Historical Aspects in the Development of Venous Autografts LYNN H. HARRISON, JR., M.D.
During the past 75 years much progress has occurred in the field of vascular surgery. During this period, contributions from clinical surgeons have stimulated new scientific discoveries which have led to further clinical applications in a mutually perpetuating cycle of surgical advancement. One of the major achievements has been the use of the venous autograft employed as an arterial substitute. First used by Goyanes in 1906 to replace a popliteal aneurysm, a venous autograft was first success'ully employed in the United States by Bernheim in 1915. The stepwise development of this aspect of modern vascular surgery is presented, and the role of other related contributions in making its use feasible is reviewed.
I N THE PROGRESS of vascular surgery, the events between 1888 and 1967 represent the period of most
significant development. Beginning with Matas' introduction of endoaneurysmorrhaphy'6 and extending to the popularization of vein grafts to bypass coronary artery obstructions by Favaloro,6 this interval is characterized as one of remarkable achievement. Why was this period marked by such ferment? Was it the result of a technical advance which suddenly opened new horizons? Was it simply part of a generalized acceleration in medical progress which began at the turn of the century and is still going on today? The answers to these questions provide a lesson in the importance of history to medicine and represent a study in the absolute interdependence of basic and clinical research. For centuries, surgeons had brought the techniques of amputation, incision and drainage to bear on problems not amenable to "diet or drugs." With the advent of anesthesia and antisepsis, however, a new group of problems arose demanding the surgeon's attention. The philosophy of removal began to be supplanted by the concept of repair. This was nowhere more apparent than in the nascent field of vascular surgery, where simple ligation of an injured vessel often entailed significant Received for publication June 9, 1975.
101
From the Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710
tissue loss secondary to gangrene. In the presence of an aneurysm, there was the additional danger of rupture and almost certain death from hemorrhage, since collateral vessels frequently supplied the aneurysm and were not included in the usual ligation procedure. Therefore, when Rudolph Matas (Fig. 1) reported the technique of endoaneurysmorrhaphy in 1902, 14 years after his first clinical application of the procedure,16 a great advance was achieved. The method was most effective in preventing recurrence of the aneurysm; however, it did interrupt normal circulatory pathways and the incidence of gangrene, though low (5-7% in Dr. Matas' hands), was nevertheless troublesome. The next logical step was resection of a segment of artery and primary reanastomosis of the severed ends. This was accomplished in 1895 by Zoege von Manteuffel,'5 and in the following year Murphy of Chicago achieved the first successful repair of an arteriovenous fistula-aneurysm with restoration of normal circulatory pathways.19 Although this approach was simple, elegant and permitted maintenance of vascular continuity, considerable problems occurred with thrombosis at the suture line. The large needles, bulky suture materials and techniques previously quite serviceable in general surgery were inadequate in the delicate and exacting world of blood vessels. Isolated clinical reports indicated that extensive vascular reconstruction was a possibility. It required the landmark contributions of laboratory scientists, however, to overcome the technical problems barring its widespread application. Although there were numerous contributors to this work, the names of Stich, Jaboulay, Murphy, Carrel and Guthrie are preeminent, and that of Alexis Carrel is the most impressive. Through
102
Ann. Surg.
HARRISON
o
February 1976
ports a fascinating case in which he transected the iliac artery and anastomosed it to the, iliac vein, which had been
ligated proximally. The femoral vein just above the knee then divided and the proximal end anastomosed to the distal femoral artery, thus bypassing the area of arterial obstruction in the upper thigh. The procedure appears to have been at least temporarily successful in restoring circulation to the lower leg, although extensive followup is not given. In the second section of his paper, Goyanes reports the case of a 41-year-old candymaker who had developed a syphilitic aneurysm of the popliteal artery over a five month period. On June 12, 1906, Dr. Goyanes removed the aneurysm and, since approximation of the severed vessels was not possible, a segment of popliteal vein was excised and used as a graft connecting the severed ends of the artery. Although the patient sustained a postoperative wound infection (probably secondary to gelatin which was injected into the popliteal space preoperatively in an attempt to encourage scar formation around the aneurysm), he eventually recovered with preservation of circulation in the extremity. Goyanes published this report in El Siglo Medico, a weekly medical bulletin which was not widely read outside Spain, and Rudolph Matas, 1860-1957. Matas' endoaneurysmorrhaphy therefore the achievement went largely unnoticed. Within was
*-.. '.''. '-
:ftr. W:._...r'
...
