Nikolay Volodos and the Origins of Endovascular Grafting

The topic of endovascular therapy and its history is a favorite subject of mine. More specifically, aortic stent-graft technologies have occupied center stage for me ever since I became involved (serendipitously) in the Parodi abdominal aortic aneurysm project in the late 1980s – as described in detail in an article appearing at the end of 2010.¹

The so-called first EVAR operation performed by Parodi et al in Buenos Aires on Friday, September 7, 1990 and its aftermath had enormous impact, leading to profound transformations that changed everything in vascular surgery, and, truthfully, in all of vascular medicine. In that same paper, I noted that the Argentineans were not alone in these pursuits. It was most noteworthy, and although they didn’t know it at the time, Harrison Lazarus had conceived and essentially completed the design of an endovascular AAA graft by the mid-1980s, and filed for a U.S. patent in 1986 (awarded in 1988).² It became the basic platform for the founding of the Endovascular Technologies Company and their first graft, as well as the subsequent evolution to the Ancure device by Guidant (first implanted in 1993).

The 2010 article acknowledged Nikolay Volodos (from the Ukraine). However, the mention may have been driven by a sense of fairness as it had been reported that he performed the first-ever aortic repair with a stent-graft in the 1980s (in a patient suffering from a post-traumatic aneurysm of the distal descending thoracic aorta). Knowledge of such accomplishment had been in the public domain (in the western world) since the mid-1990s, and affirmed in various English-language presentations and publications. However, it was almost always implied that his had been a one-off type of procedure and nothing else. We know now nothing could be further from the truth.

The real depth and meaning of Volodos’ work emerged powerfully at the Charing Cross Symposium held in London this past April during the course of a special morning session where Volodos himself was supposed to deliver a lecture on the history of endovascular grafting. Unfortunately he wasn’t able to do so due to unexpected circumstances, but his early developments with stents and stent-grafts were discussed and documented by Krassi Ivancev.³ Below is a brief account:

• Development of a “Z-stent” in the early 1980s, with and without a fabric cover: The stent was made of self-expanding stainless steel wire forms with a zigzag shape. The project was inspired by Charles Dotter’s early work.
• Both devices were patented (in the Soviet Union) on May 22, 1984. Volodos labeled them endoprostheses for blood vessels.
• They were the result of a rather rigorous and extensive pre-clinical multi-year process that included in-depth analysis of physical and physiologic characteristics of various stent designs, testing in a flow model, and animal implantations (with 6-month follow-up and detailed studies on explanted devices).
• First human implant of the fabric-covered Z-stent in 1985 for treatment of iliac artery stenosis.
• First aortic implantation on March 24, 1987 for treatment of a post-traumatic thoracic aortic aneurysm.
• Later in 1987, they performed the world’s first EVAR procedure for treatment of AAA (in Kharkov).
• In 1991, Volodos performed a hybrid transthoracic operation with antegrade delivery and deployment (through the ascending aorta) of a stent-graft to treat a post-coarctation pseudoaneurysm of the proximal descending thoracic aorta.
• By the early 1990s, he and his associates had accumulated a rather large clinical experience (of 100 cases or more) with stent-graft implantations in the abdominal and thoracic aorta and in other arterial beds.

It seems clear and unequivocal that Volodos’ work and achievements represent the essence of innovation, executed with scientific rigor and inspired by the vision to create less invasive solutions for important clinical problems. By doing this, he achieved a number of impressive firsts. It is most regrettable that all of it remained behind the curtain (literally!) for many years, incurring a failure of dissemination, which was probably related to the then prevailing political and social environment in the Soviet Union, and further compounded by Volodos’ inability to communicate in English. This was apparent to me some years later, in the late 1990s, when I had a chance to meet him personally during a vascular congress in Paris.

Armed with the above knowledge, it would be hard not to proclaim Nikolay Volodos as a giant of historic proportions in the vascular and endovascular specialties, and the father of endovascular grafting. Also, one might speculate how high a pedestal his name would occupy today if the work had been performed in the free world or disseminated early on using the English language.

References

1. Criado FJ. EVAR at 20: the unfolding of a revolutionary new technique that changed everything. J Endovasc Ther. 2010;17(6):789-796.
2. Lazarus HM. Intraluminal graft device: system and method. US patent No. 4,787,899; approved 1988.
3. Ivancev K. Personal communication, April 27, 2012.