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Arthur B. Voorhees, Jr.: Pioneer vascular surgeon
ORIGINAl. ARTICLES From the Southern Association for Vascular Surgery
Arthur B. Voorhees, Jr.: Pioneer vascular surgeon Robert B. Smith III, ME), Atlanta, Ga.
'(It is a well-known truism that the development of vascular surgery would have been unthinkable without the introduction of clinically serviceable arterial substitutes. "1
- D . E. Szilagyi This presidential address to the Southern Association for Vascular Surgery allows me the opportunity to pay posthumous tribute to my mentor, Arthur B. Voorhees, Jr., one of the pioneers in vascular surgery. Every practitioner of our specialty knows that the era of modern vascular surgery began with Voorhees' monumental innovation in 1952, the introduction of the prosthetic vascular graft. How many know of the circumstances surrounding that seminal contribution or the many other remarkable achievements of this exemplary surgeon-teacherinvestigator? Aided by information and memorabilia provided by his wife of 47 years, Margaret, I hope to provide an accurate, revealing account of a truly great physician. Arthur Bostwick Voorhees, Jr., was born near Philadelphia in Moorestown, New Jersey, in 1921. His lineage can be traced to Stephen Coert van Voorhees, an early Dutch settler in New Amsterdam, whose farm occupied what is the site of Trinity Church in present-day lower Manhattan. During World War I, Art's father was stationed at an army post in Anniston, Alabama, where he met and married Margaret Crowe, the daughter of Jefferson From the Division of Vascular Surgery, Emory University School of Medicine, Atlanta. Presented at the Seventeenth Annual Meeting of the Southern Association for Vascular Surgery, Fort Lauderdale, Fla., Jan. 29-31, 1993. Reprint requests: Robert B. Smith HI, MD, the Emory Clinic, 1365 Clifton Rd. N.E., Atlanta, GA 30322. J VASCSURG1993;18:341-8. Copyright © 1993 by The Society for Vascular Surgery and International Society for CardiovascularSurgery, North American Chapter. 0741-5214/93/$1.00 + .10 24/6]46367
Davis Crowe, a country doctor in Jacksonville, Alabama. After the war the Voorhees returned to the family home in Moorestown, where Art was born and reared. Art was greatly influenced by his modest, gentle father whose ingenious ways of solving problems and fixing things set a pattern he would emulate throughout his life. From early on, both parents urged Art to seek advanced schooling and contribute to his fellow man, perhaps in the field of medicine. All of his schooling was at Moorestown Friends School, an established, traditional Quaker day school. He performed well academically and was an accomplished athlete in baseball and soccer, serving as captain of the soccer team and president of the Varsity Club before his graduation in 1940. When the time came to select a college, his mother, still an unreconstructed southerner, insisted that Art attend a southern university to ensure his proper education. Attracted to the legacy of his boyhood idol, Thomas Jefferson, Art chose the University of Virginia in Charlottesville. There he found a highly competitive academic climate, where he was no longer the scholastic star that he had been in Moorestown. He struggled with languages in the freshman year but excelled in mathematics and physics. Eventually he chose biology to be his major, because he was determined to seek a career in medicine. To remain in school, Art worked at a variety of jobs but also found time to participate in a number of extracurricular pursuits, including drawing cartoons for the college newspaper. His talent for art became useful later in his career when he personally prepared many of the illustrations for his medical publications. Achieving honors in biology at the University of Virginia, Art was selected after his junior year of college for early acceptance into medical school as a participant in a program sponsored by the Army Specialized Training Corps. In 1943, at the peak of 341
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Fig. 1. Wedding ,photograph of Arthur and Margaret Voorhees, Moorestown, New Jersey, December 22, 1945 (provided by Margaret R. Voorhees).
World War II, he entered the College of Physicians and Surgeons of Columbia University. The wartimeaccelerated program at Columbia University was highly stressful for the students, who were subjected to a rigorous 12 month-a-year, continuous curriculum. Art found anatomy to be particularly difficult but later rallied and rose to the upper quarter of his class by the time of graduation. He was drawn to surgery under the aegis of Dr. Hugh Auchincloss, a senior surgeon for whom he had great admiration and affection. During the years since his graduation from high school, Art had courted from a distance Margaret L. Roberts ("Mags"), who had been 2 years behind him in high school. Mags' Quaker family, also well established in Moorestown, was engaged in managing the company that manufactured the renowned Flexible Flyer sled. She attended Wheaton College in Massachusetts, and she and Art were contemplating marriage after his graduation from medical school. Those plans were accelerated when Art had a near-fatal sailing incident, deciding after his rescue that life with Mags was too precious to risk further
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delays. To facilitate a midsemester wedding, Mags transferred to Barnard College in New York City and they were married during Art's senior year (Fig. 1). After graduation from medical school in 1946, Art served a straight surgical internship at the Columbia-Presbyterian Hospital of New York. During that year Arthur H. Blakemore, famed portal hypertension surgeon at Presbyterian, observed in the young trainee characteristics of inquisitiveness and determination and recognized in him the potential for a promising career in research. He offered him a 1-year research fellowship during the interim before Art was obligated to enter active military duty. That year, 1947 to 1948, marked the beginning of a long and productive relationship between Art and "Blake," as Dr. Blakemore was known by his associates. Later, Art, in tribute to his mentor, described him as "one of the greats in the history of vascular surgery... [who] created the environment in which the development of the prosthesis took place. ''2 Under Blakemore's direction, Art was assigned the task of developing in the animal laboratory a mitral valve replacement fashioned from a segment of homograft inferior vena cava. The procedure was technically demanding and complex, requiring blind placement of silk support sutures to function as "chordae tendineae" for the implanted valve. In the spring of 1948, while performing an autopsy on one of the animals several months after implantation, Art observed that an errant silk suture bridging the ventricular cavity was coated with a glistening film of what appeared to be endocardium. In a moment of inspiration that was subsequently described by Art as serendipitous, he speculated that "a piece of cloth might react in a similar way. "2'3 Documenting the event, Voorhees later wrote, "As an outgrowth of this observation it was conceived that if arterial defects were bridged by prostheses constructed of a fine mesh cloth, leakage of blood through the walls of the prosthesis would be terminated by the formation of fibrin plugs and would thus allow the cloth tube to conduct arterial flow."4 Art reported that he had been uninformed at that time of Guthric's suggestion 30 years earlier that an implant need serve only as scaffolding for ingrowth of the host's tissues. 5 It appears that he had also been unaware of a much earlier report in the German literature that had described silk sutures in the lumen of an artery having become encapsulated by a fine veil coating. 6,7 When Art's notion of a cloth prosthesis was presented to Blake, he was equally enthusiastic about its possibilities, urging him to "try it, boy. ''2 Time remaining in the fellowship allowed for only one attempt, with a cloth tube fabricated on his wife's
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Fig. 2. Vinyon-N prostheses prepared by Voorhees for use in early animal experiments (provided by Arthur B. Voorhees).
