|Year : 2015 | Volume
| Issue : 3 | Page : 105-111
History of Aortic Surgery in India
Himanshu Verma1, Kumud Rai2, S Rao Vallabhaneni3, Ramesh Tripathi1
1 Division of Vascular Surgery, Mayo Clinic, Rochester, USA
2 Department of Vascular Surgery, Max Heart and Vascular Institute, New Delhi, India
3 Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
|Date of Web Publication||8-Oct-2015|
Division of Vascular Surgery, Mayo Clinic, Rochester
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Verma H, Rai K, Vallabhaneni S R, Tripathi R. History of Aortic Surgery in India. Indian J Vasc Endovasc Surg 2015;2:105-11
| Ancient History|| |
That Indians were one of the first humans to practice medicine and surgery are well-known from the excavations of Mohen Jo Daro and Harappa 3000 BC. The arrival of steel by the Aryans, paved the way to forging of surgical instruments that were adopted by Hindu “sage surgeons” during the Vedic period. In the era of Atreya (1500 BC), there was already a specialty of surgery established by the sage surgeons called “shalya tantra". Although the first written evidence of abdominal aortic aneurysms goes back to the “Book of Hearts” from the Eber Scrolls of ancient Egypt, dating back to 1550 BC, Sushruta (800–600 BC) in India had described aneurysm as “Sira Granthi” or tumor of blood vessels, (chapter 17 of his great medical text “Sushruta Samhita"). Sushruta found these “tumors” undistinguishable from painful varicose veins and shared the Egyptian view that “only magic can cure tumors of the arteries” as “Granthi” can be cured only with the greatest difficulty.
The surgical traditions of Susruta [Figure 1] and other sage surgeons, who were world pioneers of surgery, unfortunately went into a decline in India after the Vedic period up until the Moghul period much like Greek medicine during the dark ages of European history. The rise of Brahminism and Buddhism that forbade invasion of body parts and study of cadavers and the subsequent introduction of Muslim Hakeems during the Islamic invasions of India led to the flourishing of Ayurvedic Herbal Medicine  initially and then to the faith healers, Unani medicinal herb dispensers, and the shamans.
Pre-Vedic Surgery that was passed on to generations of sage surgeons by “oral tradition” and may even have been written many years after his death when the “written tradition” was well-established.
| Modern History|| |
The surgical traditions were eventually revived by the British, Portuguese, and French colonizers of India in the late 17th and 18th centuries. In 1835, first medical colleges were established in Bombay, Madras, and Calcutta followed by Rangoon.
By the beginning of 19th century, the specialty of cardiovascular surgery was slowly emerging. Surgeons who trained in the west were gradually returning to India and establishing cardiac surgery of valvular and congenital diseases.
The first aortic surgery in India was performed in the late 1950s mainly due to the efforts of cardio-thoracic and vascular surgeons at KEM Hospital, Bombay. Dr. PK Sen, Dr. GB Parulkar, MD Kelkar, and TP Kulkarni were the pioneers who laid the foundation of Aortic surgery in India.
Dr. PK Sen [Figure 2], graduated from Seth GS Medical College, Bombay and subsequently trained in cardiovascular surgery at University of Pennsylvania. He returned to India and founded the department of cardio-thoracic and vascular surgery at KEM Hospital, Bombay, which after his death bears his name.
His leadership culminated in the recruitment of the above named surgeons of his group, and subsequently the establishment of the most well-known and busy department of cardiovascular surgery in India in the 1960s and 70s. He performed India's first and world's sixth cardiac transplant in 1968. He was very influenced by Soviet cardiac surgeons and collaborated extensively with Professor VP Demikhov and used a modified technique of cerebral perfusion by right subclavian-left common carotid bypass to perform the first successful aortic arch replacement for arch aneurysm in 1973 [Figure 3]. He also published extensively on nonspecific aortitis, and he published the first monograph on middle aortic syndrome [Figure 4].
