Endovascular Therapy: The Mother of All Turf Wars.

species competition. Perhaps the best example is Robert Ardrey’s “The Territorial Imperative.” We’re all familiar with images of the African watering hole surrounded by collections of various animal species mingling in defined patterns and demonstrating respect for the dominant animals. Once away from the watering hole, they only mix with their own species and an intra-species turf structure emerges. Only occasionally does an animal break out of its assigned role of dominance and submission. The hospital is the African watering hole of the health care world. Medical specialties are its species. The difference, however, is that a number of factors are causing old species to atrophy or evolve and new species to emerge. The stable structure of the vascular environment was first shaken in 1964 when Charles Dotter demonstrated the potential of a new revascularization procedure that didn’t require surgery. Charles was an extraordinarily innovative thinker who conceptualized and tried many new procedures that offered a number of potential advantages to patients. However, he was not a careful investigator in the eyes of his critics and was not successful in convincing a skeptical and powerful establishment that they should support his new ideas. It didn’t help that he told his surgical audiences that surgery would be obsolete in the near future. Dr. Dotter did, however, inspire others who looked past the early technical difficulties, lack of adequate supporting research, and overly optimistic expectations to see the fundamental implications of these developments. Continued progress was impeded, however, by: • A lack of understanding about the disease. Peripheral vascular disease was the province of the vascular surgeon whose knowledge contained shibboleths about the behavior of plaque when dilated, its propensity to embolize when manipulated, and the risk of vessel rupture or devastating wall damage if stretched. • Poor understanding about the critical attributes of the various tools and instruments of a system and procedure that might be most likely to succeed. • Lack of tools and technology to implement ideas and measure the benefits of one approach versus another. Catheters, wires, balloons, flow measurement instruments, and high-resolution arterial imaging devices were all in their infancy.