sewing machine from a silk handkerchief.8 The tube functioned for 1 hour in the acute dog model before the animal died of exsanguination, just long enough to offer encouragement. Soon thereafter, Art had to report to the Surgical Research Unit at Brooke Army Medical Center in San Antonio to begin a 2-year tour as a research associate. During that assignment, he had limited opportunity to pursue arterial substitutes, because the majority of his efforts were devoted to the development of more effective plasma expanders, burn management, and surgical shock problems. 9 Eventually, however, he was able to resume his experiments, using nylon parachute cloth as an aortic prosthesis. 2,1° One of six dogs receiving implants survived for 1 month and had a patent graft at autopsy. 8 The project, although still promising, was hampered by an inability to obtain satisfactory histologic studies on explanted grafts. Later, musing on the positive outcome of that handicap because it afforded him time instead to reflect on the specifications necessary for a successful biologic implant, Art wrote, "The cloth had to be strong, inert, stable, of the right porosity, supple, and yet easily traversed by a fine needle."2 On renaming to Presbyterian Hospital in 1950 to begin his surgical residency, Art resumed his work on
vascular grafts in the laboratory of Dr. Blakemore. He met an orthopedic resident, James Wallace Blunt, Jr., who was working on a synthetic tendon project and therefore was knowledgeable about suitable plastic fibers. Blunt suggested that the fabric Vinyon-N (The Union Carbon and Carbide Corp., Danbury, Conn. ) might be ideal for Art's needs.4 The Union Carbon and Carbide Corporation was contacted, which donated its last bolt of 144 x 90 strands per square inch, Vinyon-N spinnaker cloth for the project. Vinyon-N had little commercial value, because it was too inert to be dyed, but the synthetic fiber met Art's criteria. Using Vinyon-N, he fashioned a variety of tubular prostheses on his wife's sewing machine and implanted them into the abdominal aortas of mongrel dogs. The ends of the grafts were turned back French-cuffstyle to minimize fraying, and anastomoses were performed with continuous silk sutures4 or vitallium cuffs designed earlier by Blakemore and Lord n (Fig. 2). Early implantations were tedious and complicated: "We were often hard pressed to separate our technical ineptitude, the perversity of our handcrafted materials, mad the variations of host response, in analyzing our end results. "3 When consistent success was finally achieved in animal survival, the project moved
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Fig. 3. Photograph taken in 1957 of Voorhees and experimental dog 627A, "a lovely animal" that had received an aortic prosthesis in 1951 (provided by Margaret R. Voorhees).
Fig. 4. Vinyon-N graft harvested from experimental dog 627A in 1959, 8 years after implantation (provided by Margaret R. Voorhees). forward in earnest, guided and encouraged by Blakemore and George H. Httmphreys, chairman of the Department of Surgery. Art credited a number of colleagues for their contributions to the endeavor, specifically Daisy Mapes, technical head of the animal operating room, and Rafaele Lattes and Nathan Lane, pathologists who assisted in histologic studies of graft healing. 2,3 By the end of 1950, implants had been placed in 30 dogs, three quarters of which survived until
subsequent graft removal and examination. Animals were sacrificed on a predetermined schedule, ranging from hours to months and eventually up to 8 years, to provide a time-related portrayal of graft healing (Figs. 3 and 4). Other surgical residents joined the Vinyon project, Alfred Jaretzki in 19512 and Sheldon Levin 12 in 1952, providing impetus to the investigation when Art had to return to clinical duties? By mid-1951, sufficient data had been collected to prepare an optimistic preliminary report for the New
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York Society for Cardiovascular Surgery, resulting in the classic article published in theAnnals of Surgery in March 1952, "The Use of Tubes Constructed From Vinyon "N" Cloth in Bridging Arterial Defects."~ In that report the coauthors, Voorhees, Jaretzki, and Blakemore, reviewed their experience with the first 15 graft implants. Eleven dogs had been killed or had died: 5 of the 11 grafts were completely or partially thrombosed and the remainder were fully patent, with their internal surfaces covered by a thin, transparent film that on microscopic examination consisted of "multiple layers of flattened cells and collagen fibers strikingly similar to the architecture of the normal aorta with the notable absence of elastic and smooth muscle elements."4 As a result of this noteworthy contribution, Art received his first special recognition, a cash award from the New York Academy of Medicine, the Alexander Bowen-Harlow Brooks Scholar Award. February 1953, when Art was a senior resident, marked the initiation of synthetic graft implantations in humans at Columbia-Presbyterian Medical Center. 12,13 He and Blakemore had been exploring a patient with a ruptured abdominal aortic aneurysm. After proximal control had been accomplished, Dr. Blakemore was dismayed to learn that there was no aortic homograft available for implantation. Art left the operating room, fashioned a bifurcation graft of Vinyon cloth, gave it to the nurse to be autoclaved, and returned to the .operative field. After the graft had been placed and the clamps removed, the conduit functioned, and although the patient died after surgery of a generalized clotting deficiency, the prosthesis was found to be patent at the time of autopsy. Encouraged by that initial experience, several weeks later the team electively inserted another Vinyon graft in a patient with an abdominal aortic aneurysm, and that patient survived. During this exciting early period, Art prepared each prosthesis o n Mags' Necchi sewing machine, which he eventually moved to the hospital for greater convenience. Before a planned operation, he would fabricate an assortment of sizes and configurations to allow'a custom fit to the host's vessels. During the ensuing 10 months, 16 additional aneurysms were treated with cloth prostheses, and an astounding 56% of the first 18 patients survived. Art ascribed the deaths in the initial experience to an inability to deal successfully with patients in extremis, whose severely diseased arteries resulted too frequently in disastrous intraoperative hemorrhage? sxs To their credit as highly ethical physicians, Art and his colleagues made no effort to obtain patent rights on their revolution-
