A lost garage in Martínez, California, United States, as a laboratory for scientific ideas. An experimental matrix. A disruptive and advanced procedure for the time. A young and persevering Argentine doctor with a career on the rise. A single chance in ten thousand of getting your invention right and crossing the finish line. A hunch and a name: Julio Palmaz (78).
In that garage, the boy who took apart cars and watches, the teen fan of interventional cardiologythe doctor graduated from the University of La Plata who debuted at the San Martín Hospital, the son of the bus driver and the housewife made history.
After endless hours of work – and at the same time as his residency in radiology – he created el stent expansiblea device that would revolutionize the world of medicine and save millions of lives.
His “Eureka” was in the early ’70s. At the University of Michigan teaching hospital, the Argentine doctor listened to cardiologist Andreas Grüntzig, creator of balloon angioplasty, describe his method for “unclog” coronary arteries without surgery.
However, the German confessed the limitations of his intervention. had to find a superior “mechanical” solution. He had gone there with his friend, mentor and boss Stewart Reuter who had called him to join the team.
Palmaz’s mind found “the way” in 1978. He made “gadgets” with an illuminated magnifying glass, soldering material and rubber tubes. Ten years later, in August 1988, he patented his creation: the first intravascular stent in history. The label?: “Palmaz-Schatz” in recognition of Richard Schatz, the professional who obtained the resources to make the expensive project a reality.
Pioneer Argentina
At almost 80 years old – he turns 79 in December – Palmaz takes stock of his career with an eye toward the national and international medical horizon. ”Argentina continues to be a pioneer in service medicine and clinical research but basic science research is limited and the economic support, almost non-existent,” he stressed in dialogue with Viva from the United States, where he has resided since his invention was born.
-From a distance, how do you see today that doctor who went through obstacles to achieve an invention that would save millions of lives?
-I see myself as naive with no idea that the statistics for the chance of success of bringing a disruptive procedure to the finish line were 1 in 10,000.
-How many tears, energy and hours of life did you leave in the medical and legal process until you patented it?
-Energy yes. A lot. Hours of life, also many. Not tears. Maybe it was the excitement in the challenge. The patent application was relatively early. The biomedical and regulatory validation process with the FDA (Food and Drug Administration) is long and arduous. Legal experience came after approval and explosive success. The enormous amount of copying and patent infringement by competitors led to late lawsuits that lasted many years.
-How did you feel when you realized that you were inventing something superior? Could I sleep?
– My eye-opening moment was when I examined my first laboratory “specimen.” A few years later, I felt the same validation when I examined autopsy specimens on patients who received stents years earlier. There I glimpsed its potential. I never felt like I was going to go down in history until 10 years after the start, when we had long-term results and official impact data. As head of an emergency department at a large hospital (first at the Veterans Hospital in Martinez, California; then at the University of Texas Health Science Center) you never sleep well if you are on call every 3 days. When clinical trials of the stent began around the world, he received calls from remote countries, often in the middle of the night. I never went to bed expecting a full night’s rest.
-What did your family tell you?
My wife and children were incredibly supportive. Without that support, it would have been impossible for me to undertake this project.
-Do you remember the first patient who used the stent? Any person whose life it saved?
-The first was in 1987, in Freiburg, Germany. It was in peripheral vessels (non-cardiac). Then came the first coronary stent in Sao Paulo, Brazil, in ’88. In ’90, the FDA approved it in peripheral vessels and in ’94, in coronary arteries. During the first years of clinical research I did many off-protocol procedures out of critical need. In those years, many centers in the US were sending patients with problems because we were the only ones licensed to use stents experimentally. Stories of lives saved were a weekly occurrence. Over time, more centers acquired approval to use the stent and we became less essential.
A current procedure
Save lives. Palmaz had achieved it. Remembering the past gratifies him above all because his invention is still valid. According to the Argentine College of Interventional Cardioangiologists (CACI), around 110,000 coronary stents are placed per year in Argentina, that is, an average of 300 devices per day. In the US, more than 1 million are performed annually by catheterization. In Japan, 300 thousand, in India 500 thousand and in China 1.3 million, as in the entire European Union. Today the expandable metal mesh of 1 mm in diameter and 30 in length, weighing 25 grams (less than an aspirin), is the way to treat obstructions in coronary and carotid, renal, intracranial and lower limb arteries. “The stent is a band-aid. What it allows is to maintain circulation, blood flow,” Palmaz usually says.
