.
11. Dale WA. A surgeon's primer of errors. J Vasc Surg 1990;12:99-104.
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