FIG. 1. constituted the first major advance in the treatment of aneurysm since the days of Antyllus.
painstaking basic research spanning the decade beginning in 1901, Carrel (Fig. 2), working first with Morel at Lyons University and later with Guthrie at the University of Chicago, laid the foundations of modern vascular suturing techniques, as well as pioneering the field of tissue and organ transplantation. The principles of his technique remain as sound today as when he first described them, almost 70 years ago: . . . The results of the present blood-vessel surgery will be enhanced by the use of our methods of temporary hemostasis, of (gently) handling the vessels, of washing them with isotonic sodium chloride solution, of impregnating the threads and coating the vascular wall with vaseline, of exactly approximating the internal layers without invagination, and of suturing with very fine needles while the wall is somewhat stretched.4
The work of Carrel and Guthrie was widely reported in the world medical literature and Carrel was honored in 1912 with the Nobel Prize for Physiology and Medicine. Important clinical advances followed closely on the heels of Carrel's discoveries. In June of 1906, Jose Goyanes of Spain (Fig. 3) performed what was to this author's knowledge the first successful interposition of a venous graft for an aneurysmal arterial segment in man.9 Well versed in the experimental work of Jaboulay,12 Carrel, Murphy and others, Goyanes provides a brief history of vascular surgery and suturing techniques in his two-part paper and credits his teacher, Professor San Martin, with the concept of substituting a venous graft for an excised segment of artery. In the first section of his paper, Goyanes re-
Alexis Carrel,
FIG
2
field
of vascular surgery,
1873-1944.
Carrel
Medicine and Physiology in 1912.
For his basic contributions to the was
awarded
the
Nobel
Prize in
Vol. 183oNo. 2
VENOUS AUTOGRAFTS
103
clinical case. A segment of the greater saphenous vein some 10 centimeters in length was removed from the patient's leg and used to join the ends of the bisected axillary artery. Although the graft functioned beautifully, the patient died of delirium tremens on the fifth postoperative day. Lexer performed the postmortem examination himself and noted that the graft was patent. Although there was a small, non-occluding thrombus on the inner wall of the axillary artery where a clamp had been applied, the suture lines were free of thrombus. Lexer reported this patient at the Thirty-sixth Congress of the G-Yerman Society for Surgery in April 1907, and published it in that same year in the prestigious Archiv fur klinische Chirurgie. 13 The journal was read assiduously by a number of prominent surgeons in the United States, as well as virtually the entire European surgical community. Among those Americans who read Professor Lexer's article was William S. Halsted, Professor of Surgery at the Johns Hopkins Hospital and generally recognized as the foremost scholar of American surgery. Halsted was an admirer of Lexer, as he was of German surgeons in general, and he suggested to his associate, Bertram Bernheim, that he pursue this technique experimentally in animals. Bernheim (Fig. 5), son of a wealthy Kentucky distilling family, had graduated from Johns Hopkins Medical School in 1905, after which he had chosen to
FIG. 3. Jose Goyanes, 1876- . In 1906, Goyanes reported the first use of an autologous vein graft as an arterial substitute in man.
6 months, however, Erich Lexer (Fig. 4), Professor of Surgery at Konigsberg, faced a similar problem. He, too, was familiar with the experimental work of Carrel, Murphy and of Stich, for whom Lexer had particular esteem. The patient was a 69-year-old man who had suffered a subcoracoid dislocation of the shoulder 9 weeks previously. An attempt to reduce the dislocation had resulted in an injury to the axillary artery and the formation of a large false aneurysm in the axilla. Several months before, Lexer had been successful in resecting a popliteal aneurysm with primary reanastomosis of the artery using a modification of Payr's magnesium vessel prosthesis. When confronted with a hiatus of some 8 centimeters between the severed ends of the axillary and brachial arteries, however, Lexer recognized that a primary anastomosis was not possible. Fearing that the size and traumatic etiology of the aneurysm had not allowed development of adequate collateral flow to susFIG. 4. Erich Lexer, 1867-1937. An early genius in the field of recontain the arm if the artery were simply ligated, Lexer structive surgery, Lexer independently demonstrated the feasibility chose to apply the experimental work of Stich23 to this of venous arterial grafts within a year of the report by Goyanes.