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ary product, maintaining that it should be used freely for the benefit of patients. In March 1954 Art reviewed the animal model data at a symposium on vascular transplants sponsored by the National Research Council. Other panelists included Robert Gross, Charles Hufnagel, Harris Shumacker, and Michael DeBakey, all of whom were interested in the new field of synthetic grafts. It was evident that "a new era had indeed begun in vascular surgery."12 One month later both the experimental work and early results in humans were presented by Blakemore and Voorhees at the American Surgical Association meeting in Cleveland and published that year in theAnnals of Surgeryfl 3 In discourse about that presentation, Harris Shumacker and Robert Linton were complimentary of the work; looking back near the end of his career, Andrew Dale described it as " . . . one of the most important papers ever presented to the surgical world. "is Charles Rob echoed that praise when he wrote, '~Fhis advance pioneered by a resident, Arthur Voorhees, has changed arterial surgery in a most significant way and constitutes a great step forward. "16 Other prosthetic materials were rapidly introduced by an expanding industry, and surgical meetings and journals focused on textile characteristics, debating the relative merits of porosity, denier, taffeta, crimp, and other elements of fiber fabrication. 17,1s Vinyon-N gave way to competitive fibers with more favorable physical properties, including Orlon, Teflon, nylon, and Dacron; arterial homografts soon fell into disfavor because of their short supply and history of late deterioration. 19"z~Meanwhile, Art completed his surgical residency in 1955 and joined the faculty of Columbia-Presbyterian. as instructor in surgery and assistant attending surgeon, working in close association with his benefactor, Dr. Blakemore. Together they maintained a strong interest in graft experimentation, inserting 50 braided tubes of Orlon or Vinyon by 1957, with only two delayed thromboses, both instances of poor runoff. In addition to Blakemore and Voorhees, Presbyterian Hospital boasted a number of other excellent surgeons engaged in vascular surgery during that era, including Shivaji Bhonslay, Ralph Deterling, and Ferdinand McAllister. I first met Art Voothees when I was a straight surgical intern at Presbyterian Hospital in 1957. He impressed young house officers as a master technical surgeon, bright intellect, and compassionate, ethical physician. A popular teacher, he had an unusual rapport with both students and residents. During the years of my surgical residency, Art became a personal
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Fig. 5. Arthur B. Voorhees, after retirement, engaged in a favorite avocation, bird watching in the Berkshire Mountains (provided by Margaret R. Voorhees). friend, advisor, and role model. I was fortunate to participate with him in several clinical research projects and spent many hours in the operating room under his patient direction. 22,23 Our friendship continued after I completed training and returned to Atlanta in 1966 to join the faculty of the Emory University School of Medicine. Guided by the interests of Blakemore and the traditions of Allen O. Whipple and the Spleen Clinic at Presbyterian Hospital, Art naturally became involved in the management of portal hypertension and its complications, especiaUv the metabolic effects of portasystemic shunting. 24 TT~ r~,. collaborated with Blakemore on refinement of the SengstakenBlakerfiore esophageal tamponade balloon (Davol, Inc., Cranston, R.I.) and systematically reviewed and periodically reported results of the portal hypertension surgical experience at Presbyterian, still among the most extensive in the world. 2s-32 His article in 1964 describing 103 definitive operations on children with portal hypertension was a benchmark contribution to the field. 33 After careful follow-up, Art raised a caution flag 9 years later when he realized that a significant number of children who had
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undergone surgically created portal shunts had had delayed neuropsychiatric abnormalities) 4 In a personal commentary concerning this important observation, he later wrote, "As I look back, I think of this as my most interesting avenue of research. It opened many doors which I was ill-equipped to explore." After Dr. Blakemore's retirement, Art became director of the animal laboratory at Columbia, sponsored by the Fund for the Advancement of Blood Vessel Surgery, a resource largely endowed by patient contributions. As director, Art was instrumental in designating the facility as the Arthur H. Blakemore Research Laboratory. There, a variety of important projects were undertaken, frequently sparked by Voorhees' own creativity and vision. He and his faculty coworkers, John B. Price and Richard C. Britton, directed young investigators in studying arterial substitutes, hepatic regeneration, ammonia intoxication, portal flow dynamics, laser effects on blood vessels, and antibiotic protection of synthetic vascular graftsfi -4s During his 28 years on the Columbia faculty, Art held influential teaching, research, and administrative positions in the Department of Surgery. He rose to the rank of professor of clinical surgery in 1970 and served as chief of the Vascular Surgery Service. In addition, he functioned for a time as visiting surgeon on the Columbia division at Bellevue Hospital, visiting surgeon at Harlem Hospital, and consultant to the U.S. Naval Hospital in St. Albans. Art served as president of the New York Society for Cardiovascular Surgery and treasurer of the North American Chapter of the International Society for Cardiovascular Surgery. His eminent contributions to vascular surgery prompted invitations over the years to present distinguished lectures and perform surgical demonstrations overseas in Brazil, Chile, Peru, France, and England. The Association of the Alumni of the College of Physicians and Surgeons, Columbia University, presented him a medal honoring Lifetime Achievements in Medicine. In 1978 Art helped to initiate the Blakemore Award, presented each June to the senior surgical resident at Presbyterian judged to have been most productive in research during the years of residency. Faced with a chronic respiratory ailment, Voorhees retired from active practice in 1983 at age 61 years bearing the title of professor emeritus of clinical surgery, Columbia University College of Physicians and Surgeons. After his retirement, Art and Mags moved to their retreat home in West Stockbridge, situated in the Berkshire Mountains of western Massachusetts (Fig. 5). There they were able to enjoy common interests:
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gardening, music at Tanglewood, and visits by their children, Stephen, Jefferson, and Evelyn. Always one to "build a better mousetrap," Art found relaxation in his workshop, repairing and refinishing. During annual vacations to a favorite dude ranch in southern Arizona, it became evident that Art's lung problem was improved by the desert air. For that reason, they moved from West Stockbridge to Albuquerque in 1990. When I informed Art last year that his career would be the subject of this presentation, he was most flattered, responding that any inconveniences of his limited health had been "more than compensated by the joy of friends encouraging me to reminisce. What an ego boost!" In July 1991, as he and I were planning our next meeting, he anticipated, "Hopefully next year we can have a great reunion to the tunes of the Boston Symphony Orchestra at Tanglewood." Unfortunately that opportunity was never met, because Art died on May 12, 1992, at age 70 years of a metastatic brain tumor. The place of Arthur Voorhees in the history of medicine is secure. Keith Reemtsma, chairman of the Department of Surgery at Columbia University, in a presidential address to the American Association for Thoracic Surgery, credited Art as the One who "discovered the secret that made vascular grafts possible. "46 Looking back on his singular contribution, Art conceded that the initial observation had been his but unselfishly acknowledged that the outcome had been the summation of the efforts of many. 2 He inspired us and all future vascular surgeons with this challenge: "It would be a mistake to think that the development of new products, new capabilities, and new approaches is in a phase of diminishing returns. Significant problems and challenges are still there, waiting for the confluence of imaginative brains and technology. "3 We appreciate Margaret R. Voorhees for her invaluable assistance in the preparation of this manuscript and Harriet Eason and Cathy Alden for their editorial contributions. Drs. CoUin J. Weber and J. B. Price' read the manuscript critically and made important contributions.
