BK: Yes. When I was a resident, it was a decade after Charles Dotter described angioplasty, but there was very little of it happening in the U.S. But many Europeans had come over to learn the “Dotter procedure” as they called it, and then gone back to Europe—so a decade on, because of those pioneers, there had been hundreds and sometimes even thousands of angioplasties.


I had the opportunity to go to Rome and study with one of the pioneers of advanced angiography, Plinio Rossi, MD. I also had the opportunity to meet Andreas Gruentzig, because we were all going to the same meetings in this formative period in Europe.


It was in Rome, in 1974 I believe, where I did my first angioplasty. And don’t forget, there were no balloons at that time and the catheters were very simple. There were coaxial Teflon catheters and the first attempts at balloon catheters were made by the Europeans. I did my first angioplasty with what’s called a Corpsman balloon. To protect the artery from rupture, the balloon was placed inside of a caged Teflon device, so that you had the balloon inside the cage. When you blew it up, the cage would limit how big the cylinder balloon could get.


In those years, we had no sheaths. We didn’t have the basic tools that we have now. So, if we did an angioplasty, we had to quantify blood loss and use 10 or 12 French devices with no sheaths and manual compression. It was quite exciting.


RT: I assume you brought your training back to the U.S. where you tried to reintroduce and revive these procedures. How did that go? BK: I came back after only three or four months in Europe, probably towards the end of 1974, and began doing angioplasty. I was pretty excited about the procedure.


I’ve always been a highly collaborative individual and it was clear I couldn’t do this alone. I had a surgical colleague at my first institute, an academic medical center, who was very supportive. He wanted whatever was best for the patient, and if he thought we could avoid complications, he’d let us give it ago.


Now, this was right out of training for me. I went right out of New York Hospital to Rome and then back. I was a young whippersnapper in a city of very established programs. And like many things in life, your success is made by other people’s support. If you’re going to be disruptive and implement change, you can’t do it alone.


William J. Casarella, MD, FSIR—Bill— was a young interventionalist who got advanced to chair at a rapid pace, and he heard what I was doing and invited me to an angio club. That’s kind of how word of mouth got going. And it was really clear at that time that this procedure worked.


RT: You must have faced a lot of resistance. BK: At the time, no radiologists were doing this. We didn’t have a name or anything. The only reason we could continue doing something like this was because it worked. There were traditional angiographers—that’s what we were called back then—who weren’t particularly interested in embracing the additional responsibility that came with treatment. They were comfortable with a diagnostic role.


And in the beginning, there was a lot of resistance because these changes were coming from a community hospital, not from a white tower with academic credibility. That was a bit of an issue for a while, but eventually I was invited to share this in New York, and I got an invitation to go to MGH. At the end of the lecture there, the chief of vascular surgery got up and said, “We’re never doing this procedure here. Because there’s no data. It doesn’t make sense. It’s destructive. People don’t know what’s happening with plaque. You’re just going to be causing more problems. You’re doing this because you’ve never seen what plaque looks like.”


I start thinking, we’re never going to have a chance. I know this works. The people around me knows this works. And eventually, the academic institutions and big hospitals and other specialties are going to figure out this works, and they’re going to want to do it, and take it away.


And at the same time, I was cheering for radiologists to change the way they practice, to become clinicians. We were the only discipline in medicine that didn’t provide the clinical care to the patients that we were taking care of. The endoscopists, which were evolving at the same time, they were taking care of the patients, the surgeons were. Everyone but us. I felt that whatever we’re going to call ourselves, we shouldn’t be treating patients if we’re not taking care of them and providing an appropriate source.


That became a very important part of what we were teaching.


So, I started two things. I said, “We don’t have time to get this through residencies. We have to take all the radiologists that have catheter skills and train them how to do it as quickly as possible.” Getting this developed and into every program would be a 10- or 15-year cycle. So, I started running these live cases courses, which were called tutorials, in 1978. I would bring people every month and put on some homemade video technology. The enabling technology was the development of a handy cam, but the most people I could fit in was 20 and I would do it every month and they were backed up for a year and a half. We had to figure out a way to train more people quickly. There was a lot of passion about trying to disseminate the procedure and the knowledge.


Eventually those tutorials made it into the Harvard Business review, because John Abele—the co-founder of Boston Scientific—wrote about these live cases and their effect on technology and brought attention to what we were doing. And then ultimately those live cases became even bigger, and we could fit a hundred people at a time.


Want to learn more about the early days of IR? Listen to the full interview, and watch out for more episodes from the Kinked Wire celebrating the growth of IR.


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