|Figure 3: (a) Right subclavian–left carotid artery shunt done as the 1st stage of aortic arch replacement in a case of fusiform aneurysm. (b) After excision of an aneurysm. The right axillary cannula perfuses not only the right subclavian and right carotid arteries but also the left carotid artery through the shunt, thus perfusing almost the entire brain. The lower part of the body receives blood through the femoral artery cannula. (c) Note that the left carotid artery has not been anastomosed to the graft, as it is now supplied through the right subclavian-to-left carotid artery shunt (from Panday SR, Parulkar GB, Chaukar AP, and Sen PK. Simplified technique for aortic arch replacement. First-stage right subclavianto-left carotid artery bypass. Ann Thorac Surg 1974;18:186-90)|
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|Figure 4: Diagrammatic representation of the aortic obliterative syndromes|
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Dr. GB Parulkar was a colleague of Dr. PK Sen [Figure 5] and followed similar career paths. After graduating and training in General Surgery at the University of Bombay, he trained in cardiovascular surgery at Baylor College of Medicine, Houston, USA.
On his return to Bombay, he established hypothermic circulatory arrest technique of resection of aortic aneurysms in India [Figure 6]. This he used for surgery of thoracic as well as abdominal aortic aneurysms at KEM Hospital, Bombay in the late 50s and early sixties.
He also described his technique of left heart bypass for thoracic aortic aneurysms as detailed below from Dis Chest 1965 Apr. 421-9 [Figure 7].
D'Cruz IA and Kulkarni  gave us the term tuberculosis aortitis and published widely on the mid-aortic syndrome, thrombosis of small aortic aneurysms and aortoarteritis in India.
Gupta  from NRS Medical College, Calcutta in 1979 described the surgical and hemodynamic considerations in middle aortic syndrome and showed that aorto-aortic bypasses are effective for this condition [Figure 8].
|Figure 8: Surgical and hemodynamic considerations in middle aortic syndrome. S Gupta. Thorax 1979 34: 470-478|
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Kinare who trained under Dr. PK Sen in the late sixties and early seventies, emerged as a surgical leader at KEM Hospital, Bombay and quite like his seniors focused his attention toward aortitis in young patients in India. He also postulated the association of aortitis with tuberculosis (J Pathol 1970; 100: 69-76).
Dr. C Sadasivan [Figure 5], popularly known as Dr. CS, graduated with distinction from the Andhra Medical College, Visakhapatnam and qualified for his masters in surgery in 1945 under Prof. Sheppard. In 1956, he went overseas for training under pioneers such as Sir. Russel Brock, Andrew Logan, Professor Crawford, and Professor Dubost. He returned to Madras in 1957 and joined the Madras Medical College and Government General Hospital, as Professor in Cardio-thoracic Surgery. He is credited to have been the first to perform aortic surgeries in Chennai.
The seventies and eighties saw an explosion of aortic work in many centers in India in New Delhi, Calcutta, Madras, Trivandrum, Chandigarh, Vellore, and Bangalore. In 1981, Dr. A Gajaraj and Dr. Victor Solomon from Madras described their experience of tuberculous aortoarteritis emphasizing the role of tuberculosis in middle aortic syndromes (Clin Radiol 1981; 32:461-466).
Dr. Ganesh Nayak in Bangalore, Dr. Venugopal in New Delhi, Dr. Saibal Gupta in Calcutta, Dr. Veliathan in Trivandrum, Dr. SK Khanna in Chandigarh, and Dr. Stanley John in Vellore all had a big role in establishing techniques in aortic surgery in their respective cities, although the total number of cases done were miniscule compared to the cardiac and lung surgeries performed at that time.
Prof. Valiathan was a true pioneer of aortic surgery in South India. He described the precursor to Gott shunt  and invented the Sri Chitra tilting disc aortic valve [Figure 9].
|Figure 9: Dr. Valiathan (right), Dr. Victor Solomon (middle) Dr. Ganesh Nayak (left)|
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The 1990s brought a major shift in the practice of aortic surgery in India. First, the introduction of computerized tomography scan, digital subtraction angiography, and improved ultrasound scanning enhanced the diagnostic capability of picking up thoracic and abdominal aortic aneurysms. Second, the return of a new breed of fully trained aortic/vascular surgeons from abroad and the formation of Vascular Society of India in 1994 opened the way for aortic surgery to be performed by vascular surgeons predominantly. Third, the introduction of endovascular techniques for aortic aneurysm repair by Parodi et al. in 1991, fired the imagination of vascular surgeons who went to specifically train in these techniques and subsequently perform EVAR in India.
