This article celebrates the remarkable life and achievements of Dr. Fedor A. Serbinenko, the pioneering neurosurgeon who invented balloon embolization in the 1960s. His work, developed under challenging conditions in the former Soviet Union, fundamentally changed how doctors treat complex brain blood vessel conditions like aneurysms and fistulas, giving birth to the entire field of endovascular neurosurgery. Through incredible persistence over nine years of development, his techniques have since been used to evaluate and treat over 3,000 patients, providing a less invasive alternative to open brain surgery for countless individuals worldwide.

The Father of Modern Brain Vessel Treatment: The Story of Dr. Fedor Serbinenko

Table of Contents

• Introduction: A Medical Revolution
• Early Life and Education
• A Chance Observation That Changed Medicine
• Developing the Balloon Catheter
• The First Successful Procedures
• Establishing a New Medical Specialty
• Global Impact and Recognition
• The Man Behind the Medicine
• Source Information

Introduction: A Medical Revolution

It is difficult to imagine modern treatment for brain blood vessel conditions without the field of endovascular neurosurgery. This specialty allows doctors to treat complex problems like brain aneurysms, arteriovenous malformations (AVMs - abnormal tangles of blood vessels), and carotid-cavernous fistulae (CCFs - abnormal connections between arteries and veins behind the eye) from inside the blood vessels themselves, avoiding open brain surgery.

The variety of conditions now treated by neurointerventionalists is impressive, ranging from vascular tumors to stroke management. Today's doctors use advanced tools like braided hydrophilic catheters, complex aneurysm coils, and vascular stents designed for delicate brain vessels. However, just 5-6 years before this article was written in 2000, many of these devices didn't exist or were still in development.

Twenty years before this article, only a few physicians worldwide performed these procedures using rudimentary technology guided by primitive imaging systems. This article tells the story of the pioneer who started it all - Fedor Serbinenko, who developed novel catheter-based therapies for neurovascular diseases more than 30 years earlier in Soviet Russia under enormously difficult conditions.

Early Life and Education

Fedor Andreevitch Serbinenko was born on May 24, 1928, in the small village of Dmitriovsk in the Stavropol region of Northern Caucasus, in what was then the Soviet Union. When he was a small boy, his family moved to Mineralnye Vody City, where his father worked as a mechanic in the local flour mill and his mother was a homemaker.

His middle school studies were interrupted by World War II (called the Great Patriotic War in Russia), during which his older brother, Yuri, was killed. His father, also a soldier, survived the war. To support his mother and grandmother during the conflict years of 1941 to 1945, young Serbinenko went to work at age 14 as an apprentice machinist.

After the war, he continued working as a machinist but also studied at night, completing secondary school with honors in 1948. He was then admitted to the I.M. Sechenov First Moscow Medical Institute, where he was an enthusiastic scholar and athlete who excelled in volleyball, swimming, and ice skating.

Economic hard times in postwar Russia compelled Serbinenko to work frequently at extracurricular jobs involving difficult physical labor. Despite this, he maintained a perfect medical school attendance record. By his third year of medical school, he was interested in scientific research involving surgery, pharmacology, and urology.

When he graduated from medical school in 1954, he received an appointment as an Academy of Medical Sciences intern at the N.N. Burdenko Neurosurgery Institute in Moscow, where he has worked continuously for the past 44 years at the time this article was written. The Burdenko Institute was renowned as the Soviet Union's preeminent center for the neurosciences.

It soon became apparent that Serbinenko had superior innate technical and intellectual skills that afforded him the potential for an outstanding surgical career. This was immediately recognized by his mentors, Professors A. Shlykov and M.A. Salazkin, two of the leading Soviet neurosurgeons of the day. They encouraged Serbinenko to become involved with percutaneous cerebral angiography, which at that time was performed by direct carotid and vertebral artery puncture.

Serbinenko soon became an expert in this technique, leading to his interest in neurovascular pathology. In 1957, he became a neurosciences doctoral candidate. A portion of his thesis was devoted to the study of the pathophysiology and clinical manifestations of CCFs. He proposed a new classification system for CCFs based on their influence on cerebral circulation, which stirred his imagination in the quest for alternative treatment options.

A Chance Observation That Changed Medicine

In 1959, at May Day celebrations in Moscow's Red Square, Serbinenko's attention was attracted to helium-filled balloons held by children. He noticed how these balloons were easily maneuvered by simple manipulations of their tether lines. He began to wonder whether a tiny balloon at the end of a long catheter could be similarly maneuvered and navigated intravascularly for diagnostic or therapeutic blockade of a vessel.

This simple observation set in motion a medical revolution. Serbinenko soon organized a small laboratory to investigate potential materials for the creation of such a balloon catheter. He examined balloon materials including polyvinyl chloride, polyethylene, nylon materials, silicone, and latex. After much trial and error, he created prototype silicone and latex balloon catheters.