104
Ann. Surg. * February 1976
HARRISON
tive, so the presumed diagnosis was a syphilitic aneurysm of the popliteal artery. Before operating on the patient, Bernheim performed the Moszkowicz test,* the results of which indicated that insufficient collateral circulation had developed to prevent loss of the leg if permanent interruption of the popliteal blood flow proved to be necessary. On the morning of September 3, 1915, at the Union Protestant Infirmary in Baltimore, Bernheim exposed the aneurysm "prepared to do any operation that might be indicated."2 It was necessary to remove some 15 cm of popliteal artery, which he replaced with a 12 cm segment of saphenous vein. The patient enjoyed an uneventful recovery, and Bernheim presented the case before the Johns Hopkins Hospital Medical Society on October 18, 1915, where it received great acclaim from Dr. Halsted. Other cases followed, and the concept of vascular reconstructive surgery was on its way to becoming a reality. During the next 20 years (1915-1935), the last remaining obstacles to the development of vascular surgery as a * A clinical test used to assess the extent of collateral circulation in an extremity.17
FIG. 5. Bertram M. Bernheim, 1880-1957. Though always in the shadow of Halsted and Cushing, Bermheim made important contributions in the areas of blood transfusion and vascular reconstruction. He was the first American to substitute a segment of vein for an artery in man.
spend a period of 18 months in Germany working in hospitals in Baden, Freiburg and Berlin. Returning briefly to his home in Kentucky, Bernheim felt the need of further surgical training and applied to Dr. Halsted for a position. Halsted afforded him the opportunity of working in the Hunterian Laboratory under the direction of Harvey Cushing. Acting upon Dr. Halsted's suggestion that he attempt to duplicate Lexer's work in the laboratory, Bernheim soon found he had an affinity for meticulous vascular work. In 1909, Halsted called upon Bentheim to attempt a long venous graft (12-14 cm) to repair a defect in the popliteal artery created by removal of a sarcoma in the popliteal space. In this case the graft failed because of thrombosis; however, Bernheim continued his work and by 1913 was able to publish an authoritative monograph on vascular surgical techniques, in which he made significant early contributions.1 Bernheim apparently achieved recognition as a vascular surgeon because of this monograph, and in August 1915, a patient was referred to him by Dr. William Bruce of Sydney, Nova Scotia. The patient was a 43-year-old man who had over the course of three months developed a painful swelling in the right popliteal fossa. The patient had a FIG.
history of syphilis and his Wassermann reaction was posi-
6
Wilhelm Konrad
radiation
Rntgen, 1845-1923. Discoverer of gamma Rontgen was awarded the Nobel Prize in Physics for 1901.
Vol. 183 . No. 2
VENOUS AUTOGRAFTS
full-fledged discipline were overcome. These obstacles centered on the problems of accurate preoperative diagnosis and prevention of thrombosis in the intraoperative period. With aneurysms of the extremities, diagnosis posed no particular problem, for the site of the pathological lesion was clinically manifest. In the case of atherosclerotic lesions, which were considerably more common than aneurysms, there were no surface indicators of the precise location of the lesion. The problem was a difficult one and required the birth of a completely new clinical science to overcome it. On November 8, 1895, a relatively obscure physicist performing basic research at the Institute of Physics, Wurzburg University, first observed the new rays which were to become a cornerstone of the diagnostic armamentarium in virtually every branch of medicine.20 The man's name, of course, was Wilhelm Konrad Rontgen (Fig. 6), and in his discovery lay the key to accurate diagnosis of vascular lesions. I'n 1918, D. F. Cameron published a paper on the use of iodide salts as a contrast medium in roentgenography.3 This work stimulated Sicard and Forestier who are credited with the develo'pment of an iodized poppyseed oil (Lipiodol) which was the first vascular contrast medium to be used in humans.21 With Forssmann's report of the first successful cardiac catheterization in 1929,7 virtually every segment of the vascular'circuit was opened to diagnostic examination. The solution to the problem of thrombosis lay in basic research, and the man who almost single-handedly solved it was William Henry Howell. Born in Baltimore and a product of Johns Hopkins, Howell and Jay MacLean, a medical student, working in Howell's laboratory, happened upon an anticoagulant which they extracted from liver while trying to isolate thromboplastin.14 Howell named this substance "heparin,"11 and with the discovery by Charles and Scott of a means for large scale extraction of heparin from beef liver and lung in 1933,5 the problem of intraoperative thrombosis was solved. While basic and clinical research was providing the means for peripheral vascular surgery, the World Wars demonstrated the need. According to Matas, one-fourth of the wounded treated at the front in World War I required special attention for injuries of the blood vessels, and at the base hospitals 2% of the wounded were admitted for the treatment of traumatic aneurysms."8 If the first World War demonstrated the need, it also demonstrated the fact that most surgeons were inadequately trained in vascular techniques to fill that need. The improved results obtained in the treatment of vascular combat injuries in World War II and the Korean War were attributable to several factors, among them better evacuation methods, improved treatment of hemorrhagic shock, blood banking and the advent of antibiotics. In large part, however, this was a result of increased skill and better training in vascular surgical techniques.
