Journal of Vascular Surgery
Volume 28, Issue 4 , Pages 746-752, October 1998

Early history of aortic surgery☆☆☆★

Presented at the Twenty-first Annual Meeting of the Midwestern Vascular Surgical Society, Chicago, Ill, Sep 12–13, 1997, as an Honored Guest Lecturer.

Dallas, Tex

Received 25 February 1998; accepted 2 March 1998.

Article Outline

Abstract 

J Vasc Surg 1998;28:746-52.

 

In the past 50 years, we have witnessed the most spectacular period of growth and development in the long and fascinating history of vascular surgery. As in all things, the basis for today's modern vascular surgery rests on achievements from the past. As Thomas Carlyle wrote, “History is the essence of innumerable biographies.”

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ANEURYSMS 

Studies of Egyptian mummies have revealed that atherosclerosis and arterial calcification were relatively common 3500 years ago.1 The Ebers Papyrus is among the earliest medical writings and is thought to have been prepared around 2000 bc. The writer clearly identified arterial aneurysms, probably peripheral aneurysms, and recommended the following treatment: “Treat it with a knife and burn it with a fire so that it bleeds not too much.”2

Antyllus, a Greek surgeon of the 2nd century ad, has left the earliest record of attempted therapy of aneurysms. Although his writings have been destroyed, his ideas are recorded in the works of Oribasius, who lived in the 4th century ad. According to Oribasius, Antyllus said, “We decline exceptionally big aneurysms, but we will operate as follows on aneurysms in the extremities, the limbs and the head.” Antyllus applied ligatures to the arteries that entered and left the aneurysm and then cut into the aneurysm sac, evacuated the contents, and packed the cavity. Antyllus did not resect the aneurysm sac. He stated, “Those who tie the artery, as I advise, at each extremity, but amputate the intervening dilated part, perform a dangerous operation. The violent tension of the arterial pneuma often displaces the ligatures.”3 This good advice was given 1800 years ago.

Few advances were made in the treatment of aneurysms during the ensuing millennium. Ambroise Paré (1510-1590) advocated the application of a proximal ligature to aneurysms but did not believe the sac should be opened because of the danger of severe and fatal hemorrhage. Paré also described a ruptured aneurysm of the thoracic aorta and wrote, “The aneurysms which happen in the internal parts are incurable.”1, 2 Andreas Vesalius (1514-1564) was a friend and colleague of Paré and apparently was the first to describe thoracic and abdominal aortic aneurysms.4

Matheus Purmann operated on an antecubital space aneurysm in 1680, and he ligated the artery above and below the aneurysm and removed the sac. In medieval times the antecubital fossa aneurysm was quite common as a complication of bloodletting by puncture of the median basilic vein.2

With John Hunter (1728-1793), surgery began to emerge as a scientific discipline on the basis of anatomy and physiology. Hunter's contributions to vascular surgery were basic. In addition to his clinical observations, he studied the development of collateral circulation of occluded main arteries, which led to his method of treating aneurysms. On December 12, 1785, he ligated the superficial femoral artery high in the thigh in the area now known as Hunter's canal to treat a popliteal aneurysm. The patient did well; the aneurysm shrunk to a hard knot, and the limb survived. The specimen from Hunter's first case is located in the Hunterian Museum in London. This case represented the first major innovation in the treatment of popliteal aneurysm after the Antyllus operation of the 2nd century. Hunter's method lasted until the operation of Rudolph Matas was developed in 1888.5

The discussion now brings us to Astley Cooper (1768-1841), one of the great English surgeons of the late 18th and early 19th century. Cooper made contributions in many fields of surgery, but his name is linked permanently to advances in vascular surgery. In 1817, he was called to see a man in extremis with a leaking iliac aneurysm. Cooper decided that the only possible treatment was ligation of the aorta above the aneurysm. He managed to get his finger around the aorta through a small transperitoneal incision, and he passed a single ligature around the vessel with an aneurysm needle. The ligature then was tied. The patient's right leg remained viable, but the left leg was totally ischemic, livid, and cold, and the patient died 40 hours later. This was the first recorded case of ligation of the aorta for aneurysm. The specimen of Cooper's operation is preserved in the Department of Surgery at St. Thomas's Hospital in London.6

During the next 100 years several attempts were made to ligate the aorta, but all the patients died, until April 9, 1923, when Matas successfully ligated the abdominal aorta in the treatment of an aneurysm. The patient survived the operation but died 18 months later of pulmonary tuberculosis.7 By 1940, Dan Elkin8 was able to identify only 24 recorded cases of ligation in the world literature to which he added one of his own. In only five of these cases was the operation a success.