Among the eminent vascular surgeons to return in the early 1990s were Dr. N Sekar in Chennai, Dr. Kumud Rai and Dr. Rajiv Parakh in New Delhi, Dr. Varinder Bedi in Mumbai, Dr. K Neelakandhan in Trivandrum, and Dr. NK Bhagavan in Bangalore. By the mid-1990s more vascular surgeons joined this group that included Dr. Anil Bhan in New Delhi, Paresh Pai and Dr. Riza Ibrahim in Mumbai, Dr. V Balaji in Chennai, Dr. M Unnikrishnan in Trivandrum and Dr. KR Suresh and Ramesh K Tripathi in Bangalore [Figure 10].
|Figure 10: Dr. Neelakandhan, Dr. Kumud Rai, Dr. Sekar, Dr. M Unnikrishnan, Dr. VS Bedi, Dr. KR Suresh, Dr. Rajiv Parakh|
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Our radiology and cardiology colleagues were at the forefront at this period of time performing a wide variety of angioplasty and stenting procedures for stenotic aortic diseases. These included Dr. H Deshmukh, Dr. Vimal Someshwar, and Dr. Sandeep Punamiya in Mumbai, Dr. Sanjay Tyagi and Dr. Sanjiv Sharma in New Delhi, Dr. George Joseph in Vellore, Dr. AK Gupta in Trivandrum, and Dr. Mathew Cherian in Coimbatore.
Dr. AK Gupta et al. from Sri Chitra Institute of Medical Sciences, Trivandrum were the first to report aneurysmal form of Takayasu's disease in 1990. This was followed by a new classification of Takayasu's arteritis by Dr. BK Sharma and Dr. Numano in 1997.
Dr. Ramesh Tripathi's group in Bangalore was already exploring endovascular repair of an aortic aneurysm after an advanced training at the University of Cologne. Before custom grafts were available, Dr. Tripathi's group had already performed a home-made stent grafting of an external iliac artery pseudoaneurysm [Figure 11].
|Figure 11: First home-made stent graft used for External iliac Pseudoaneurysm by Dr. Tripathi's team in Bangalore in 1996|
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In July of 1997, supported by Dr. Mariano Fereira from Dr. Juan Parodi's group, Dr. Ramesh Tripathi, and Dr. Sriram Rajgopal performed the first endovascular aneurysm repair EVAR in India at Railway Hospital, Perambur, Tamil Nadu [Figure 12]. Unfortunately, although the stent grafting of infra-renal AAA went smoothly and achieved an excellent exclusion of an aneurysm, the patient developed a type B aortic dissection. In those days, EVAR was performed by a “brachio-femoral floss technique” over a 0.035” Amplatz Super Stiff wire. Dissection occurred during removal of this floss wire in the “euphoria” of a successful procedure that was first for our country. Dr. Tripathi received a significant amount of condemnation and isolation from his colleagues of the Vascular Society of India for having performed this procedure and EVAR was generally relegated to the status of a failed experiment. Despite all the negative publicity due to his “failure,” Dr. Tripathi made a visit to Perth, Australia during this time to see how this procedure could be perfected and a successful EVAR could be performed in India. Back home, he got his chance when on June 6, 1998, a 68-year-old man presented with a 6.5 cm AAA to Metro Hospital, New Delhi. Dr. Tripathi was flown into India's capital city and performed the first successful EVAR in India with a custom designed modular bifurcated Vanguard ™ stent graft (Boston Scientific Inc., Natick, USA). History was made!
Slowly but surely after that there was a major turnaround in the thinking of vascular surgeons about the endovascular repair of aortic aneurysms.
In 1998, World Medical Inc., introduced its Talent stent graft for thoracic aortic aneurysm and on the heels of his EVAR success, Dr. Tripathi ably assisted by his fellow Dr. Sanjay Desai performed the first successful TEVAR in India in MS Ramaiah Medical College, Bangalore on November 12, 1998. Now there was no looking back.
In 1999, Dr. Sanjay Tyagi reported the first experiences of stenting for failed angioplasty of stenotic aorto-arteritic lesions.