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REFERENCES 1. Szilagyi DE. Perspectives in vascular grafting. In: Sawyer PN, Kaplitt MJ, eds. Vascular grafts. New York: AppletonCentury-Crofts, 1978:23-6. 2. Voorhees AB Jr. The origin of the permeable arterial prosthesis: a personal reminiscence. Surg Rounds 1988;2: 7984. 3. Voorhees AB Jr. The development of arterial prostheses: a personal view. Arch Surg 1985;120:289-95. 4. Voorhees AB Jr, Jaretzki A HI, Blakemore AH. The use of
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tubes constructed from Vinyon 'oN" cloth in bridging arterial defects: a preliminary report. Ann Surg 1952;135:332-6. Guthrie CC. End-results of arterial restitution with devitalized tissue. JAMA 1919;73:186-7. Barker WF. A history of vascular surgery. In: Moore WS, ed. Vasoalar surgery: a comprehensive review. 3rd ed. Philadelphia: WB Saunders, 1991:1-19. D6rfler J. Ueber Arteriennaht. Beitt Klin Chir 1899;25:781825. Friedman SG. The arterial prosthesis: Arthur Voorhees. In: A history of vascular surgery. Mt Kisco: Futura Publishing, 1989:131-9. Voorhees AB, Baker HJ, Pulaski EJ. Reactions of albino rats to injections of dextran. Proc Soc Exp Biol Med 1951;76: 254-6. Voorhees AB Jr. How it all began. In: Sawyer PN, Kaplitt MJ, eds. Vascular grafts. New York: Appleton-Century-Crofts, 1978:3-4. Blakemore AH, Lord JW Jr. A nonsuture method of blood vessel anastomosis: experimental and clinical study. JAMA 1945;127:685-753. Levin SM. Reminiscences and ruminations: vascular surgery then and now. Am J Surg 1987;154:158-62. Blakemore AH, Voorhees AB Jr. The use of tubes constructed from Vinyon "N" cloth in bridging arterial defects: experimental and clinical. Ann Surg 1954;140:324-34. Blakemore AH, Voorhees AB Jr. Aneurysm of the aorta: a review of 365 cases. Angiology 1954;5:209-31. Dale WA. A surgeon's primer of errors. J VAsc SURG 1990; 12:99-104. Rob CG. Introduction. In: Rob CG, ed. The classics of vascular surgery. Medford: Apollo Press, 1981:III-V. Callow AD. Historical development of vascular grafts. In: Sawyer PN, Kaplitt MJ, eds. Vascular grafts. New York: Appleton-Century-Crofts, 1978:5-22. Deterling RA Jr, Bhonslay SB. An evaluation of synthetic materials and fabrics suitable for blood vessel replacement. Surgery 1955;38:71-91. Creech O Jr, Deterling RA Jr, Edwards S, Julian OC, Linton RR, Shumacker H Jr. Vascular prostheses: report of the Committee for the Study of Vascular Prostheses of the Society for Vascular Surgery. Surgery 1957;41:62-80. Gross RE, Bill AH, Peirce EC. Methods for preservation and transplantation of arterial grafts: observations on arterial grafts in dogs. Report of transplantation of preserved arterial grafts in 9 human cases, Surg Gynecol Obstet 1949;88:689701. Szilagyi DE, McDonald RT, Smith RF, Whitcomb JG. Biologic fate of human arterial homografts. Arch Surg 1957; 75: 506-29. Wangensteen SL, Orahood RC, Voorhees AB Jr, Smith RB HI, Healey WV. Intragastric cooling in the management of hemorrhage from the upper gastrointestinal tract. Am J Surg 1963;105:401-12. Smith RB III, Voorhees AB, Davidson EA, Barker HG. Toxic effects of ingested whole proteins and amino acid mixtures in patients with portal systemic encephalopathy. Surg Forum 1964; 15:98-9. Whipple AO. The problem of portal hypertension in relation to the hepatosplenopathies. Ann Surg 1945;122:449-75. Voorhees AB Jr. Management of portal hypertension. Bull NY Acad Med 1959;35:223-30. Voorhees AB Jr, Blakemore AH. Superior mesenteric vein-
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-inferior vena cava shunt in treatment of portal hypertension. Surgery 1963;54:559-62. Price JB Jr, Voorhees AB Jr, Britton RC. Operative hemodynamic studies in portal hypertension: significance and limitations. Arch Surg 1967;95:843-52. Britton RC, Voorhees AB Jr, Price IB lr. Selective portal decompression. Surgery 1970;67:104-13. Voorhees AB Jr, Price JB Jr, Britton RC. Portasystemic shunting procedures for portal hypertension: twenty-six year experience in adults with cirrhosis of the liver. Am J Surg 1970;119:501-5. Garrett JC, Voorhees AB ~[r, Sommers SC. Renal failure following portasystemic shunt in patients with cirrhosis of the liver. Ann Surg 1970;172:218-25. Voorhees AB Jr, Price JB Jr. Extrahepatic portal hypertension: a retrospective analysis of 127 cases and associated clinical implications. Arch Surg 1974;108:338-41. Voorhees AB Jr. Portal hypertension as I see it. In: Child CG III, ed. Major problems in clinical surgery. 14th ed. Philadelphia: WB Saunders, 1974:60-77. Voorhees AB Jr, Harris RC, Britton RC, Price JB Jr, Sanmlli TV. Portal hypertension in children: 98 cases. Surgery 1965;58:540-9. Voorhees AB Jr, Chaitman E, Schneider S, Nicholson JF, Kornfeld DS, Price JB Jr. Portal-systemic encephalopathy in the noncirrhotic patient: effect of portal-systemic shunting. Arch Surg 1973;107:659-63. Price JB Jr, McCullough W, Peterson L, Brirton RC, Voorhees AB. Determinants of ammonia tolerance in animals with and without portal systemic shunting. Surgery 1966; 60:701-9. Price JB Jr, Voorhees AB Jr, Britton RC. Partial hepatic autotransplantation with complete revascularization in the dog. Arch Surg 1967;95:59-64.
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37. Reilly JW, Price JB Jr, Sawada M, Davidson DB, Voorhees AB Jr. Effect of increased outflow resistance on retrograde portal flow and hepatic metabolic efficiency following a side-to-side portacaval shunt. Surgery 1969;66:1026-33. 38. Price JB Jr, Takeshige K, Parsa M, Voorhees AB Jr. Characteristics of animals maintained without splanchnic portal organs. Surgery 1971;70:768-77. 39. Max MH, Price JB Jr, Takeshige K, Voorhees AB Jr. The role of factors of portal origin in modifying hepatic regeneration. J Surg Res 1972;12:120-3. 40. Price JB Jr, Takeshige K, Max MH, Voorhees AB Jr. Glucagon as the portal factor modifying hepatic regeneration. Surgery 1972;72:74-82. 41. Whittemore AD, Kasuya M, Voorhees AB Jr, Price JB Jr. Hepatic regeneration in the absence of portal viscera. Surgery 1975;77:419-26. 42. Greisler HP, Voothees AB Jr, Price JB Jr. The nonportal origin of the factors initiating hepatic regeneration. Surgery 1979;86:210-7. 43. Treat MR, Weld FM, White IV, et al. Effect of CO2 laser on the luminal surface of blood vessels in vivo. Lasers Surg Med 1983;3:247-54. 44. White J-V,BenvenistyAI, Reemtsma K, et al. Simple methods for direct antibiotic protection of synthetic vascular grafts. J V~sc SURG 1984;1:372-80. 45. Greisler HI', Rim DU, Price JB, Voorhees AB Jr. Arterial regenerative activity after prosthetic implantation. Arch Surg 1985;120:315-23. 46. Reemtsma K. Discovery in surgery: reflections on a golden age (presidential address). J Thorac Cardiovasc Surg 1991; 102:653-6.
