Author: M. Aroon Kamath, M.D.
I recently came across a very interesting article listing the many extended uses of the Foley’s catheter in plastic surgery [1]. This article prompted me to attempt to compile information on the various ways in which Balloon catheters and other devices based on the balloon principle have been used in medicine in general, and surgery in particular.
Through this blog, I have tried to provide what may turn out to be just a sample of a very exhaustive list of indications for the use of balloon devices (air filled and water filled) and devices that have an underlying balloon principle, in the various medical disciplines.
The first balloon was invented by an Italian-born Portuguese priest, Bartolomeu de Gusmao, and publicly exhibited to the Portuguese Court on August 8, 1709, in the hall of the Casa da Índia in Lisbon. The rubber balloon was later invented by Michael Faraday in 1824. He inflated it with hydrogen and used it in his experimental studies involving that element. The latex balloons were first manufactured in London, 1847, by J.G. Ingram. Catheters are nowadays made from various synthetic polymers, mainly flexible PVC (polyvinyl chloride), polyethylene, polyurethane, teflon, silicone, nylon, etc.
In 1869, Trendelenburg first ‘proposed’ the use of a cuffed tracheotomy tube [2]. Samuel Siegfried Ritter von Basch in 1880 first described the sphygmomanometer, in which a water-filled bulb was connected to a manometer. In 1896 Scipione Riva-Rocci introduced the mercury sphygmomanometer. His new instrument used an ‘inflatable cuff’ to obliterate the brachial artery and also incorporated a mercury manometer [3, 4, 5, 6].
Military anti-shock trousers (Pneumatic anti-shock garments)
The concept of Military anti-shock trousers (MAST) was first described in 1903 by the eminent surgeon George W Crile, as a pneumatic suit to decrease postural hypotension in neurosurgical patients [7]. The resuscitation of the apparently dead and a demonstration of the pneumatic rubberized suit as a means of controlling blood pressure was reported at the meeting of The Southern Surgical and Gynaecologic Association in 1903. During World War II, Crile’s suit was used to prevent blackout in pilots who were subjected to high G forces while flying combat aircraft. The North America Space Association (NASA), then claimed responsibility for the development of the medical anti-shock trousers at their AMES Research Centre in 1960s [8]. Lt. Col. Burton Kaplan is credited for using MAST during the Vietnam conflict (1955) [9]. In the 1970s, MAST began to be introduced into the civilian Emergency Medical Services (EMS) systems. MAST look similar to a pair of pants. They are opened and placed around the legs and pelvis of the patient and each section inflated as indicated.
Pneumatic tourniquets
In 1904, Harvey Cushing created a pneumatic tourniquet. August Bier used a double tourniquet technique for administering segmental anesthesia in 1908. In this procedure circulation is isolated in a limb and the limb is then infused intravenously (Bier block) [10].
Water bottle & Thermal blankets
Eduard (Slavoljub) Penkala (1871-1922), was born in Slovakia and later became a naturalized Croat after his family immigrated to Zagreb. He invented the mechanical ‘pen’ in 1906 and fountain pen in 1907. He also invented the first hot water bottle [11]. Hot water bottles were initially used to provide warmth in bed or to provide warmth to localized areas of the body. A similar principle is used in today’s convective air blankets (convective thermal blankets) which have become indispensable for patient warming (to prevent hypothermia).
Endotracheal tube (ETT) cuffs
In 1926, Arthur Guedel experimented with various implements such as condoms, gloves, dental dams, etc, in an effort to find a design for the first endotracheal tube (ETT) ‘cuff’. The need for a cuffed tube was spurred by the invention of the ‘Water’s closed circuit’ for positive pressure ventilation. Effective positive pressure ventilation required that the administered gases did not leak out around the endotracheal tube. Initially gauzes were used to pack the space around the ETT [12]. Thus, the balloon principle came to be practically applied for prevention of gas leak (to the best of my knowledge, perhaps, for the first time in medicine), although theoretically it was first conceived by Trendelenburg.
Foley’s catheter
Foley’s catheter was designed by Frederic Foley, a surgeon working in Boston, Massachusetts, in the 1930s, where he was a medical student. He devised it to prevent the catheter from slipping out and thereby to allow it to remain “indwelling” [13].
Sengstaken and Blakemore
Next came the balloons with an intent to utilize the balloon as a means to cause local pressure to stop bleeding (tamponade). This was used for the first time for this indication by Sengstaken and Blakemore to stop bleeding from esophageal varices [14].
Fogarty® balloon embolectomy catheter
In 1963, Thomas Fogarty received a patent for his ‘Fogarty® balloon embolectomy catheter’ [15]. Here, the idea was to use the balloon to evacuate fresh clots from blood vessels.
Swan and Ganz catheter
The balloon ‘floatation’ catheter was developed by Swan and Ganz for the measurement of the pulmonary artery wedge pressures. The idea was to advance and position the catheter tip and the balloon in the cavity of the right ventricle and allow it to literally ‘float’ into the pulmonary artery, guided by the blood stream [16].