Multiple benchtop and clinical failures during the next 9 years prompted repeated refinements in his design. It soon became apparent that, with an improved design and with careful balloon inflation and deflation, the balloon-tipped microcatheter had excellent flow directional capabilities that allowed navigation of the tortuous vascular anatomy at the cranial base.

This made possible the first effective intracranial catheterization. These same flow directional characteristics also allowed the balloon tip to preferentially seek out high-flow arteriovenous fistulae and major AVM feeding arteries. With the use of multiple balloon devices, superselective intracranial catheterization became possible.

Developing the Balloon Catheter

The first balloon catheters had permanently attached balloons and diameters of less than 1 mm. These devices were introduced through needles inserted directly into the cervical carotid artery. On February 8, 1964, the first selective external carotid angiogram was performed with the assistance of temporary internal carotid balloon occlusion.

Thereafter, temporary balloon occlusion became an important adjunct to direct puncture carotid angiography at the Burdenko Institute. Two types of balloon devices came into use:

• A non-endhole device used only to occlude vessels
• A balloon catheter that not only created occlusion but also allowed passage of liquids though a separate lumen either distal or proximal to the balloon (a forerunner of the calibrated leak balloon catheter)

The most important initial use of Serbinenko's invention was temporary diagnostic occlusion of major cerebral arteries. From 1969 to 1972, Serbinenko performed 304 such procedures with only two deaths.

Permanent therapeutic occlusion was accomplished using a non-endhole balloon device inflated at a target site with a mixture of silicone polymer and tantalum powder to create a radiopaque material that would quickly become a stable gel within the balloon and distal catheter lumen. This allowed the catheter to be severed without risking polymer leakage from the distal catheter segment, which was left in place intra-arterially.

The first such reported vessel occlusion was performed on April 24, 1970, to sacrifice an internal carotid artery and treat CCF. (Serbinenko later claimed that his first successful balloon embolization was accomplished on December 15, 1969.)

The technique was improved by inflating the balloon initially with less viscous iodinated contrast material to determine whether the position was satisfactory. Once correct placement was confirmed, the contrast material was aspirated and silicone polymer was injected into the balloon.

Serbinenko subsequently developed a balloon with an ingenious valve mechanism that allowed balloon detachment from its delivery microcatheter by placing traction on the catheter. This modification eliminated the attached distal catheter segment used in the earlier deployment system.

From 1970 to 1973, Serbinenko performed 162 permanent therapeutic cerebral vascular occlusions, treating aneurysms, CCFs, and major feeding vessels to AVMs, with only two reported deaths. He later devised a balloon incorporating a tiny distal radiopaque gold pellet, which created a heavy tip and conferred greater fluoroscopic visibility and directional properties.

Although most of his early work was performed through direct carotid punctures, Serbinenko later adopted the transfemoral Seldinger technique for his endovascular procedures. Carefully and methodically he amassed an impressive patient series. To date, more than 3000 patients have been evaluated and/or treated by Serbinenko using balloon catheter techniques.

The First Successful Procedures

Serbinenko's work made possible, for the first time, effective therapies for a variety of neurovascular lesions. The basic concepts he pioneered 30 years before this article for the treatment of CCFs, AVFs, and inoperable cavernous internal carotid artery fusiform aneurysms remain just as viable and important today.

His burgeoning endovascular practice demanded all of his time, forcing him to abandon conventional operative neurosurgery. However, his focus on endovascular procedures opened a new chapter in the investigation of cerebrovascular pathophysiology.

With the collaboration of neuropsychologist Alexander Luria, also of the Burdenko Institute, Serbinenko's balloon test occlusion of cerebral arteries aided in brain mapping and presurgical assessment of potentially eloquent areas of the cerebral cortex. These temporary balloon occlusions, similar to current selective Wada tests performed by the injection of sodium amytal, were complemented by electrophysiological and biochemical studies.

Establishing a New Medical Specialty

To their credit, other researchers in the 1960s and early 1970s had reported or proposed the use of endovascular techniques to treat neurovascular lesions. These included Luessenhop and Spence, who embolized cerebral AVMs therapeutically and attempted to treat a supraclinoid carotid aneurysm using an intravascular silicone balloon; Alksne and Fingerhut, who performed magnetically assisted transarterial embolization of experimental canine aneurysms; and Prolo and Hanbery, who described the transluminal occlusion of a CCF using a nondetachable balloon.

The work of these early investigators was visionary, but Serbinenko's invention of the balloon catheter in the 1960s and the achievement of the first successful permanent balloon occlusion of an intracranial vessel using his device in 1969 were the seminal events marking the birth of endovascular neurosurgery.

Global Impact and Recognition

In 1971, at the first All Soviet Neurosurgical Congress held in Moscow, Serbinenko presented his cumulative endovascular experience. That same year, he published his landmark article describing the use of his balloon catheter for the diagnosis and treatment of cerebrovascular disorders.

