Jean Louis Petit

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Jean-Louis Petit (1731) was the first surgeon to study hae-mostasis [38].

The famous English surgeon Sir Astley Cooper, at Guy's Hospital, made two important contributions: a successful ligation of the common carotid artery for aneurysm in 1805 and in 1817 his attempt to treat an aneurysm of the iliac artery by ligation, for the first time, of the aorta above the bifurcation. He was also the first to use the ex-traperitoneal approach to the abdominal aorta, which was reintroduced by C. Rob in 1963 [56].

The end of the eighteenth and the beginning of the nineteenth century marked a golden age in which many surgeons contributed to knowledge on vascular diseases and surgery. There follows a brief description of their contributions. Hallowel applied the first arterial suture, an idea proposed by Lambert around 1770. In 1774 Morel, a

Fig. 1.1.1 William Harvey, Exercitatio Anatomica de Motu Cor-dis et Sanguinis in Animalibus [Anatomical Exercise on the Motion of the Heart and Blood in Animals]. Edition, Roterdami, A pud Arnoldum Leers A 1661. (From author's personal collection)

1.1.2 The Origin and the Foundations of European Vascular Surgery

military surgeon, applied the haemostatic tourniquet to the extremities in the battlefield. During the eighteenth century 123 studies had been conducted on aneurysms and their treatment with arterial ligation and the discussion on this topic continued until the middle of the twentieth century [38].

The pathologist Rudolf Virchow, the "Pope of German medicine", described in 1852 the existence of arterial embolism. He also coined the terms thrombosis and embolism and later described the aetiological triad of venous thrombosis known as Virchow's triad. In 1859 Karl Huet-er in Germany reported the first case of venous gangrene of the extremities [25].

The pioneer of vascular surgery in Russia was N. I. Pirogov who, in 1865, developed surgical approaches to the aorta and peripheral arteries, arguing against the dogmatic views that a vascular suture was not promising. P. Girsztowt of Warsaw recommended in 1868 the excision of the large varicose veins. Eugene Koeberle, a surgeon in Strasburg, invented a simple haemostatic clamp and applied it in surgery in 1868. It was the first operation actually ushering in our present technique of clamping and tying, which was carried out and popularized by J. Pean with a clamp he invented in 1869 [38]. N. V. Ekk, an outstanding Russian surgeon and physiologist in Pavlov's laboratory in St. Petersburg, performed in

Fig. 1.1.2 This illustration depicts one of William Harvey's experiments included in the book Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus. Harvey shows that venal blood flows only towards the heart. He ligatured an arm to make obvious the veins and their valves, then pressed blood away from the heart and showed that the vein would remain empty because it was blocked by the valve

Fig. 1.1.2 This illustration depicts one of William Harvey's experiments included in the book Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus. Harvey shows that venal blood flows only towards the heart. He ligatured an arm to make obvious the veins and their valves, then pressed blood away from the heart and showed that the vein would remain empty because it was blocked by the valve

1877 the first experimental vascular anastomosis between the portal vein and the inferior vena cava (Ekk's fistula) [54]. Rudolf Matas, born in Louisiana USA and trained in the USA (with additional training in Paris and Barcelona), made history in 1888 by performing the first endoan-eurysmorraphy for a traumatic aneurysm of the brachial artery [22]. In 1895 the Russian surgeon I. F. Sabaneyev made the first attempt in the world to remove an embolus from the femoral artery while the Russian R. R. Vreden performed in 1897 the first retrograde embolectomy of the aorta with limited success [54]. In 1896 the Lyon veterinarian M. Jaboulay proposed in the journal Lyon Medical an inverted suture of the arteries, known as the mattress-suture. Interestingly, this suture technique was clinically applied 50 years later by A. Blalock in Baltimore, USA [23]. In 1897 the Turkish Cemil Topuzlu Pacha, Pean's pupil, repaired an axillary artery with five stitches [3]. Jaboulays technique was improved by one of his pupils, Alexis Carrel, who in 1902 published the technique of suturing the vessels in Lyon Medical. Also during this period Carrel performed outstanding research work in Lyon on arterial suturing and transplantation of arteries and organs. He successfully performed the first experimental cardiac homo-transplantation in the world, transplanting the heart of an animal to the neck of another by joining the carotid arteries (!). He published his work in the journal Lyon Medical in 1902 [24]. Carrel left Lyon in 1904 for Canada and the USA later, following political-religious turmoil due to his testimony of a miracle at Lourdes. In Chicago as Director of the Hull Laboratory of Physiology at the University of Chicago in collaboration with Charles C. Guthrie, he mastered his suturing techniques as the well-known Carrel's Triangulation Techniques, and also the venous patch grafts made to enlarge the diameter of arteries. Later as Director of the Department of Experimental Surgery, at the Rockefeller Institute for Medical Research in New York, he worked on the preservation of arterial and venous segments for replacement of arteries and veins. He performed canine transections and end-to-end anastomosis of the descending aorta, or inserted a segment of preserved vena cava between the divided segments of the aorta. He also experimented with the insertion of a paraffined tube as an internal shunt within the aortic lumen in order to prolong the time of safe occlusion [24]. In addition to transplanting vessels and organs, Carrel worked on tissue cultures and organ preservation. The Norwegian R. Ingebrigtsen participated in this work and performed later interesting scientific work on arteriovenous fistulae in his country. In