Rudolph Matas9, 10 (1860-1957), of New Orleans, was a pioneer in the field of vascular surgery. He made many contributions to all areas of surgery, but he is best remembered in vascular surgery for his operation of endoaneurysmorrhaphy. He first performed this operation May 6, 1888, on a patient with a large traumatic brachial artery aneurysm of the left arm. After ligation of the proximal and distal arteries, an incision was made into the aneurysm, and the clot was removed. The orifices of the blood vessels that entered the sac then were sutured from within, which preserved the collateral blood supply to the extremity. This operation markedly reduced the incidence of gangrene and amputation that followed the procedure in a high percentage of patients who underwent the Hunterian ligation for popliteal aneurysm. This principle is still used.

An interesting note is the experience of William Osler11 in his 16 years at the Johns Hopkins Hospital from 1889 to 1904. Osler saw only 17 cases of abdominal aortic aneurysm, an average of one per year.

Over the years a number of methods have been used in efforts to treat aortic aneurysms. These methods were designed either to cause thrombosis of the aneurysm or to fibrose the wall to prevent rupture. The methods included needling, wiring, proximal banding, ligation, and cellophane wrapping.

In 1864, Moore, a British surgeon from Middlesex Hospital, introduced wiring of aneurysms by inserting either silver, iron, steel, or copper wire in an effort to thrombose the aneurysm. In 1879, Alfonso Corradi from Pavia attached Moore's wires to a battery in an attempt to induce coagulation. The results were dismal, with only an occasional reported cure.11 The principle persisted, however, and was brought to its culmination by Blakemore, of New York. Blakemore advocated progressive constrictive occlusion of the abdominal aorta with a rubber band wrapped with polythene film proximal to the aneurysm, followed by insertion of wire and electrothermic coagulation with 100 volts of direct current. In fact, Blakemore's final major presentation of this method was given December 10, 1952, before the Southern Surgical Association. (Interestingly, in the discussion after Blakemore's paper, DeBakey reported his first two cases of resection of aneurysm with homograft replacement that had been done in the month before Blakemore's presentation.12)

At Johns Hopkins, William Stewart Halsted (1852-1922) attempted proximal aortic ligation with either silver or aluminum bands. These patients usually died because the metallic bands cut through the aortic wall and fatal hemorrhage occurred. In 1910, Halsted operated in Kocher's clinic in Bern, Switzerland, and put a metallic band on an aortic aneurysm above the renal arteries. The patient apparently was cured but 6 weeks later died of rupture at the site of banding.13

On October 19, 1944, Crafoord and Nylin14 in Sweden reported the first successful end-to-end anastomosis of the aorta after resection of an aortic coarctation. Robert Gross,15, 16 of Boston, performed his first successful coarctation resection and anastomosis on July 6, 1945. Shortly thereafter, on May 24, 1948, Gross17 successfully replaced a longer segment of a resected coarctation with a preserved arterial homograft with methods devised by Charles Hufnagel for the preservation of human homografts. The stage was set for the rapid developments that were to follow.

Now we take a short bypass into arteriography. On November 8, 1895, Wilhelm Konrad Roentgen first observed the new rays that would become a cornerstone of our diagnostic armamentarium. Roentgen received the Nobel Prize in 1901 for this discovery. In 1923, Barney Brooks18 initiated clinical angiography by injecting sodium iodide and studied the femoropopliteal system. In 1927, the first cerebral arteriography was performed by Egas Moníz, of Portugal. In 1929, Reynaldo dos Santos, another Portuguese physician, was the first to report translumbar aortography, and he envisioned this method as valuable to studying diseases of the arteries. These pioneering achievements have evolved into today's sophisticated methods of visualizing all the vessels in the body.19