Submitted Feb. 2, 1993; accepted Feb. 8, 1993.
Arthur B. Voorhees, Jr.: Pioneer vascular surgeon Robert B. Smith III, ME), Atlanta, Ga.
'(It is a well-known truism that the development of vascular surgery would have been unthinkable without the introduction of clinically serviceable arterial substitutes. "1
- D . E. Szilagyi This presidential address to the Southern Association for Vascular Surgery allows me the opportunity to pay posthumous tribute to my mentor, Arthur B. Voorhees, Jr., one of the pioneers in vascular surgery. Every practitioner of our specialty knows that the era of modern vascular surgery began with Voorhees' monumental innovation in 1952, the introduction of the prosthetic vascular graft. How many know of the circumstances surrounding that seminal contribution or the many other remarkable achievements of this exemplary surgeon-teacherinvestigator? Aided by information and memorabilia provided by his wife of 47 years, Margaret, I hope to provide an accurate, revealing account of a truly great physician. Arthur Bostwick Voorhees, Jr., was born near Philadelphia in Moorestown, New Jersey, in 1921. His lineage can be traced to Stephen Coert van Voorhees, an early Dutch settler in New Amsterdam, whose farm occupied what is the site of Trinity Church in present-day lower Manhattan. During World War I, Art's father was stationed at an army post in Anniston, Alabama, where he met and married Margaret Crowe, the daughter of Jefferson From the Division of Vascular Surgery, Emory University School of Medicine, Atlanta. Presented at the Seventeenth Annual Meeting of the Southern Association for Vascular Surgery, Fort Lauderdale, Fla., Jan. 29-31, 1993. Reprint requests: Robert B. Smith HI, MD, the Emory Clinic, 1365 Clifton Rd. N.E., Atlanta, GA 30322. J VASCSURG1993;18:341-8. Copyright © 1993 by The Society for Vascular Surgery and International Society for CardiovascularSurgery, North American Chapter. 0741-5214/93/$1.00 + .10 24/6]46367
Davis Crowe, a country doctor in Jacksonville, Alabama. After the war the Voorhees returned to the family home in Moorestown, where Art was born and reared. Art was greatly influenced by his modest, gentle father whose ingenious ways of solving problems and fixing things set a pattern he would emulate throughout his life. From early on, both parents urged Art to seek advanced schooling and contribute to his fellow man, perhaps in the field of medicine. All of his schooling was at Moorestown Friends School, an established, traditional Quaker day school. He performed well academically and was an accomplished athlete in baseball and soccer, serving as captain of the soccer team and president of the Varsity Club before his graduation in 1940. When the time came to select a college, his mother, still an unreconstructed southerner, insisted that Art attend a southern university to ensure his proper education. Attracted to the legacy of his boyhood idol, Thomas Jefferson, Art chose the University of Virginia in Charlottesville. There he found a highly competitive academic climate, where he was no longer the scholastic star that he had been in Moorestown. He struggled with languages in the freshman year but excelled in mathematics and physics. Eventually he chose biology to be his major, because he was determined to seek a career in medicine. To remain in school, Art worked at a variety of jobs but also found time to participate in a number of extracurricular pursuits, including drawing cartoons for the college newspaper. His talent for art became useful later in his career when he personally prepared many of the illustrations for his medical publications. Achieving honors in biology at the University of Virginia, Art was selected after his junior year of college for early acceptance into medical school as a participant in a program sponsored by the Army Specialized Training Corps. In 1943, at the peak of 341
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Fig. 1. Wedding ,photograph of Arthur and Margaret Voorhees, Moorestown, New Jersey, December 22, 1945 (provided by Margaret R. Voorhees).
World War II, he entered the College of Physicians and Surgeons of Columbia University. The wartimeaccelerated program at Columbia University was highly stressful for the students, who were subjected to a rigorous 12 month-a-year, continuous curriculum. Art found anatomy to be particularly difficult but later rallied and rose to the upper quarter of his class by the time of graduation. He was drawn to surgery under the aegis of Dr. Hugh Auchincloss, a senior surgeon for whom he had great admiration and affection. During the years since his graduation from high school, Art had courted from a distance Margaret L. Roberts ("Mags"), who had been 2 years behind him in high school. Mags' Quaker family, also well established in Moorestown, was engaged in managing the company that manufactured the renowned Flexible Flyer sled. She attended Wheaton College in Massachusetts, and she and Art were contemplating marriage after his graduation from medical school. Those plans were accelerated when Art had a near-fatal sailing incident, deciding after his rescue that life with Mags was too precious to risk further
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delays. To facilitate a midsemester wedding, Mags transferred to Barnard College in New York City and they were married during Art's senior year (Fig. 1). After graduation from medical school in 1946, Art served a straight surgical internship at the Columbia-Presbyterian Hospital of New York. During that year Arthur H. Blakemore, famed portal hypertension surgeon at Presbyterian, observed in the young trainee characteristics of inquisitiveness and determination and recognized in him the potential for a promising career in research. He offered him a 1-year research fellowship during the interim before Art was obligated to enter active military duty. That year, 1947 to 1948, marked the beginning of a long and productive relationship between Art and "Blake," as Dr. Blakemore was known by his associates. Later, Art, in tribute to his mentor, described him as "one of the greats in the history of vascular surgery... [who] created the environment in which the development of the prosthesis took place. ''2 Under Blakemore's direction, Art was assigned the task of developing in the animal laboratory a mitral valve replacement fashioned from a segment of homograft inferior vena cava. The procedure was technically demanding and complex, requiring blind placement of silk support sutures to function as "chordae tendineae" for the implanted valve. In the spring of 1948, while performing an autopsy on one of the animals several months after implantation, Art observed that an errant silk suture bridging the ventricular cavity was coated with a glistening film of what appeared to be endocardium. In a moment of inspiration that was subsequently described by Art as serendipitous, he speculated that "a piece of cloth might react in a similar way. "2'3 Documenting the event, Voorhees later wrote, "As an outgrowth of this observation it was conceived that if arterial defects were bridged by prostheses constructed of a fine mesh cloth, leakage of blood through the walls of the prosthesis would be terminated by the formation of fibrin plugs and would thus allow the cloth tube to conduct arterial flow."4 Art reported that he had been uninformed at that time of Guthric's suggestion 30 years earlier that an implant need serve only as scaffolding for ingrowth of the host's tissues. 5 It appears that he had also been unaware of a much earlier report in the German literature that had described silk sutures in the lumen of an artery having become encapsulated by a fine veil coating. 6,7 When Art's notion of a cloth prosthesis was presented to Blake, he was equally enthusiastic about its possibilities, urging him to "try it, boy. ''2 Time remaining in the fellowship allowed for only one attempt, with a cloth tube fabricated on his wife's
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Fig. 2. Vinyon-N prostheses prepared by Voorhees for use in early animal experiments (provided by Arthur B. Voorhees).