105 After the War, experience gained in the management of traumatic lesions was applied to the problem of acquired obstructive disease. In 1950, Holden reported the use of a saphenous vein to bypass an atherosclerotic femoral artery occlusion, with prior angiographic demonstration of the site of the lesion.10 In the following year, Voorhees, Jaretzki and Blakemore opened further the horizons of vascular surgery with their report of a synthetic substitute for blood vessels, Vinyon "N.' '24 Although this original graft material did not withstand the test of time, its descendants are now a mainstay of vascular reconstructive
operations everywhere. The remaining achievement of this extraordinarily productive period in the history of vascular surgery was a logical extension of the techniques of catheterization and vein grafting. In 1958, at the Cleveland Clinic, Sones successfully performed selective coronary angiography, allowing forthe first time antemortem correlation of electrocardiographic' and hemodynamic parameters with specific alterations in myocardial perfusion.22 The logical extension of this work was the application of vein grafting techniques to the coronary circulation. In Baltimore in 19b2, a 41-year-old patient who had had a previous right coronary endarterectomy for angina pectoris returned with recurrence of symptoms. Coronary arteriography was performed and demonstrated complete occlusion of the previously endarterectomized segment. Faced with the obvious -shortcomings of the endarterectomy technique on the one hand and on the other with the incapacitating symptoms of the patient, Sabiston performed an aorta-to-right coronary artery graft using an autologous saphenous vein. Unfortunately, the patient suffered a cerebrovascular accident in the postoperative period and expired three days later. At autopsy, thrombus was present at the aortic anastomosis, and this was the presumed source of the fatal stroke. This complication discouraged further pursuit of the technique at that time. In 1964, Garrett and associates at Baylor performed a successful graft from the aorta to the left coronary artery and demonstrated patency 7 years later.8 The pioneering work of Rene Favaloro established the aorto-coronary bypass graft as a feasible proced9re.6 This work was accomplished at the Cleveland Clinic, where Sones had earlier perfected the diagnostic technique of selective coronary arteriography almost a decade before. The significance of this advance is indicated by the fact that over half of the procedures in which cardiopulmonary bypass was used in 1972 involved vein grafts to the coronary arteries. There have been many contributors to the field of vascular surgery whose work has been omitted from this brief survey only because a complete coverage of the subject would be impossible except in a major work. The justification for choosing the contributors and events of this particular period lies in' the fact that this represented
Ann. Surg. m February 1976 HARRISON a time of accelerated progress and, more importantly, 8. Garrett, H. E., Dennis, E. W. and DeBakey, M. E.: Aortocoronary Bypass with Saphenous Vein Graft. Seven-year that it is a classic example of the symbiotic relationship Follow-up. JAMA, 223:792, 1973. between basic and clinical research. This latter point is in 9. Goyanes, D. J.: Substitution Plastica de las Arterias por las Venas, 6 Arterioplastia Venosa, Aplicada, Como Nuevo Metodo, al danger of being forgotten in the current period of inTratamiento de los Aneurismas. El Siglo Medico, Sept. 1, 1906; creased demand for "clinical relevance" in the allocation p. 346; Sept. 8, 1906, p. 561. of our research support and efforts. Yet clinical investiga- 10. Holden, W. D.: Reconstruction of the Femoral Artery for Arteriosclerotic Thrombosis. Surgery, 27:417, 1950. tion without basic research grows rapidly sterile, and W. H. and Holt, E.: New Factors in Blood Coagulationbasic research without clinical application becomes 11. Howell, Heparin and Pro-antithrombin. Am. J. Physiol., 47:328, 1918. rapidly impotent. That this interplay between the research 12. Jaboulay, M.: Recherches Experimentales sur la Suture et la Greffe Arterielles. Lyons Med., 1896; p. 97. laboratory and the clinical situation is a sine qua non for E.: Die ideale Operation des Arteriellen und des Arteriellmedical progress is one of the lessons of history. The 13. Lexer, venosen Aneurysma. Archiv. Klin. Chir., 83:459, 1907. development of vascular surgery is clearly a striking 14. MacLean, J.: The Thromboplastic Action of Cephalin. Am. J. Physiol., 41:250, 1916. example.
