introduce in a moment Dr. Gary Rubin. This is an incredible honor for me. Gary has been my hero for many years, and I think everybody who has learned carotid stenting originally learned it from him. If we're going to get biblical, I guess that kind of makes you Abraham, Gary. And so he was, of course, one of Andreas Grunzig's fellows and disciples, and his career has spanned four decades, and he's been an innovator and a leader in that time. We all remember the Gian Turco stent in the early days of carotid stenting. And then, of course, I think Gary's legacy will be carotid artery stenting, where he really, initially with his work at the University of Alabama in Birmingham with his friends and colleagues, Sri Yair and Jerry Vitek and Jay Yadav, really took it from the napkin to what it is today, an established and very effective treatment. So I am very much looking forward to hearing about your journey personally and professionally with regards to carotid stenting. And Gary, again, it's just really an honor, a privilege for you to be here. So please give us some of your pearls of wisdom here. Actually, probably we should put up that introduction big slide, because I'm not, I'm not doing this with slides. I thought about showing the same slides that we've all seen. We keep seeing them. We keep seeing them multiple times at this meeting and every other meeting we've been to. And I thought I would spend just a few minutes giving you some personal perspectives about what it takes to move a discipline forward and most importantly to improve patient care. And I thought a lot about, while he could entitle this talk, what I thought I would put on my opening slide. And it could go something like, how intersocietal greed, egos and self-interest runs counter to best patient care in the United States. But an interesting subject with the reflection of my last 30 years in developing carotid stenting and considering where we are today. And I didn't think that would look good on a slide. So I thought I would just speak to you as one does in a TED talk about the experience of trying to break into this carotid revascularization business. A little bit of background, and Peter mentioned I worked with Andreas Gronzig when I first came to the States back in the early 1980s. I saw an opportunity back then in the mid-1980s, we could solve the problem of abrupt closure in coronary arteries by developing coronary stent. It was considered absolutely crazy. The cardiovascular surgeons thought this was really a huge problem for them. And I battled with the likes of Rene Favalero and other prominent cardiovascular surgeons for a decade. And we all now know where coronary stenting has gone and how much it's improved patient care and become a standard of care. It was approximately 10 years later, having worked with Gronzig, I had an entree, a unique entree. There were two or three of us in the entire country as cardiologists who started to work in addition to the coronaries, outside the heart, in the legs, in the pelvic arteries, in the renal arteries, and in the great vessels coming off the aorta. So there was some background for me as a cardiologist in delving out. Now there was incredible resistance, as some of you in this room will remember, from the interventional radiologists. Cardiologists should have nothing to do with anything outside the heart. And vascular surgeons, of course, who had not accepted endovascular care in any way at that point. In fact, there were great advocates, individuals like John Porter, who some of you may remember, were great. They were fond of saying there is no future for endovascular care. I mention these things because it will give you a sense that when it came to approaching the carotids, I had some experience that this was not going to be particularly easy. Andreas Gronzig was successful with coronary intervention because of one important thing. He figured out very quickly that it was all about patient selection. And if you can select the proximal, non-calcified, non-tortuous lesions, even with his most primitive balloons, he could demonstrate successful coronary revascularization. So it was early 1993 and I'm at the University of Alabama in Birmingham and I get a phone call from a neurologist by the name of Jay Yadav, board-certified neurologist. And he says, look, we're not doing anything about stroke and you guys are doing great work now with acute myocardial infarction, STEMI care, and I want to do this and I want you to show me how to do it in the brain. And I said, well, why don't we talk? And after a chat, I said to Jay, look, if we're going to do this, we're going to start with the low-hanging fruit and the carotid bifurcation, which I knew we could easily access, and we're going to start this work. And I said, for me to teach you as a neurologist within my interventional cardiology program, you're going to have to do a two-year interventional cardiology vascular training. So he did. He came to Birmingham, Alabama. He was a board-certified neurologist. We engaged a fabulous interventional neuroradiologist who became a dear friend and my partner for the next 30 years, Jerry Vitek. We formed a multidisciplinary team. We tried to engage the vascular surgeons. They would have no part of it. The neurosurgeons, interestingly, back then and going forward to this day, were rather supportive of the idea that we could do percutaneous intervention at the carotid bifurcation. In 1994, there had been individuals around the world, Jacques Theron in France, Karlsberg Theis in Germany, Jerry Vitek in Birmingham, Alabama, who had done some bloom work in the great vessels. Anecdotes, case reports, no one had done a prospective IRB-approved study of what you could do at the carotid bifurcation. We applied to the University of Alabama for approval, and we went ahead with ballooning the carotid bifurcation. The fourth case, acute closure, thrombosis, massive stroke and death. I remember to this day talking to this woman's, the patient's, two daughters outside the elevator as I was going up to tell them what was happening. At that point, we stopped and we said, we need to stent these. We'd already been pioneering stenting in the coronaries. The only stent that we had was a Palmaz stent, and you crimped it on the balloon. We did that, and we did about 40 cases, and that was pretty damn successful. We maybe had one or two neurological events, no embolic protection. But according to our protocol, we brought these patients back very quickly and looked at them, and we saw two or three that crushed in the neck, back to the drawing board. This is the process by which for all of the interventional procedures we've had and developed over these decades, this is the iterative process that one does. We had the self-expanding stent. It was a tracheobronchial wall stent with a 350 centimeter delivery system, and we had to have Cook Incorporated make us a wire. Someone held it almost outside the cath lab door to get this thing. We did this in live cases because like Andreas Grunzig, I wanted to demonstrate it could be done, and this is how you do it. I won't mention his name, but if I did, you'd all recognize, some of you who remember these times. One guy stood up in this meeting with about 500 physicians in the room in Birmingham, Alabama, and said, this is the most medico-legally negligent thing I've ever seen anyone do, let alone in a live case. Well, self-extending stents, again in the crotch, is now becoming gold standard. We got CMS approval about six months ago. We've developed them by protection. We've taken our complication rates, which in the hands of thoughtful, careful operators have always been reasonable, and now they are extraordinarily good. And so we are where we are with all of the current information we have on patient selection and new device technology coming. That's a brief summary of how we all got to be here tonight, and I appreciate your attention. Thank you very much. Thank you.

carotid stenting

Gary Rubin

revascularization

multidisciplinary team

medical innovations