sewing machine from a silk handkerchief.8 The tube functioned for 1 hour in the acute dog model before the animal died of exsanguination, just long enough to offer encouragement. Soon thereafter, Art had to report to the Surgical Research Unit at Brooke Army Medical Center in San Antonio to begin a 2-year tour as a research associate. During that assignment, he had limited opportunity to pursue arterial substitutes, because the majority of his efforts were devoted to the development of more effective plasma expanders, burn management, and surgical shock problems. 9 Eventually, however, he was able to resume his experiments, using nylon parachute cloth as an aortic prosthesis. 2,1° One of six dogs receiving implants survived for 1 month and had a patent graft at autopsy. 8 The project, although still promising, was hampered by an inability to obtain satisfactory histologic studies on explanted grafts. Later, musing on the positive outcome of that handicap because it afforded him time instead to reflect on the specifications necessary for a successful biologic implant, Art wrote, "The cloth had to be strong, inert, stable, of the right porosity, supple, and yet easily traversed by a fine needle."2 On renaming to Presbyterian Hospital in 1950 to begin his surgical residency, Art resumed his work on
vascular grafts in the laboratory of Dr. Blakemore. He met an orthopedic resident, James Wallace Blunt, Jr., who was working on a synthetic tendon project and therefore was knowledgeable about suitable plastic fibers. Blunt suggested that the fabric Vinyon-N (The Union Carbon and Carbide Corp., Danbury, Conn. ) might be ideal for Art's needs.4 The Union Carbon and Carbide Corporation was contacted, which donated its last bolt of 144 x 90 strands per square inch, Vinyon-N spinnaker cloth for the project. Vinyon-N had little commercial value, because it was too inert to be dyed, but the synthetic fiber met Art's criteria. Using Vinyon-N, he fashioned a variety of tubular prostheses on his wife's sewing machine and implanted them into the abdominal aortas of mongrel dogs. The ends of the grafts were turned back French-cuffstyle to minimize fraying, and anastomoses were performed with continuous silk sutures4 or vitallium cuffs designed earlier by Blakemore and Lord n (Fig. 2). Early implantations were tedious and complicated: "We were often hard pressed to separate our technical ineptitude, the perversity of our handcrafted materials, mad the variations of host response, in analyzing our end results. "3 When consistent success was finally achieved in animal survival, the project moved
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Fig. 3. Photograph taken in 1957 of Voorhees and experimental dog 627A, "a lovely animal" that had received an aortic prosthesis in 1951 (provided by Margaret R. Voorhees).
Fig. 4. Vinyon-N graft harvested from experimental dog 627A in 1959, 8 years after implantation (provided by Margaret R. Voorhees). forward in earnest, guided and encouraged by Blakemore and George H. Httmphreys, chairman of the Department of Surgery. Art credited a number of colleagues for their contributions to the endeavor, specifically Daisy Mapes, technical head of the animal operating room, and Rafaele Lattes and Nathan Lane, pathologists who assisted in histologic studies of graft healing. 2,3 By the end of 1950, implants had been placed in 30 dogs, three quarters of which survived until
subsequent graft removal and examination. Animals were sacrificed on a predetermined schedule, ranging from hours to months and eventually up to 8 years, to provide a time-related portrayal of graft healing (Figs. 3 and 4). Other surgical residents joined the Vinyon project, Alfred Jaretzki in 19512 and Sheldon Levin 12 in 1952, providing impetus to the investigation when Art had to return to clinical duties? By mid-1951, sufficient data had been collected to prepare an optimistic preliminary report for the New
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York Society for Cardiovascular Surgery, resulting in the classic article published in theAnnals of Surgery in March 1952, "The Use of Tubes Constructed From Vinyon "N" Cloth in Bridging Arterial Defects."~ In that report the coauthors, Voorhees, Jaretzki, and Blakemore, reviewed their experience with the first 15 graft implants. Eleven dogs had been killed or had died: 5 of the 11 grafts were completely or partially thrombosed and the remainder were fully patent, with their internal surfaces covered by a thin, transparent film that on microscopic examination consisted of "multiple layers of flattened cells and collagen fibers strikingly similar to the architecture of the normal aorta with the notable absence of elastic and smooth muscle elements."4 As a result of this noteworthy contribution, Art received his first special recognition, a cash award from the New York Academy of Medicine, the Alexander Bowen-Harlow Brooks Scholar Award. February 1953, when Art was a senior resident, marked the initiation of synthetic graft implantations in humans at Columbia-Presbyterian Medical Center. 12,13 He and Blakemore had been exploring a patient with a ruptured abdominal aortic aneurysm. After proximal control had been accomplished, Dr. Blakemore was dismayed to learn that there was no aortic homograft available for implantation. Art left the operating room, fashioned a bifurcation graft of Vinyon cloth, gave it to the nurse to be autoclaved, and returned to the .operative field. After the graft had been placed and the clamps removed, the conduit functioned, and although the patient died after surgery of a generalized clotting deficiency, the prosthesis was found to be patent at the time of autopsy. Encouraged by that initial experience, several weeks later the team electively inserted another Vinyon graft in a patient with an abdominal aortic aneurysm, and that patient survived. During this exciting early period, Art prepared each prosthesis o n Mags' Necchi sewing machine, which he eventually moved to the hospital for greater convenience. Before a planned operation, he would fabricate an assortment of sizes and configurations to allow'a custom fit to the host's vessels. During the ensuing 10 months, 16 additional aneurysms were treated with cloth prostheses, and an astounding 56% of the first 18 patients survived. Art ascribed the deaths in the initial experience to an inability to deal successfully with patients in extremis, whose severely diseased arteries resulted too frequently in disastrous intraoperative hemorrhage? sxs To their credit as highly ethical physicians, Art and his colleagues made no effort to obtain patent rights on their revolution-