On March 2, 1951, Schafer and Hardin20 resected an abdominal aortic aneurysm with a bypass shunt and replaced the aorta with a human homograft. The patient survived the operation but died 29 days later of hemorrhage from a leak in the native aortic wall. The first successful resection of abdominal aortic aneurysm with graft replacement was performed on March 29, 1951, by Charles Dubost in Paris. He used an extraperitoneal thoracoabdominal approach with resection of the 11th rib. The graft used was the thoracic aorta taken 3 weeks previously from a 20-year-old woman. The patient's left common iliac artery then was anastomosed to the side of the graft.21 After Dubost's landmark procedure, reports of successful operations appeared in quick succession by Julian,22 Brock,23 DeBakey and Cooley,24 and Bahnson25 (Table I).

Table I. Early cases of elective resection of abdominal aortic aneurysm with homograft replacement
CaseDate of case
Schafer & Hardin20Mar 2, 1951*
Dubost et al21Mar 29, 1951
Julian et al22Oct 25, 1952
Brock23Nov 5, 1952
DeBakey & Cooley24Nov 6, 1952
Bahnson25Feb 14, 1953

*Case resulted in death of patient.

After Dubost's report, the abdominal aortic aneurysm sac would be completely removed before the graft was placed, but this technique was sometimes difficult and hazardous. Therefore, in 1966, Oscar Creech,26 of Houston, combined the endoaneurysmorrhaphy technique of Matas with graft replacement that left the aneurysmal sac in place. This single step has greatly simplified aneurysm surgery.

Ruptured abdominal aneurysms were subjected to resection and repair after successful elective treatment of abdominal aortic aneurysms. Henry Bahnson27 is credited with the first successful repair of a ruptured aortic aneurysm, performed March 13, 1953. Other early operations are shown in Table II.

Table II. Early cases of ruptured abdominal aortic aneurysm successfully treated by resection with homograft replacement
CaseDate of case
Bahnson27Mar 13, 1953
Gerbode58Before 1954
Cooley & DeBakey59Apr 26, 1954
Javid et al60Dec 21, 1954
The first successful repair of a ruptured aneurysm by our own group in Dallas was performed on October 21, 1954, at Baylor Hospital.

The arterial homografts were a great step forward, but problems of procurement and availability were major factors for limitation. The development of satisfactory arterial substitutes was basic for progress in vascular surgery.28 Veins had been substituted for arteries as early as 1906,29 but methods of graft preservation were perfected and artery banks were established in the 1940s and early 1950s on the basis of the early works of Carrel and Guthrie30, 31 and Gross et al.17

In 1952, Voorhees, Jaretski, and Blakemore32 reported that a tube of Vinyon-N cloth as a plastic artificial substitute for an artery would remain open in a dog's aorta. This observation was soon confirmed, and although Vinyon-N cloth did not prove to be satisfactory material, the principle was established. In 1955 Sterling Edwards33 reported the development of nylon prostheses and also devised a technique of crimping prosthetic grafts. Nylon did not hold, but Teflon and Dacron grafts followed in short order.

In 1954, DeBakey and his group began working on various materials for grafts. DeBakey collaborated with Professor Thomas Edman, a Philadelphia textile engineer, to build a new knitting machine to make seamless Dacron grafts of all sizes, shapes, and configurations.34 Various refinements were made in these grafts, which culminated in the standard grafts in use at the present time. Szilagyi35 played an important role in the development of vascular grafts with his introduction of the elasticized woven Dacron graft that bears his name. His follow-up reports on aortic aneurysm surgery have been landmark contributions. A number of investigators also were involved in the development of vascular grafts, including Deterling, Julian, and Shumacker.28

Thoracic aneurysms have presented a challenge to surgeons for many years. These aneurysms can be saccular or fusiform or associated with coarctation of the aorta. After the lead of Moore, in 1864, the aneurysms were treated by wiring until more definitive measures were developed.11 In Ann Arbor in 1941, John Alexander36 simply resected the aneurysm with the coarctation and sewed off the ends without anastomosis or graft in the case of lesions associated with coarctation. On June 28, 1949, Henry Swan37 apparently was the first to resect an aneurysm associated with a coarctation and to replace the resected area with a homograft. In 1951, Robert Gross reported five cases of aneurysm associated with coarctation treated by resection and graft.38 In the early 1950s, Bahnson39 and Cooley and DeBakey40 resected saccular aneurysms and repaired the arterial walls by lateral suture. DeBakey and Cooley41 reported the first case of a successful resection and graft of a fusiform thoracic aneurysm that was performed January 5, 1953. Since that time, all sections of the thoracic aorta from the arch to the diaphragm have been resected successfully and replaced by grafts of various sorts.