106
Acknowledgments The author wishes to thank Mrs. Bertram Bernheim for contributing biographical information concerning her husband, Professor Bernheim. Thanks are also due Kaye Townsend and Sandra Justice for assistance in preparing the manuscript.
References 1. Bernheim, B. M.: Surgery of the Vascular System. Phila. J. B. Lippincott Co., 1913. 2. Bernheim, B. M.: The Ideal Operation for Aneurysm of the Extremity. Report of a Case. Bull. Johns Hopkins Hosp., 27:93, 1916. 3. Cameron, D. F.: Aqueous Solutions of Potassium and Sodium Iodide as Opaque Medium in Roentgenography. JAMA, 70:754, 1918. 4. Carrel, A.: The Surgery of Blood Vessels. Bull. Johns Hopkins Hosp., 190:18, 1906. 5. Charles, A. F. and Scott, D. A.: Studies on Heparin. J. Biol. Chem., 102:425, 1933. 6. Favaloro, R.: Saphenous Vein Autograft Replacement of Severe Segmental Coronary Artery Occlusion. Ann. Thorac. Surg., 5:334, 1968. 7. Forssmann, W.: Die Sondierung des rechten Herzens. Klin. Wochnsch, 8:2085, 1929.
15. von Manteuffel, Z.: Demonstration eines Praparates von Aneurysma arteriovenosum ossificans der Arteria femoralis profunda. Chirurgencongress-Verhandlungen I, 1895; p. 167. 16. Matas, R.: An Operation for the Radical Cure of Aneurism Based Upon Arteriorrhaphy: With the Report of Four Cases Successfully Operated Upon by the Author. Trans. Am. Surg. Assoc., 20:396, 1902. 17. Matas, R.: Testing the Efficiency of the Collateral Circulation as a Preliminary to the Occlusion of the Great Surgical Arteries. JAMA, 63:1441, 1914. 18. Matas, R.: Endoaneurismorrhaphy. Surg. Gynecol. Obstet., 30: 456, 1920. 19. Murphy, J. B.: Resection of Arteries and Veins Injured in Continuity. Med. Rec., 51:73, 1897. 20. Rontgen, W. K.: Uber eine neue Art von Strahlen. (trans.) Nature, 53:274, 1896. 21. Sicard, A. and Forestier, J.: L'huile iodee en clinique; applications therapeutiques et diagnostiques. Bull. Mem. Hop. Par., 47:309, 1923. 22. Sones, F. M., Jr. and Shirey, E. K.: Cine Coronary Arteriography. Mod. Con. Cardiovasc. Dis., 31:735, 1962. 23. Stich, R., Makkas, M., and Dowman, C. E.: Beitrage zur Gefasschirurgie; cirkulare Arteriennaht und Gefasstransplantationen. Beitr. Klin. Chir., 53:113, 1907. 24. Voorhees, A. B., Jaretzski, A., III, and Blakemore, A. H.: The Use of Tubes Constructed from Vinyon "N" Cloth in Bridging Arterial Defects: A Preliminary Report. Am. Surg., 135:332, 1952.