1906, Carrel wrote the following instructions which are still valid a century later: "The vessels must be handled very gently and the endothelium must be protected.. .No dangerous metallic forceps are used. Great care is exercised to obtain accurate and smooth approximation of the endothelium of the vessel without invagination. Sutures should be made with very fine needles while the wall is somewhat stretched. Stenosis or occlusion only occurs as a result of faulty technique" [24]. Carrel received the Nobel Prize in Physiology and Medicine in 1912 for his spectacular experimental work [24]. During the ceremony of presentation of the Prize, the President of the Committee J. Ackerman among other things also said "To the great intelligence you have received from your mother country, France, to whom humanity owes so many great things, is united the energy and resolve of your adapted country. Your miraculous operations are the evident result of this happy collaboration..". With his associate C. A. Lindbergh (famed for making the first solo airplane transatlantic flight in 1927) he developed in 1935 the first mechanical heart, a pump for circulating blood or fluids through preserved organs, namely the precursor of the extra-corporeal circulation which is in use today [24]. C.A. Lindbergh wrote in 1974 "medical scientists evaluating his work in the light of modern developments have said that he was fifty to a hundred years ahead of his time" [24].

In 1901, the Austrian Erwin Payr performed a vascular anastomosis with absorbable magnesium rings. Also arterial suturing was applied experimentally by Stich and Makkas (Germany) and many others [38]. In 1902 Tuffier attempted the resection of a syphilitic aneurysm of the ascending aorta but the patient died on the 13th day. Joe Goyanes of Madrid in 1929, after excision of a popliteal aneurysm, used an adjacent segment of popliteal vein to successfully bridge the defect (the first in situ vein graft) [27]. Six months later Erich Lexer at the University Hospital in Konigsberg, Germany performed excision of an axillary aneurysm and restored the arterial continuity by using a segment of the great saphenous vein [43]. This case was reported in the prestigious journal Archiv für Klinische Chirurgie which was read assiduously by prominent surgeons in Europe and in the United States. Among them was the American William S. Halsted, the famous first Professor of Surgery at the Johns Hopkins Medical School and Hospital, who had trained in Europe and, besides pioneering radical surgery of breast cancer, was also interested in vascular surgery, establishing a school of experimental vascular surgery. He studied various types of arterial ligatures, among which was banding to achieve progressive arterial occlusion in order to reduce the size of distal aneurysms. In 1892 he successfully ligated the first part of the subclavian artery for the treatment of a huge distal aneurysm. Georges Labey, in 1911, performed the first successful arterial embolectomy of the extremities in the world [41], although there is information that in the same year the Hungarian surgeon J. Bakay performed a direct femoral embolectomy (D. Dzsinich, personal communication). In 1914 in Innsbruck, Austria, Hans von Haberer was the first surgeon to excise a false aneurysm of the carotid artery and to restore its continuity by an end-to-end anastomosis. He also published a monograph on "Kriegsaneurysmen" reporting on 72 operated cases of aneurysms [26].

During the First World War the pioneer Polish vascular surgeon Romuald Weglowski recommended the direct arterial reconstruction of arterial injuries, also using venous grafts for arterial bridging [57]. Vojislav Soubbotich, a pioneer vascular surgeon in Serbia during the Balkan wars (1912-14), performed repair, instead of ligation, of the injured vessels and of the post-traumatic aneurysms by using circular and lateral sutures, an experience commented on favourably by R. Matas [45, 59]. It is ironic that nearly 40 years passed before similar efforts were successful during the latter part of the Korean conflict [55].

Friedrich Trendelenburg, in Leipzig Germany, introduced an operation for varicose veins and in 1907 attempted a pulmonary embolectomy; however, he saw his pupil W. Kirchner perform a successful embolectomy in 1924, which was popularized later by many surgeons in Europe and the USA [40]. I was fortunate to attend the first pulmonary embolectomy under extra-corporeal circulation by Denton Cooley and A. Bell in 1960 at Saint Luke's Hospital in Houston, Texas.

The great breakthrough in the diagnosis of arterial diseases was the introduction of arteriography, namely the opacification of the arterial lumen, disclosing the abnormalities and even the occlusion of the artery, by intra-ar-terial injection of a liquid opacified by X-rays, which was first performed by J. Coapody in 1925 [13]. In Lisbon in 1926 EgazMoniz, a Portuguese neurosurgeon, performed the first intra-carotid injection of thorium dioxide for the opacification of the carotid artery in a case of brain tumour [49]. Reynaldo dos Santos, a professor of urology in Lisbon, had performed the first translumbar aortography in 1929 [20] (Fig. 1.1.3).

The first successful replacement of a semi-occluded femoral artery with a segment of the large saphenous

Fig. 1.1.3 A copy of the original aortograph performed by Reynaldo dos Santos in 1929, kindly given to the author by his son Joao Cid dos Santos in Lisbon in 1969

vein was performed by the Russian N. A. Bogoraz in 1935 (cited by A.N. Filatov) [54].

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