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ary product, maintaining that it should be used freely for the benefit of patients. In March 1954 Art reviewed the animal model data at a symposium on vascular transplants sponsored by the National Research Council. Other panelists included Robert Gross, Charles Hufnagel, Harris Shumacker, and Michael DeBakey, all of whom were interested in the new field of synthetic grafts. It was evident that "a new era had indeed begun in vascular surgery."12 One month later both the experimental work and early results in humans were presented by Blakemore and Voorhees at the American Surgical Association meeting in Cleveland and published that year in theAnnals of Surgeryfl 3 In discourse about that presentation, Harris Shumacker and Robert Linton were complimentary of the work; looking back near the end of his career, Andrew Dale described it as " . . . one of the most important papers ever presented to the surgical world. "is Charles Rob echoed that praise when he wrote, '~Fhis advance pioneered by a resident, Arthur Voorhees, has changed arterial surgery in a most significant way and constitutes a great step forward. "16 Other prosthetic materials were rapidly introduced by an expanding industry, and surgical meetings and journals focused on textile characteristics, debating the relative merits of porosity, denier, taffeta, crimp, and other elements of fiber fabrication. 17,1s Vinyon-N gave way to competitive fibers with more favorable physical properties, including Orlon, Teflon, nylon, and Dacron; arterial homografts soon fell into disfavor because of their short supply and history of late deterioration. 19"z~Meanwhile, Art completed his surgical residency in 1955 and joined the faculty of Columbia-Presbyterian. as instructor in surgery and assistant attending surgeon, working in close association with his benefactor, Dr. Blakemore. Together they maintained a strong interest in graft experimentation, inserting 50 braided tubes of Orlon or Vinyon by 1957, with only two delayed thromboses, both instances of poor runoff. In addition to Blakemore and Voorhees, Presbyterian Hospital boasted a number of other excellent surgeons engaged in vascular surgery during that era, including Shivaji Bhonslay, Ralph Deterling, and Ferdinand McAllister. I first met Art Voothees when I was a straight surgical intern at Presbyterian Hospital in 1957. He impressed young house officers as a master technical surgeon, bright intellect, and compassionate, ethical physician. A popular teacher, he had an unusual rapport with both students and residents. During the years of my surgical residency, Art became a personal
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Fig. 5. Arthur B. Voorhees, after retirement, engaged in a favorite avocation, bird watching in the Berkshire Mountains (provided by Margaret R. Voorhees). friend, advisor, and role model. I was fortunate to participate with him in several clinical research projects and spent many hours in the operating room under his patient direction. 22,23 Our friendship continued after I completed training and returned to Atlanta in 1966 to join the faculty of the Emory University School of Medicine. Guided by the interests of Blakemore and the traditions of Allen O. Whipple and the Spleen Clinic at Presbyterian Hospital, Art naturally became involved in the management of portal hypertension and its complications, especiaUv the metabolic effects of portasystemic shunting. 24 TT~ r~,. collaborated with Blakemore on refinement of the SengstakenBlakerfiore esophageal tamponade balloon (Davol, Inc., Cranston, R.I.) and systematically reviewed and periodically reported results of the portal hypertension surgical experience at Presbyterian, still among the most extensive in the world. 2s-32 His article in 1964 describing 103 definitive operations on children with portal hypertension was a benchmark contribution to the field. 33 After careful follow-up, Art raised a caution flag 9 years later when he realized that a significant number of children who had
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undergone surgically created portal shunts had had delayed neuropsychiatric abnormalities) 4 In a personal commentary concerning this important observation, he later wrote, "As I look back, I think of this as my most interesting avenue of research. It opened many doors which I was ill-equipped to explore." After Dr. Blakemore's retirement, Art became director of the animal laboratory at Columbia, sponsored by the Fund for the Advancement of Blood Vessel Surgery, a resource largely endowed by patient contributions. As director, Art was instrumental in designating the facility as the Arthur H. Blakemore Research Laboratory. There, a variety of important projects were undertaken, frequently sparked by Voorhees' own creativity and vision. He and his faculty coworkers, John B. Price and Richard C. Britton, directed young investigators in studying arterial substitutes, hepatic regeneration, ammonia intoxication, portal flow dynamics, laser effects on blood vessels, and antibiotic protection of synthetic vascular graftsfi -4s During his 28 years on the Columbia faculty, Art held influential teaching, research, and administrative positions in the Department of Surgery. He rose to the rank of professor of clinical surgery in 1970 and served as chief of the Vascular Surgery Service. In addition, he functioned for a time as visiting surgeon on the Columbia division at Bellevue Hospital, visiting surgeon at Harlem Hospital, and consultant to the U.S. Naval Hospital in St. Albans. Art served as president of the New York Society for Cardiovascular Surgery and treasurer of the North American Chapter of the International Society for Cardiovascular Surgery. His eminent contributions to vascular surgery prompted invitations over the years to present distinguished lectures and perform surgical demonstrations overseas in Brazil, Chile, Peru, France, and England. The Association of the Alumni of the College of Physicians and Surgeons, Columbia University, presented him a medal honoring Lifetime Achievements in Medicine. In 1978 Art helped to initiate the Blakemore Award, presented each June to the senior surgical resident at Presbyterian judged to have been most productive in research during the years of residency. Faced with a chronic respiratory ailment, Voorhees retired from active practice in 1983 at age 61 years bearing the title of professor emeritus of clinical surgery, Columbia University College of Physicians and Surgeons. After his retirement, Art and Mags moved to their retreat home in West Stockbridge, situated in the Berkshire Mountains of western Massachusetts (Fig. 5). There they were able to enjoy common interests:
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gardening, music at Tanglewood, and visits by their children, Stephen, Jefferson, and Evelyn. Always one to "build a better mousetrap," Art found relaxation in his workshop, repairing and refinishing. During annual vacations to a favorite dude ranch in southern Arizona, it became evident that Art's lung problem was improved by the desert air. For that reason, they moved from West Stockbridge to Albuquerque in 1990. When I informed Art last year that his career would be the subject of this presentation, he was most flattered, responding that any inconveniences of his limited health had been "more than compensated by the joy of friends encouraging me to reminisce. What an ego boost!" In July 1991, as he and I were planning our next meeting, he anticipated, "Hopefully next year we can have a great reunion to the tunes of the Boston Symphony Orchestra at Tanglewood." Unfortunately that opportunity was never met, because Art died on May 12, 1992, at age 70 years of a metastatic brain tumor. The place of Arthur Voorhees in the history of medicine is secure. Keith Reemtsma, chairman of the Department of Surgery at Columbia University, in a presidential address to the American Association for Thoracic Surgery, credited Art as the One who "discovered the secret that made vascular grafts possible. "46 Looking back on his singular contribution, Art conceded that the initial observation had been his but unselfishly acknowledged that the outcome had been the summation of the efforts of many. 2 He inspired us and all future vascular surgeons with this challenge: "It would be a mistake to think that the development of new products, new capabilities, and new approaches is in a phase of diminishing returns. Significant problems and challenges are still there, waiting for the confluence of imaginative brains and technology. "3 We appreciate Margaret R. Voorhees for her invaluable assistance in the preparation of this manuscript and Harriet Eason and Cathy Alden for their editorial contributions. Drs. CoUin J. Weber and J. B. Price' read the manuscript critically and made important contributions.