Thoracoabdominal aneurysms have presented an even greater challenge. A forgotten pioneer in the field of vascular surgery is the Austrian surgeon Ernst Jeger, who died at 30 in World War I. Jeger was a brilliant investigator who devised many vascular and cardiac procedures that included a procedure for complicated thoracoabdominal aneurysms. In 1913, Matas commented on Jeger's work,

“His contribution had a great bearing upon the future of aortic and visceral surgery. If it ever became practicable to transplant the coeliac axis, the mesenteric arteries and the renals from their normal origin…to other segments of the aorta, there was hope still left for this usually insurable class of aneurysms.”42

Etheredge, in 1955, described resection of this lesion. He used a temporary shunt from the distal thoracic aorta to the distal abdominal aorta. A homograft then was inserted, and the visceral vessels were implanted into the homograft.43 In 1956, DeBakey44 described a similar technique with a temporary bypass shunt. Shumacker45 modified this technique by using the homograft shunt as the permanent conduit, implanting the visceral vessels into the shunt, and then excising the aneurysm. In 1974, Stanley Crawford46 reported his experience. The earliest cases consisted of the insertion of a Dacron graft and the reattachment of consecutively involved branches to side-arm tube grafts that arose from the bypass graft. In the later cases, the graft was inserted inside the aneurysm with reattachment of visceral branch origins directly to an opening in the graft wall, which is the inclusion technique that we use today.

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ARTERIAL OCCLUSIVE DISEASE 

Rene Leriche (1879-1955) first published his observations on obliteration of the terminal aorta in 1923 and stated that the ideal treatment would be resection of the area and reestablishment of graft patency. In 1940, he published a detailed description of the syndrome that now bears his name. He recommended resection of the terminal aorta and common iliac arteries together with bilateral lumbar sympathectomy through a retroperitoneal approach. The results of this procedure were variable and depended on the preoperative status of the patient. His final observations on this syndrome, published in 1948, preceded by 2 years the operation of Jacques Oudot, which was resection of the terminal aorta with homograft replacement to restore graft patency, a procedure that had been recommended by Leriche47 in 1923, almost 30 years earlier.

A direct attack on occluded vessels was made by J. Cid dos Santos,48 of Portugal, in 1946. He performed the first successful thromboendarterectomy for peripheral occlusive disease and established this procedure as feasible. His first operation was performed August 27, 1946, on a left femoral artery, his second, on December 12, 1946, on a subclavian artery. Both of these cases were successful for the graft patency. This operation was termed disobliteration but came to be known as thromboendarterectomy or just endarterectomy. By 1948, Bazy, in France, had performed endarterectomies on 12 abdominal aortic occlusion cases, and Kunlin also had carried out the procedure in a number of cases in Leriche's clinic.

In 1951, aortic endarterectomy was introduced into the United States by E. Jack Wylie49 of San Francisco. Jack Cannon and Wiley Barker,50 of Los Angeles, were pioneers in the use of endarterectomy for femoral occlusive disease. Aortic endarterectomy was popularized by Wylie and by Robert Linton,51 of Boston. Endarterectomy has gradually given way to bypass grafting, except in the carotid area and in certain localized obstructions in other large vessels.

A giant step forward in the treatment of aortic occlusive disease was made on November 14, 1950. Oudot, another Frenchman, was the first to resect the terminal aorta for the Leriche syndrome and replace the aorta with a preserved 24-day-old homologous aortic graft with end-to-end anastomoses. Six months later, because of thrombosis of the right iliac limb of the graft, Oudot placed a crossover graft from the left distal external iliac to the right external iliac—the first extraanatomic bypass graft. Oudot, a famous mountaineer, died ironically in an automobile accident at the age of 40.52 Resection of the aortoiliac segment with graft replacement first gave way to endarterectomy and then gradually to aortoiliac or aortofemoral bypass graft, which left the native vessels in situ.

