Published online before print November 28, 2013, doi: 10.3174/ajnr.A3823
AJNR 2014 35: E1

G. Guglielmi
University of Rome “La Sapienza”
Rome, Italy

F. Viñuela
UCLA School of Medicine and Medical Center, Los Angeles
Los Angeles, California

In the July 2013 issue of the American Journal of Neuroradiology an editorial appeared, authored by Dr H.J. Cloft, entitled “Capitalism and Commodities: My Two Cents.”1

In the editorial, Dr Cloft explains that nowadays “more that 20 years after the invention of the Guglielmi Detachable Coil” neurointerventional devices are “mature,” and that, for a skilled operator, an endovascular aneurysm case is routine and analogous to an appendectomy.

Dr Cloft also explains that currently our specialty has progressed to the point that “it no longer consists of a few pioneers trying to improvise new therapies by using nonapproved materials.”

After reading this editorial, I felt compelled and obliged to express my point of view and my criticism regarding these 2 questionable assertions, as well as the way in which these assertions were presented and the language used.

First, one has the right to assert that the devices we use nowadays are more “mature” than they were in the past (I doubt, however, that all the modern “approved” devices and techniques are “mature”), but one cannot assert that the endovascular treatment of brain vascular diseases (like an aneurysm) is analogous to an appendectomy! This inopportune analogy has all the potential of acting as a diminutio capitis2 of the doctors who perform neuroendovascular procedures. Notwithstanding the progress of the devices we use, this proposed analogy seems an inadequate and heretical way of evaluating things. The analogy constitutes an unnecessary and self-harming way of downplaying our difficult discipline. The reality is that there is no comparison between the often very complex, treacherous, and potentially life-threatening treatment of a brain aneurysm and the relatively simple appendectomy, which is often performed by unsupervised residents. To reinforce this concept, I shall say that I never accepted the unfortunate labeling of our techniques as “minimally invasive”: our procedures are less invasive than open neurosurgery, but they are not minimally invasive!

Second, one should pay more respect to the fathers of our discipline, the pioneers who created the discipline starting from zero. No one should say “[our specialty] no longer consists of few pioneers trying to improvise new therapies while using non-FDA-approved materials.” The expression “trying to improvise” has a negative connotation that I find unacceptable. It is a derogatory way of depicting the enormous effort of the pioneers of our discipline. Most pioneers did not “improvise.” On the contrary, they “invented.” Moreover, they did it in a rational way. The distinction between “improvising” and “inventing” is crucial. Most pioneers did not use only standard, available materials simply because they were creative scientists and game changers. Therefore, in the process that eventually led to the creation of the discipline, they used materials that were the fruit of their “pioneeristic” work. Unavoidably, there were some excesses by a few. Nevertheless, I would have shown more deference and humility (and less pride) in referring to those who paved the way of the new discipline, often paying a high price for following their creativity. I would not have called them “improvisators.”

References

1. Cloft HJ. Capitalism and commodities: my two cents. AJNR Am J Neuroradiol 2013;34:1295–1296 » FREE Full Text
2. Enciclopedia Treccani. http://www.treccani.it/vocabolario/capitis-deminutio.

Reply

Published online before print November 28, 2013, doi: 10.3174/ajnr.A3827
AJNR 2014 35: E2

H.J. Cloft, Senior Editor

I meant no disrespect when I stated that the field of neurointervention was started by “pioneers trying to improvise new therapies.” “Pioneers” is a word with very positive connotations, and that is how I intended it to be understood. I was referring to the people who were the first to enter and develop the field, thus opening it up for others, including myself, to have an opportunity to follow. The word “improvise” was not the best choice, but it was not meant to be disparaging in the least. While as a fan of jazz music I greatly respect talented improvisors, I completely agree that “invent” would be a better word to convey the creativity as well as the design that went into the work of those who blazed a trail. It is the work of these pioneers, including Dr Guglielmi, that led to the mature field that I am privileged to work in today. Moreover, that mature field now supports a device industry that produces commodity products in bulk. I am thankful that I have these products and techniques because I doubt that I would have the patience, persistence, and inventiveness of the pioneers.

As far as the comparison between appendectomies and coiling, I leave it to the reader to decide if this comparison is apt. The comparison was meant to indicate that endovascular treatment of cerebral aneurysms has become quite common. We must give much of the credit for this to Dr Guglielmi for what has undeniably been a major revolution in the treatment of cerebral aneurysms. The point of my article was that this revolution has led to procedures being done in large numbers throughout the world, which brings about economic concerns as a major issue to be confronted in the next decade of the evolution of endovascular care of cerebral aneurysms.