5.01 Antecedentes de la Propuesta:
5.02.06 Formulación del proceso de aplicación de la propuesta:
Maxime Noel-Lamy, MD FRCPC, Fellow in Vascular and Interventional Radiology, University of Toronto University Health Network, Toronto
I
n 1953, Sven-Ivar Seldinger described a novel technique for vascular access that would have a great influence on modern medicine. His work revolutionized diagnostic an- giography and contributed to the emergence of intervention- al radiology as a specialty. The Seldinger technique is used by physicians of various specialties for a myriad of procedures in a vast array of pathologies.To realize the importance of this technique, we have to un- derstand the state of angiography and vascular access in the first half of the 20th century. The first description of percuta-
neous vascular access for imaging was by dos Santos, Caldas and Lamas in 1929.1 They described aortography via a direct,
trans-lumbar puncture of the aorta. This was a relatively inva- sive technique, since it involved puncturing the aorta using a large bore needle. It was also limited, as it allowed imaging of the aorta only from the level of puncture. In the following decades, others tried to find a way to safely insert catheters in vessels to perform angiograms at a distance from the punc- ture site. The goal was to obtain arteriography of different arteries at multiple levels. In 1940, Farinas, a Cuban radiolo- gist, successfully advanced a catheter into the aorta from the common femoral artery after a surgical cut-down.2 As impres-
Corresponding Author: Maxime Noel-Lamy [email protected]
Figure 1. Schematic representation of the Seldinger technique for vascular access. A- A hollow needle is used to puncture the blood vessel. B- A metallic guide-wire is introduced in the needle and pushed distally in the blood vessel. C-The needle is removed and the wire left in place. Pressure is applied upstream to the puncture site to prevent bleeding (arrow). D- The catheter is introduced over the wire. E- Safe vascular access is obtained, and the wire can be removed.
The Seldinger Technique: A Short History, and its Applications 60 Years Later
of arteries were no longer necessary. Therefore, hemostasis could be achieved by manual compression only. Seldinger published his results in 1953 in the journal Acta Radiologica.4
The Seldiner technique is still widely used today to insert a catheter into arteries, veins, fluid collections and hollow or- gans. It remains the preferred method for access in almost all percutaneous vascular and non-vascular interventions.
The discovery of a safe technique for percutaneous access made selective angiographies of different vessels possible. Seldinger himself used it to perform selective renal angiogra- phy and to localize a para-thyroid adenoma.5,6 The advance-
ment of diagnostic angiography paved the way for other pio- neers of interventional radiology, such as Charles Dotter, who described the first percutaneous balloon-angioplasty of arte- rial atherosclerotic stenosis in 1964.7 As imaging technology
evolved with the arrival of ultrasound, CT-scan, and digital angiography, Seldinger’s eponym technique could be used for new applications. For instance, ultrasound is commonly used today to guide the puncture, allowing for safer access. Additionally, CT-guidance can be used to access percutane- ously deep fluid collections or vessels that cannot be seen un- der ultrasound. Innumerable types of guide-wires, catheters, balloons, stents and other devices were created and are now
used with Seldinger’s method. Today, micro-catheters as small as 0.010 inches can be used to reach distal arteries anywhere in the body.
Percutaneous access is part of the daily work of inter- ventional and neuro-interventional radiologists, as well as interventional cardiologists. The common femoral artery is most often used for arterial procedures. Radial access is fre- quently used for coronary angioplasty and stenting. Other less commonly accessed arteries include the brachial, axillary, popliteal, and tibial arteries. Interventional radiologists also use the Seldinger technique for non-vascular interventions, such as percutaneous abscess drainage, nephrostomy, biliary drainage, and gastrostomy. In these procedures, a drainage catheter with side-holes is inserted over the wire and a distal cope-loop is formed to lock the catheter in place. The Seld- inger technique is also commonly used by internists, intensiv- ists and anesthesiologists to insert central venous and arterial lines. The table below is a non-exhaustive list of minimally invasive procedures in modern medicine that would not be possible without the Seldinger technique (Table 1).