The principle of bypass graft surgery had been considered in the laboratory for some years, and Jean Kunlin, a French surgeon who worked in Leriche's clinic, performed the first long bypass graft of the femoral artery with a saphenous vein, on June 3, 1948, with both proximal and distal end-to-side anastomoses.53 The first patient treated by Kunlin was a 54-year-old man who previously had undergone an arteriectomy of the superficial femoral artery in the manner of Leriche. The patient's ischemia was not relieved, and Kunlin decided to perform a venous graft with end-to-end anastomoses. However, exposure of the previous operative sites was difficult because of a tremendous fibrotic reaction, and end-to-end anastomoses could not be done. Kunlin had no other choice but end-to-side implantations of the venous graft into the femoral artery above and below the resected area. Thus the bypass graft procedure was born by serendipity. The bypass graft principle was extended to the aorta by Frank Cockett, of London. Cockett probably performed the first aortic bypass graft for treatment of aortic thrombosis without removing the aorta in 1955.2 This operation was another step forward and was less demanding than aortoiliofemoral endarterectomy.

I will only mention other interesting historical aspects of aortic surgery because space does not permit discussion. These aspects include aortic embolectomy, aortoduodenal fistula, aortocaval fistula, dissecting aortic aneurysms, extraanastomotic bypass grafts, and the retroperitoneal approach to the aorta, which first was advocated by Astley Cooper in 1817.

In the early days of aortic surgery, a major problem that beset surgeons was proper fluid management during and immediately after the operative procedure. At first, we and others followed the recommendations that were current at that time: we avoided salt solutions and almost exclusively used limited quantities of dextrose in water. We found a high incidence of shock, oliguria, and renal shutdown with this regimen. An example of the results of such a regimen is emphasized in a 1966 report from Duke University. The report described 183 aortic aneurysm operations in which an average 2.5 L of dextrose in water plus blood usually comprised the 24-hour fluid complement.54 The operative mortality rate for elective aneurysms was 18%. The rate of development of azotemia of varying degrees in patients was 47%; 11% of the patients died of azotemia, and 10 of the 40 deaths were caused by renal failure.

As a result of such problems, we began to follow the recommendations of Shires et al.55 We began to use a regimen of 5% dextrose in lactated Ringer's solution or balanced salt solution in fairly large amounts of 3 to 4 L or about 600 ml/hr during the operation to keep the perioperative urinary output above 125 ml/hr. These large quantities compensated for the sequestration of extracellular fluid to maintain an effective circulating blood volume. With this regimen, hypotensive and renal complications of aortic surgery largely disappeared. In our 1968 report on the subject, we studied 474 cases of elective aortic surgery for both aneurysmal and occlusive disease, and only two patients died of renal failure, which was an incidence rate of 0.4% and an overall mortality rate of 3.2%.56 The use of proper amounts of balanced salt solution during aortic surgery is now well standardized.

Prominent individuals who have suffered from or have been treated for aortic disease are interesting to note. Albert Einstein had an abdominal aortic aneurysm that was wrapped with cellophane in 1949. The aneurysm ruptured 6 years later, on April 13, 1955. Surgical treatment was recommended, but Einstein rejected the surgery and remarked, “I want to go when I want. It is tasteless to prolong life artificially. I have done my share. It is time to go. I will do it elegantly.” On April 18, he died at Princeton, NJ, at the age of 76.57 By contrast, the Duke of Windsor traveled to Houston and had his aortic aneurysm repaired electively by Dr DeBakey, in 1965, with a very successful outcome.

Aortic surgery thus has had a fascinating history. From Cooper to Matas, 106 years were needed to obtain a successful outcome of aortic ligation for abdominal aortic aneurysms. However, more progress has been made in the last 50 years than in the preceding 2000 years since Antyllus ligated, incised, and packed his cases of aneurysms.

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☆ From the Department of Surgery, Baylor University Medical Center.

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Journal of Vascular Surgery
Volume 28, Issue 4 , Pages 746-752, October 1998

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