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REFERENCES 1. Szilagyi DE. Perspectives in vascular grafting. In: Sawyer PN, Kaplitt MJ, eds. Vascular grafts. New York: AppletonCentury-Crofts, 1978:23-6. 2. Voorhees AB Jr. The origin of the permeable arterial prosthesis: a personal reminiscence. Surg Rounds 1988;2: 7984. 3. Voorhees AB Jr. The development of arterial prostheses: a personal view. Arch Surg 1985;120:289-95. 4. Voorhees AB Jr, Jaretzki A HI, Blakemore AH. The use of
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tubes constructed from Vinyon 'oN" cloth in bridging arterial defects: a preliminary report. Ann Surg 1952;135:332-6. Guthrie CC. End-results of arterial restitution with devitalized tissue. JAMA 1919;73:186-7. Barker WF. A history of vascular surgery. In: Moore WS, ed. Vasoalar surgery: a comprehensive review. 3rd ed. Philadelphia: WB Saunders, 1991:1-19. D6rfler J. Ueber Arteriennaht. Beitt Klin Chir 1899;25:781825. Friedman SG. The arterial prosthesis: Arthur Voorhees. In: A history of vascular surgery. Mt Kisco: Futura Publishing, 1989:131-9. Voorhees AB, Baker HJ, Pulaski EJ. Reactions of albino rats to injections of dextran. Proc Soc Exp Biol Med 1951;76: 254-6. Voorhees AB Jr. How it all began. In: Sawyer PN, Kaplitt MJ, eds. Vascular grafts. New York: Appleton-Century-Crofts, 1978:3-4. Blakemore AH, Lord JW Jr. A nonsuture method of blood vessel anastomosis: experimental and clinical study. JAMA 1945;127:685-753. Levin SM. Reminiscences and ruminations: vascular surgery then and now. Am J Surg 1987;154:158-62. Blakemore AH, Voorhees AB Jr. The use of tubes constructed from Vinyon "N" cloth in bridging arterial defects: experimental and clinical. Ann Surg 1954;140:324-34. Blakemore AH, Voorhees AB Jr. Aneurysm of the aorta: a review of 365 cases. Angiology 1954;5:209-31. Dale WA. A surgeon's primer of errors. J VAsc SURG 1990; 12:99-104. Rob CG. Introduction. In: Rob CG, ed. The classics of vascular surgery. Medford: Apollo Press, 1981:III-V. Callow AD. Historical development of vascular grafts. In: Sawyer PN, Kaplitt MJ, eds. Vascular grafts. New York: Appleton-Century-Crofts, 1978:5-22. Deterling RA Jr, Bhonslay SB. An evaluation of synthetic materials and fabrics suitable for blood vessel replacement. Surgery 1955;38:71-91. Creech O Jr, Deterling RA Jr, Edwards S, Julian OC, Linton RR, Shumacker H Jr. Vascular prostheses: report of the Committee for the Study of Vascular Prostheses of the Society for Vascular Surgery. Surgery 1957;41:62-80. Gross RE, Bill AH, Peirce EC. Methods for preservation and transplantation of arterial grafts: observations on arterial grafts in dogs. Report of transplantation of preserved arterial grafts in 9 human cases, Surg Gynecol Obstet 1949;88:689701. Szilagyi DE, McDonald RT, Smith RF, Whitcomb JG. Biologic fate of human arterial homografts. Arch Surg 1957; 75: 506-29. Wangensteen SL, Orahood RC, Voorhees AB Jr, Smith RB HI, Healey WV. Intragastric cooling in the management of hemorrhage from the upper gastrointestinal tract. Am J Surg 1963;105:401-12. Smith RB III, Voorhees AB, Davidson EA, Barker HG. Toxic effects of ingested whole proteins and amino acid mixtures in patients with portal systemic encephalopathy. Surg Forum 1964; 15:98-9. Whipple AO. The problem of portal hypertension in relation to the hepatosplenopathies. Ann Surg 1945;122:449-75. Voorhees AB Jr. Management of portal hypertension. Bull NY Acad Med 1959;35:223-30. Voorhees AB Jr, Blakemore AH. Superior mesenteric vein-
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-inferior vena cava shunt in treatment of portal hypertension. Surgery 1963;54:559-62. Price JB Jr, Voorhees AB Jr, Britton RC. Operative hemodynamic studies in portal hypertension: significance and limitations. Arch Surg 1967;95:843-52. Britton RC, Voorhees AB Jr, Price IB lr. Selective portal decompression. Surgery 1970;67:104-13. Voorhees AB Jr, Price JB Jr, Britton RC. Portasystemic shunting procedures for portal hypertension: twenty-six year experience in adults with cirrhosis of the liver. Am J Surg 1970;119:501-5. Garrett JC, Voorhees AB ~[r, Sommers SC. Renal failure following portasystemic shunt in patients with cirrhosis of the liver. Ann Surg 1970;172:218-25. Voorhees AB Jr, Price JB Jr. Extrahepatic portal hypertension: a retrospective analysis of 127 cases and associated clinical implications. Arch Surg 1974;108:338-41. Voorhees AB Jr. Portal hypertension as I see it. In: Child CG III, ed. Major problems in clinical surgery. 14th ed. Philadelphia: WB Saunders, 1974:60-77. Voorhees AB Jr, Harris RC, Britton RC, Price JB Jr, Sanmlli TV. Portal hypertension in children: 98 cases. Surgery 1965;58:540-9. Voorhees AB Jr, Chaitman E, Schneider S, Nicholson JF, Kornfeld DS, Price JB Jr. Portal-systemic encephalopathy in the noncirrhotic patient: effect of portal-systemic shunting. Arch Surg 1973;107:659-63. Price JB Jr, McCullough W, Peterson L, Brirton RC, Voorhees AB. Determinants of ammonia tolerance in animals with and without portal systemic shunting. Surgery 1966; 60:701-9. Price JB Jr, Voorhees AB Jr, Britton RC. Partial hepatic autotransplantation with complete revascularization in the dog. Arch Surg 1967;95:59-64.
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37. Reilly JW, Price JB Jr, Sawada M, Davidson DB, Voorhees AB Jr. Effect of increased outflow resistance on retrograde portal flow and hepatic metabolic efficiency following a side-to-side portacaval shunt. Surgery 1969;66:1026-33. 38. Price JB Jr, Takeshige K, Parsa M, Voorhees AB Jr. Characteristics of animals maintained without splanchnic portal organs. Surgery 1971;70:768-77. 39. Max MH, Price JB Jr, Takeshige K, Voorhees AB Jr. The role of factors of portal origin in modifying hepatic regeneration. J Surg Res 1972;12:120-3. 40. Price JB Jr, Takeshige K, Max MH, Voorhees AB Jr. Glucagon as the portal factor modifying hepatic regeneration. Surgery 1972;72:74-82. 41. Whittemore AD, Kasuya M, Voorhees AB Jr, Price JB Jr. Hepatic regeneration in the absence of portal viscera. Surgery 1975;77:419-26. 42. Greisler HP, Voothees AB Jr, Price JB Jr. The nonportal origin of the factors initiating hepatic regeneration. Surgery 1979;86:210-7. 43. Treat MR, Weld FM, White IV, et al. Effect of CO2 laser on the luminal surface of blood vessels in vivo. Lasers Surg Med 1983;3:247-54. 44. White J-V,BenvenistyAI, Reemtsma K, et al. Simple methods for direct antibiotic protection of synthetic vascular grafts. J V~sc SURG 1984;1:372-80. 45. Greisler HI', Rim DU, Price JB, Voorhees AB Jr. Arterial regenerative activity after prosthetic implantation. Arch Surg 1985;120:315-23. 46. Reemtsma K. Discovery in surgery: reflections on a golden age (presidential address). J Thorac Cardiovasc Surg 1991; 102:653-6.
Submitted Feb. 2, 1993; accepted Feb. 8, 1993.