Balloon angioplasty
A balloon catheter for ‘opening’ or ‘widening’ the iliac artery was developed in 1973 by Dr. Porstmann. Dr. Andreas Gruentzig, working at the University hospital of Zurich in Switzerland, is credited with performing the first balloon angioplasty in humans on September 16, 1997 [17].He had earlier presented results of his experiments on coronary arteries in dogs in November, 1976.
Intraaortic balloon pump has been in use in the management of cardiogenic shock and as a mechanical assist device in cardiac operative procedures. Transcatheter interventions (catheter-based cardiovascular procedures have become increasingly used in the treatment of patients with congenital heart defects. These procedures may be broadly grouped as dilations (valvuloplasty, angioplasty, and endovascular stenting) or as closures (vascular embolizations and device closure of defects).
Balloon valvuloplasty has become the treatment of choice for simple valvular pulmonic stenosis in all age groups and, although not curative, appears at least comparable to surgery for noncalcific aortic stenosis in newborns through young adults. Balloon angioplasty is successfully applied to a wide range of aortic, pulmonary artery, and venous stenoses. Ballon catheters are also used in the management of congenital heart diseases [18].
Balloon catheters have been inserted into the right atrium via the right atrial appendage for rapid intracardiac administration of fluids [19]. Balloon devices have been deployed through ventricular stab wounds to reduce bleeding in the course of repairs of ventricular stab wounds [20] and in the control of bleeding from major veins [21, 22].
Balloon devices have been used for selective bronchial occlusion in cases where lung separation by a double-lumen endotracheal tube may be relatively contraindicated either because insertion is either considered difficult or dangerous. Foley’s as well as Fogarty’s catheters have been used in this connection [23, 24].
There have been reports of Improvised balloon devices using segments of Penrose catheters for tamponading liver injuries [24]. Balloon catheters have also been used for occluding segmental vessels in the management of hepatic tumors [26].
Balloon catheter dilatation (balloon catheter dacryocystoplasty) has been used as an alternative therapeutic option for the treatment of stenoses of the common canaliculus [27, 28].
Balloon catheters are now being used in the procedure of “balloon sinuplasty” [29, 30, 31]. This was first described in a cadaver model by Bolger and Vaughan in 2006. Choanal balloon catheters are being used to stop epistaxis (posterior epistaxis). Earlier, Foley’s catheters had been used by some for this purpose [32, 33]. More recently, double balloon devices have become available. There have been reports of cricopharyngeal achalasias responding to balloon dilations [58].
Balloon catheters have been in use in hysterosalphingography [34]. Cervical ripening balloon catheters have been designed to accelerate cervical dilation prior to the induction of labor. Initially Foley’s catheters were used but they have given way to a double balloon device [35, 36, 37, 38].
Sengstaken-Blakemore tube has been used for control of massive postpartum haemorrhage [39] as well as Foley catheters [40]. More recently, the SOS Bakri Balloon catheters are being used [41].
Balloon catheters have found an application in the treatment of trigeminal neuralgia [42] and in thrombolysis of thrombosis involving intracranial blood vessels [43]. Coronary microballoon percutaneous transluminal angioplasty catheters have been reportedly used for mechanical thrombectomy in a case of sagittal sinus and transverse-sigmoid sinus thrombosis that had a poor response to superselective chemical thrombolysis [44]. Balloon catheters have been used in embolizing intracranial vascular lesions and in embolization of angiomas and cerebral arteriovenous malformations [45, 49]. Cerebral endovascular revascularization is now rapidly emerging as a selective therapeutic modality for stroke prevention [46, 47]. Carotid angioplasty with stenting (CAS) is increasingly being used in the treatment of extracranial carotid disease [48].
For tissue expansion, the first attempt at use of a rubber balloon placed subcutaneously in the postauricular region to provide cover for a cartilaginous reconstruction of a traumatic defect of the external ear was by Newmann [50].
Since then, tissue expansion has come to be used in numerous applications in several surgical sub-specialities that are far too many to be listed here individually.
The uses of the versatile Foley catheter in urology has already been alluded to. Ingemar Henry Lundquist (1921 - 2007), a Swedish mechanical engineer, who later migrated to the US and became an American citizen in 1950, is quoted to have co-invented the first “over the wire balloon catheter” for Transurethral radiofrequency needle ablation of the prostate (TUNA) [51]. This technique has found varied applications today. He was a prolific product inventor and is said to be credited with over one hundred U.S. patents. I have come across quite a few articles on the internet mistaking him to be a female inventor! Endoscopic balloon dilation for treatment of benign prostatic hyperplasia (BPH) involves the insertion of a balloon catheter tip through the urethra into the prostatic channel where it is inflated to stretch the urethra narrowed by the prostate. This has fallen out of favor in recent times [53, 54]. Balloon catheters have also been used at times, during the procedure of ureterorenoscopic removal of ureteric stones [55].
Intragastric balloons have been tried for inducing weight loss in morbid obesity [56]. They are approved in some countries only.
Balloon devices have many applications in general surgery including, endoscopic balloon dilatation of esophageal strictures [57], for dilating the pyloric sphincter [59], in the management of achalasia cardia [60], for percuteneous dilatation of biliary strictures [61], in studies on esophageal motility [62], in anorectal manometry [63], retrieval of biliary and pancreatic duct stones [64], as well as for numerous other indications.