In the 2000–2014 period, new and established stars have been very productive on the horizon of aortic surgery. Dr. Ajay Yadav and Dr. Tarun Grover in New Delhi, Dr. Gireesh Warawdekar in Mumbai, Dr. Vidyasagaran, Dr. V Balaji, and Dr. VV Bashi in Chennai, and Dr. Vivekanand, Dr. Sanjay Desai, and Dr. Robbie K George in Bangalore have strengthened the work of pioneering vascular surgeons in these cities. Aortic surgeries especially of ascending, arch and descending aorta have reached a world-class level.
During this time, Dr. Neelakandan from Trivandrum pioneered repair of Thoracoabdominal aneurysms in India. Dr. M Unnikrishnan in Trivandrum, Dr. Tripathi in Bangalore, Dr. VV Bashi in Chennai, and Dr. Anil Bhan in New Delhi are the major centers that continue to evolve in this tradition.
In 2005, Dr. Tripathi performed experimental work on in situ fenestration of thoracic endografts and showed that preservation of subclavian and carotid perfusion was possible safely.
India's first fully integrated Hybrid OR was established at Narayana Institute of Vascular Sciences on September 5, 2011 [Figure 13].
Endovascular and open techniques including hybrid surgeries are being performed in large numbers by the Trivandrum, Bangalore, New Delhi, and Mumbai groups.
In 2012, Verma, George, and Tripathi from Bangalore and Sen, Stephen, and Agarwal reported their experience with occlusive aortic diseases., There continues a serious interest in aortic pathology in India from our Western collaborators.
Coarctation of Aorta is now being managed almost exclusively by endovascular technique. Dr. Bharat Dalvi in Mumbai, Dr. Sivakumar in Chennai, and Dr. PV Suresh and Dr. Sreesha Maiya from Bangalore has the highest number of cases in the world.
Fenestrated grafts were adopted for complex anatomy in India by the Vellore Mumbai groups as early as 2011 and adopted by other groups in Bangalore and New Delhi by 2013. Surgeon fenestrated grafts have been popularized by the Vellore group with the development of metal sizers to allow easy and accurate fenestrations [Figure 14].
Obviously a lot of learning has come from overseas. Dr. Michael Lawrence-Brown from Perth, Australia, Dr. Krassi Ivancev, and Dr. Martin Malina from Malmo, Sweden, Dr. Roy Greenberg of Clevelend Clinic and Dr. Gustavo Oderich of Mayo Clinic from USA, Dr. Stephan Haulon from Lille, France, Dr. Brian Hopkinson, Dr. Matt Thompson, and Rao Vallabhaneni from UK, Dr. Eric Verhoeven from Nuremberg, Germany, and Dr. Roberto Chiesa and Dr. Germano Melissano of Milan and Dr. Gioachino Coppi of Modena, Italy have been great supporters of advanced aortic work in India [Figure 15].
|Figure 15: Hybrid Repair of Arch Aneurysm – Debranching – TEVAR (Courtesy Narayana Institute of Vascular Sciences, Bangalore)|
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Dr. Rahul Sheth and Dr. Ramesh K Tripathi are establishing a database of all aortic aneurysm procedures and their follow-up as a part of establishing a quality initiative of the aortic groups in the country. Screening programs for AAA are been conducted in many hospitals across India. On the education front, aorta specific conferences that have succeeded are Aorta India by All India Institute of Medical Sciences in New Delhi, METAA conference by MIOT, Chennai, and Indovasc Symposium by Narayana Institute of Vascular Sciences, Bangalore.
There is a heightened awareness of the endovascular aortic market in India. Newer stent-grafts are being introduced in India. At the time of publication, Gore Excluder and TAG Devices, Cook Zenith Flex and TX2 range, Medtronic Endurant and Valiant grafts, Vascutek Anaconda, and Bolton Relay grafts are licensed in India. Trivascular Ovation and Endologix Ventana and Nellix devices are in the process of licensing.
Transfemoral aortic valve implantation TAVI has come to India this year and currently two centers are undergoing proctor-mentoring for this complex procedure.
Although India was one of the earliest germ beds for the development of surgery, it has resurged after an uneventful middle age. It has matured to world-class levels presently with an eye toward a bright future.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]