Barney Brooks: The Unrecognized Hero behind 100 Years of Peripheral Angiography

Many factors and individuals have contributed to the development of vascular surgery as we know it today. The classic contributions of Carrel, Matas, deTakats, Crafoord, Blalock, Gross, Julian, Shumacher, DeBakey, Linton, and others too numerous to mention are examples. However, one of the most important factors in the rapid development of vascular surgery over the last few decades has been the widespread application of arteriography in the study of patients with suspected arterial disease. Before 1952, most physicians considered arteriosclerosis to be a generalized systemic disease for which little or nothing could be done. In the initial days, arteriography was considered to be meddlesome, unwarranted, and dangerous. Following the reports of Oudot and of DuBost and his associates of successful resection and homograft replacement of the abdominal aorta, interest in vascular surgery skyrocketed.[1] This interest in vascular surgery provided a tremendous impetus for the development of improved angiographic techniques and safer contrast media. Arteriograms were performed with an ever-increasing frequency. It soon became apparent that while arteriosclerosis is a generalized disease, it also is often characterized by short, segmental occlusive lesions amenable to surgical correction. Today as we see a tremendous growth in the endovascular management for vascular diseases, and almost all vascular issues can be safely treated with endovascular technique, its time to celebrate 100 years of arteriography – the basis of all the progress in endovascular sciences. Most importantly to remember and appreciate Barney Brooks, who started and did the first peripheral angiogram through the femoral artery in 1924 [Figure 1].Figure 1: The first peripheral angiogramIn 1895, Roentgen announced the discovery of X-rays. Over the next 28 years, there were many reports of arteriograms done in cadavers and amputated extremities, as well as animal studies. In 1923, Sicard and Forestier injected iodized poppyseed oil into the antecubital vein of a patient and, with the fluoroscope, observed the flow of the medium through the heart and pulmonary arteries. Later in 1923, Berberich and Hirsch reported the first brachial arteriograms in man; strontium bromide was the contrast medium.[2] They were interested in using this procedure to study the physiology and anatomy of the circulatory system in man. In 1924, unaware of the German experience, Barney Brooks reported three cases of femoral arteriography. Sodium iodide was the contrast medium [Figure 2]. He used the procedure to help determine whether a lower extremity should be amputated and, if so, the proper level of amputation. The angiography by Brooks used sodium iodide as a contrast agent, although the injection of sodium iodide into the arteries caused severe vascular pain and required general anesthesia.[3] This was the first reported use of arteriography to determine how a patient should be treated and was the birth of clinical angiography.Figure 2: Barney BrooksTHE FIRST PERIPHERAL ANGIOGRAPHY In his technique, he described using intra-arterial injection of a solution of sodium iodide and roentgen-ray photography. The solution injected is prepared by dissolving 100 g of sodium iodide crystals in 100 cc of distilled water. The solution is sterilized in the autoclave and is always used soon after its preparation. The solution should be colorless or very faintly yellowish. A solution that shows any considerable iodine color has not been used. The entire thigh is prepared for operation. A sterile tourniquet is placed around the thigh as high as possible but is not tightened. With a local anesthetic of 0.5% procaine, the femoral artery is exposed in the proximal end of Hunter’s canal. Only enough of the artery is exposed to permit the application of a Crile artery clamp, which is not tightened. The roentgen-ray tube is placed over the knee region, and a large photographic film with a screen is placed under the knee and leg. The patient is now given nitrous oxide gas. It has been found that there is pain during the period the solution is in the artery, and the patient cannot be kept still enough to get a good roentgenogram unless a general anesthetic is used. The tourniquet proximal to the exposed artery is tightened enough to produce a filling of the veins. When the veins are full, the clamp on the artery is tightened enough to occlude the artery completely. A short interval is then allowed to elapse for the artery distal to the clamp to empty its blood. A medium-sized needle is introduced into the lumen of the artery, and 10 cc of the sodium iodide solution is injected. The roentgen-ray tube is then operated for the briefest period possible to secure a good plate. A second plate may be taken of the distal third of the leg and foot. The tourniquet is released, the clamp removed from the artery, and the gas anesthetic discontinued. The wound is then closed. His work in arteriography, which was initially limited to basic diagnostic applications, was eventually expanded with technological advancements in X-ray equipment and contrast agents. The basic principles Dr. Brooks helped develop would go on to evolve into the modern angiography techniques used in cardiology, vascular surgery, and neurology today. His work laid the foundation for what would later become modern angiography, including digital subtraction angiography, which is an advanced imaging technique that enables high-quality visualization of blood vessels and surrounding structures. Unfortunately the historical records from the early 20th century when the arteriography was developed, has not preserved a wealth of information about Dr. Brooks, and remains incomplete. However, his contributions to medical imaging remain invaluable. The arteriography he pioneered continues to shape the way we understand and treat vascular conditions, solidifying his place in the annals of medical innovation, and the vascular fraternity will forever remain indebted to him for his tremendous contribution. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.