Short Biography of Sven-Ivar Seldinger (1921-1988)8 Sven-Ivar Seldinger was born in the small town of Mora, Swe- den in 1921. He studied medicine at the Karolinska Institute in Stockholm (1940-1948). He took an early interest in radiology and chose this field as his specialty. His training in radiology started in 1950 at the Karolinska Sjukhuset. He was working at the university clinic at this center when he developed the novel catheterization technique named after him. After publishing his innovation in 1953, he applied his new technique to per- form selective angiographies of the kidney and other arteries. In addition, he used it to puncture bile ducts for cholangiogra- phy. He defended his thesis on the topic in 1966. He qualified for the title of Docent of Radiology in 1967. He subsequently returned to his hometown of Mora and became Head of the Diagnostic Radiology Department at the local hospital. This is where he worked for most of his career. He is considered one of the pioneers of interventional radiology. He was awarded the Valentine award from the New York Academy of Medicine in 1975. He passed away in his home in the province of Dalar- na, Sweden, in 1998, at the age of 77.
References
1. Dos Santos R, Pereira Caldas J and Lamas A. Arterografia da aorta e dos vasos abdominais. A Medicina Contemporanea. 1929; 11: 93-96.
2. Farinas PL. A new technique for the arteriographic examination of the ab- dominal aorta and its branches. Am J Roentgenol 1941; 46: 641.
3. Pierce EC. Percutaneous femoral artery catheterisation in man with special reference to aortography. Surg Gynaecol Obstet 1951; 93: 56.
4. Seldinger SI. Catheter replacement of the needle in percutaneous arteriog- raphy; a new technique. Acta Radiol. 1953; 39: 368-76.
5. Seldinger SI. Localization of parathyroid adenomata by arteriography. Acta Radiol 1954; 42: 353-366.
6. Seldinger SI, Lindblom K. Renal arteriography, as compared with renal puncture in the diagnosis of cysts and tumours. Athens: Société Internatio- nale d’Urologie. 1955; 45: 15-20.
7. Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruc- tion. Description of a new technique and a preliminary report of its applica- tion. Circulation. 1964; 30: 654-670.
8. Sven-Ivar Seldinger: biography and bibliography. AJR Am J Roentgenol. 1984;142(1):4.
9. Higgs ZC, Macafee DA, Braithwaite BD, Maxwell-armstrong CA. The Seld- inger technique: 50 years on. Lancet. 2005;366(9494):1407-9.
Reviews
Table 1. Current applications of the Seldinger technique
Field Procedure
Vascular Access Central venous lines Dialysis catheters Implanted ports
Peripherally-inserted central catheters (PICCs) Oncology Chemo and radio-embolization
Bland embolization of vascular tumors/me- tastasis
Portal vein embolization
Arterial Interventions Angioplasty and stenting for atherosclerosis Endovascular aneurysm repair
Embolization of bleeds (trauma, gastro-intesti- nal, iatrogenic, etc.)
Vascular malformations embolization Venous Interventions Catheter-directed thrombolysis of acute ve-
nous thrombosis/pulmonary embolism Vein recanalization/angioplasty
Inferior vena cava filter insertion for thrombo- embolic protection
Varicose veins ablations
Uro-genital Percutaneous nephrostomy and percutaneous stone treatments
Dilatation of ureteric strictures Uterine fibroid embolization Varicocele embolization Gastrointestinal -
Hepatobilliary Percutaneous abscess drainagePercutaneous cholecystostomy
Trans-hepatic biliary drainage/stone extraction Trans-jugular porto-systemic shunts (TIPS Percutaneous gastrostomy
Neuro-intervention Cerebral aneurysms embolization Brain and spine vascular malformations embolization
Stroke intervention Carotid arteries stenting Cardiology Coronary angioplasty and stenting
Percutaneous closure of atrial and ventricular septum defects
evolved from ancestral primitive microbes to animals, fungi, plants, algae, and humans underlying the critical process of single cell division. He moves on to aging and provides an interesting perspective on the different and rising life-expec- tancies of men and women. He notes the paradoxical fact of how longevity and senescence can occur at the same time. Some parts of this longevity puzzle lies in the genes. This has given rise to scientific efforts to find the ‘longevity gene’ and to understand the genetic role of diseases.
In the second part, the author moves on to explain the role of evolution and natural selection in explaining the differ- ent lifespans of species. There is an interesting discourse on
Corresponding Author: Mayvis Rebeira