From Palm Leaves to Thermoplastic Polyurethanes—The History of Vascular Catheter Development and Use

Vascular catheterization procedures are performed on millions of patients in the United States annually. Diagnostic and therapeutic, these procedures allow for the detection of diseased vessels and the treatment of occluded vessels via manual clearance or the delivery of clot-dissolving medications, among other functions. The use of catheters, however, is no new phenomenon, and its history dates back to thousands of years. Ancient Egyptians, Greeks, and Romans constructed tubes from hollow reeds and palm leaves to be tunneled through the vasculature of cadavers to study the function of the cardiovascular system. In the 17th century, English architect and anatomist Sir Christopher Wren developed an interest in intravenous therapy, using a cannula made from a goose quill with a pointed tip, which he inserted into the veins of dogs to inject drugs such as opium, alcohol, and emetics. In the 18th century, English physiologist Stephen Hales used a brass pipe as a cannula to perform the first central vein catheterization on a horse in an effort to learn more about hemodynamics, while in the 19th century, French physiologist Claude Bernard attempted the first carotid artery cannulation on a horse using a mercury thermometer. ¹

The 20^th century saw a shift away from using catheters on cadavers and animals to learn about cardiovascular anatomy and physiology toward using them to treat human illness. French surgeon Alexis Carrel, M.D. who was awarded the Nobel Prize in Physiology or Medicine in 1912 for his work in vascular medicine was the first to use nonbiological structures to repair arterial blood vessels. ² In 1929, the first right heart catheterization in a human was performed by German physician Dr. Werner Forssmann on himself. Although his findings were initially rejected and ridiculed, he ended up winning the 1956 Nobel Prize in Medicine along with colleagues Dr. André Cournand and Dr. Dickinson Richards, the latter two of who introduced diagnostic cardiac catheterization in the 1940s. ¹ In 1953, the Seldinger technique which was developed by Swedish radiologist Dr. Seldinger involved inserting first a guide wire through the needle lumen into the artery and then withdrawing the needle and subsequently inserting a catheter of the same size as the needle via the guide wire. In 1958, Swedish surgeon Åke Senning, M.D. further refined the method of coronary endarterectomy by using venous patches to seal coronary arteries after removing coronary plaques. ²

In 1963, Thomas Fogarty, then a medical student, developed a balloon embolectomy catheter later called the Fogarty catheter, which was widely adopted and dramatically improved outcomes after embolectomies. He had been inspired a decade earlier while working as a scrub technician and noticing how attempts to remove thrombi from artery and veins were often invasive and futile, frequently resulting in undesired amputations. The Fogarty catheter was advantageous in that it caused little damage to the vessel while retrieving both the target embolus and the secondary thrombus. In this manner, the Fogarty embolectomy catheter allowed for procedures to be safer and less minimally invasive. ³

Dr. Charles Dotter, a US vascular radiologist credited with developing interventional radiology, performed the first transluminal angioplasty in 1963. Interestingly enough, this was done by accident; Dotter had been performing an abdominal aortogram on a patient with renal artery stenosis when he accidentally passed the catheter into the stenosed right iliac artery, effectively recanalizing it. In 1965, after attempting to dilate a stenosed iliac artery using an embolectomy balloon without success, he realized that a more rigid balloon would be necessary for large arteries; thus, he constructed a balloon-dilating catheter that was surrounded by and reinforced by woven fiberglass sheath. It was not until 1967 that René Favaloro, M.D. introduced aorto-coronary bypass surgery to revascularize coronary arteries. ² Prior to this event, the focus of these catheters was on treating peripheral artery disease rather than advanced coronary artery disease.

In 1973, German radiologist and cardiologist Dr. Andreas Grüntzig used caged balloon-dilating catheters that had been introduced by Werner Porstmann, M.D. and subsequently modified by Dotter to treat iliac artery obstructions; however, these balloon catheters caused early thrombosis, so they were never widely used. A year later, Grüntzig, determined to construct an even more suitable catheter, and with advice from expert chemist Heinrich Hopff Ph.D., began constructing single-lumen polyvinyl chloride (PVC) balloon catheters, which had better rigidity than the versions used by his colleagues. ²

With his new single-lumen dilating catheter that had a 4 mm balloon, Grüntzig was able to successfully recanalize a severely stenosed femoral artery, a procedure which he initially called “percutaneous transluminal dilatation,” now known as percutaneous transluminal angioplasty in peripheral arteries and percutaneous coronary intervention in coronary arteries. Of note, these interventions are now the most frequently used treatments in coronary and peripheral circulation emergencies. Grüntzig subsequently developed a double-lumen catheter that could apply equal, constant, and defined pressure to the vascular wall, allowing for greater versatility and better handling when treating patients with peripheral vascular disease. Eventually, Grüntzig began to use this newfound knowledge to develop catheters of reduced diameter to treat coronary artery disease as well. Because of their significant achievements in the treatment of atherosclerotic vascular disease, both Grüntzig and Dotter received a nomination for the Nobel Prize in Physiology or Medicine in 1978. ²

Although PVC catheters allowed for considerable progress in the refinement and expansion of these techniques, they are less commonly used today as they have been shown to be a nidus for bacterial colonization. Additionally, they contain phthalate plasticizers that are known to be cytotoxic, and they have elevated thrombogenicity when compared to other polymers. For these reasons, PVC catheters have largely been replaced with thermoplastic polyurethanes and other similar polymers, which have been shown to have excellent biostability, flexibility without the use of plasticizers, and low thrombogenicity. Furthermore, many catheters today also contain heparin coats to reduce coagulation, silver sulfadiazine to impart antimicrobial properties, and other diverse construction materials that fit the needs of various procedures. ⁴

Because of these developments, clinicians today have had even more success with diagnosing and treating various pathologies and have seen vast improvements in obtaining intravenous access, monitoring arterial blood, and treating stenotic and occluded vessels. However, these innovations would not have been possible without the rich and diverse history of development that spanned several centuries.