Despite the barriers to the exchange of ideas between East and West created by the Cold War, such revolutionary new concepts could not help but have an impact on medical thinking worldwide. In 1974, another article reporting his endovascular neurosurgical results was published in the Journal of Neurosurgery.

Thereafter, the Burdenko Institute became a destination for foreign physicians wishing to observe neurointerventional techniques. Recognition of Serbinenko's work created opportunities for other Soviet neurointerventionalists, including Y.N. Zubkov from the A.L. Polenov Neurosurgery Institute in Leningrad and V.I. Shcheglov from the Kiev Research Institute of Neurosurgery.

Serbinenko's work spawned numerous innovations by other investigators around the world, leading to a technological explosion and the current wide application of neurointerventional techniques. In the late 1970s and early 1980s, Debrun et al. reported their results using the Debrun latex balloon in the treatment of cerebral aneurysms and CCFs.

The introduction of nondetachable balloon catheters made balloon test occlusions of the carotid and vertebral arteries practical. The same type of device has been used for balloon protection of the cerebral circulation during carotid angioplasty and stenting procedures.

The calibrated leak balloon (a variation of Serbinenko's invention) afforded antegrade flow arrest within AVM feeding arteries during embolization of the AVM nidus with a liquid adhesive agent. The subsequent development of supple flow-directed and over-the-wire microcatheters greatly expanded the role of embolization in the treatment of AVMs.

In the late 1970s, Hieshima et al. developed a silicone detachable balloon with a self-sealing valve, which was more compliant than latex balloons. This device has been used to treat CCFs, AVFs, intracranial aneurysms, AVM feeding arteries, and neurovascular traumatic lesions.

By 1990, a number of groups had amassed considerable experience using detachable balloons to treat intracranial aneurysms with parent artery preservation. However, complications remained significant, with one study reporting death and stroke rates of 17.9% and 10.7%, respectively, associated with endosaccular aneurysm balloon embolizations.

Another study reported a 10% incidence of technical failures, a 4% death rate, and a 10% rate of neurological complications during these procedures. These complication rates eventually led to the development of Guglielmi detachable coils, which have largely replaced balloons for the endovascular treatment of intracranial aneurysms, though balloons are still used in conjunction with the balloon remodeling technique for treating wide-neck aneurysms.

The Man Behind the Medicine

In recognition of his many contributions to medicine, Serbinenko has been awarded honorary membership in multiple international scientific and medical societies, including the American Society of Neuroradiology. In 1976, the Soviet State Prize was bestowed on him in recognition of his invention.

In 1986, he became a member correspondent of the Russian Academy of Medical Sciences, and in 1995, he became an academician. Serbinenko was a special honoree during the 1999 Scientific Conference of the World Federation of Interventional and Therapeutic Neuroradiology.

Serbinenko serves as the Burdenko Institute's Vice-Director of Scientific Affairs and is scientific secretary of the Specialized Council for Thesis Defense. He is also a member of the editorial board of Voprosy Neurochirurgii. He has authored or co-authored more than 150 scientific publications and holds 11 patents for medical devices in Russia, the United States, Germany, Sweden, Canada, Japan, and France.

Serbinenko is known as a driven and exacting physician and researcher. In the name of patient care, he expects nothing less than maximal effort from his colleagues and co-workers, but most of all from himself. He can conceive of no greater expression of compassion for his patients than consistently delivering excellent medical care.

Beneath this demanding exterior resides a warm and compassionate sentimentalist. His genuine sense of concern extends beyond patients and colleagues to include people in general. He never is too busy or thinks himself too important to find time to write a personal note to a friend, remember a special occasion, do a small favor, or comfort the family of an ailing patient.

Serbinenko met his wife, Maya, who holds a doctorate in neurophysiology, while he was a medical student. Because of their similar upbringing, the two found that they shared much common ground. Their friendship blossomed into a loving relationship that has strengthened and deepened over the years.

Maya has truly "completed" Fedor, providing him with support and encouragement that has sustained him during his demanding career. They have a daughter, Natalia, who is also a physician. Although the Serbinenkos have a home in Moscow, they spend all of their vacation time in the heart of the Russian countryside near the banks of the Volga River in the Kostroma region.

Source Information

Original Article Title: A Tribute to Dr. Fedor A. Serbinenko, Founder of Endovascular Neurosurgery

Authors: George P. Teitelbaum, M.D., Donald W. Larsen, M.D., Vladimir Zelman, M.D., Ph.D., Anatolii G. Lysachev, M.D., Leonid B. Likhterman, M.D., Ph.D.

Publication: Neurosurgery 46:462-470, 2000

Note: This patient-friendly article is based on peer-reviewed research and preserves all factual information, dates, technical details, and medical findings from the original tribute article.