What’s coming
-Is there any invention that you would have liked to create?
-In the ’70s the stent was the most desirable invention due to the critical needs of the time such as acute myocardial infarction. Today I would aspire to invent a drug with high specificity and low or no toxicity to treat and prevent arteriosclerosis. That is, if I were starting today, I would choose biomolecular engineering.
The cardiologist Julio Palmaz, on one of his visits to Buenos Aires. Photo: Clarín Archive/ Guillermo Rodriguez Adami.-How many patents do you have in your name? Which one represents you the most beyond the stent?
-It is difficult to maintain an account. I have approximately 90 patents as a first inventor and about 250 as a co-inventor. Many expired, others were abandoned as obsolete. My patents derived from the physical-chemistry of the surface of biomaterials are the ones that make me most proud.
-Is Argentina still a pioneer in cardiovascular medicine?
-Clinical service and research medicine is excellent in Argentina worldwide. But basic science research is limited and the necessary financial support is almost non-existent.
-Why didn’t you settle in our country after inventing the stent?
-For my family, for roots, for the development of my career, for acculturation. Nor can the difficulty of doing basic research in Argentina be ignored. Basic scientific research has always been my passion and the reason I stayed in the United States.
-With your experience, do you see any innovative inventions on the horizon that could improve heart function?
-In 2024, the most exciting thing is highly selectivity and low toxicity pharmacotherapy. Biological medicines and those derived from RNA or ribonucleic acid promise to limit the risk of many diseases that have plagued humans. These diseases are common like diabetes or rare like Amyloidosis (the buildup of amyloid protein in the heart, kidneys, liver and other organs). Today there are drugs for conditions that were untreatable a few years ago. Prevention and treatment promise to extend life. Patients in the near future will be older and more fragile. The most frequent cause of death then may change from cardiovascular to cancer, plagues or accidents.
-What do you think of artificial intelligence applied to cardiovascular medicine?
-I don’t see it as something that is disruptive in this area. AI is being applied in tedious, high-volume diagnostics such as histopathology, cytopathology, mammography, chest films, and other imaging examinations that are overwhelming in quantity. Also, in the differential diagnosis of clinical history material. AI can help prescreen to reduce the overhead of interpreting massive volumes of information by classifying and distributing. However, in medicine, it will never replace clinical judgment based on experience.
The legacy
-Today you have a family wine business. What strain do you prefer? Can we conclude that wine is vital for the proper functioning of the heart?
-Vinegrowing is great for a family business. The area of Napa where we are living is very favorable from the point of view of climate and terrain conditions. Yes, I like wine and I am convinced that, in moderation, it is pleasant and healthy. Cabernet is my favorite strain.
-How would you like to be remembered in the history of Medicine?
-As a good-humored and pleasant type. I do regret being difficult in the years of working hard in the laboratory with my colleagues, assistants, residents, and academics. If I could retrace that path, I would be more cordial and sensitive. In retrospect, dealing with illness and suffering does not justify hardening one’s character.
-Did you know René Favaloro closely? What do you remember about him?
-Yes, I met him in Buenos Aires in 1972. He had recently arrived from Cleveland and was known for his work in coronary bypass. I went to see him for surgery for my father-in-law who had advanced coronary heart disease and congestive heart failure. We reviewed his coronary angiography and medical history together and it was decided to try multiple bypass surgery. I was present at the surgery but my father-in-law did not survive. I never met him again.
-What would René Favaloro say if he were listening to it now?
– At this time Favaloro, like other highly experienced surgeons, would accept the need for catheterization treatments as the mode of choice in acute myocardial infarction. Years ago, there was controversy over the relative role of bypass surgery compared to transcatheter treatment (angioplasty and stents) in patients with chronic myocardial ischemia. I’m sure you would agree that surgeons should share patients with coronary artery disease with interventional cardiologists based on established criteria. Surely he would also congratulate me on the wine I make.