During the past 75 years much progress has occurred in the field of vascular surgery. During this period, contributions from clinical surgeons have stimulated new scientific discoveries which have led to further clinical applications in a mutually perpetuating cycle of surgical advancement. One of the major achievements has been the use of the venous autograft employed as an arterial substitute. First used by Goyanes in 1906 to replace a popliteal aneurysm, a venous autograft was first success'ully employed in the United States by Bernheim in 1915. The stepwise development of this aspect of modern vascular surgery is presented, and the role of other related contributions in making its use feasible is reviewed.
I N THE PROGRESS of vascular surgery, the events between 1888 and 1967 represent the period of most
significant development. Beginning with Matas' introduction of endoaneurysmorrhaphy'6 and extending to the popularization of vein grafts to bypass coronary artery obstructions by Favaloro,6 this interval is characterized as one of remarkable achievement. Why was this period marked by such ferment? Was it the result of a technical advance which suddenly opened new horizons? Was it simply part of a generalized acceleration in medical progress which began at the turn of the century and is still going on today? The answers to these questions provide a lesson in the importance of history to medicine and represent a study in the absolute interdependence of basic and clinical research. For centuries, surgeons had brought the techniques of amputation, incision and drainage to bear on problems not amenable to "diet or drugs." With the advent of anesthesia and antisepsis, however, a new group of problems arose demanding the surgeon's attention. The philosophy of removal began to be supplanted by the concept of repair. This was nowhere more apparent than in the nascent field of vascular surgery, where simple ligation of an injured vessel often entailed significant Received for publication June 9, 1975.
101
From the Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710
tissue loss secondary to gangrene. In the presence of an aneurysm, there was the additional danger of rupture and almost certain death from hemorrhage, since collateral vessels frequently supplied the aneurysm and were not included in the usual ligation procedure. Therefore, when Rudolph Matas (Fig. 1) reported the technique of endoaneurysmorrhaphy in 1902, 14 years after his first clinical application of the procedure,16 a great advance was achieved. The method was most effective in preventing recurrence of the aneurysm; however, it did interrupt normal circulatory pathways and the incidence of gangrene, though low (5-7% in Dr. Matas' hands), was nevertheless troublesome. The next logical step was resection of a segment of artery and primary reanastomosis of the severed ends. This was accomplished in 1895 by Zoege von Manteuffel,'5 and in the following year Murphy of Chicago achieved the first successful repair of an arteriovenous fistula-aneurysm with restoration of normal circulatory pathways.19 Although this approach was simple, elegant and permitted maintenance of vascular continuity, considerable problems occurred with thrombosis at the suture line. The large needles, bulky suture materials and techniques previously quite serviceable in general surgery were inadequate in the delicate and exacting world of blood vessels. Isolated clinical reports indicated that extensive vascular reconstruction was a possibility. It required the landmark contributions of laboratory scientists, however, to overcome the technical problems barring its widespread application. Although there were numerous contributors to this work, the names of Stich, Jaboulay, Murphy, Carrel and Guthrie are preeminent, and that of Alexis Carrel is the most impressive. Through
102
Ann. Surg.
HARRISON
o
February 1976
ports a fascinating case in which he transected the iliac artery and anastomosed it to the, iliac vein, which had been
ligated proximally. The femoral vein just above the knee then divided and the proximal end anastomosed to the distal femoral artery, thus bypassing the area of arterial obstruction in the upper thigh. The procedure appears to have been at least temporarily successful in restoring circulation to the lower leg, although extensive followup is not given. In the second section of his paper, Goyanes reports the case of a 41-year-old candymaker who had developed a syphilitic aneurysm of the popliteal artery over a five month period. On June 12, 1906, Dr. Goyanes removed the aneurysm and, since approximation of the severed vessels was not possible, a segment of popliteal vein was excised and used as a graft connecting the severed ends of the artery. Although the patient sustained a postoperative wound infection (probably secondary to gelatin which was injected into the popliteal space preoperatively in an attempt to encourage scar formation around the aneurysm), he eventually recovered with preservation of circulation in the extremity. Goyanes published this report in El Siglo Medico, a weekly medical bulletin which was not widely read outside Spain, and Rudolph Matas, 1860-1957. Matas' endoaneurysmorrhaphy therefore the achievement went largely unnoticed. Within was
*-.. '.''. '-
:ftr. W:._...r'
...
FIG. 1. constituted the first major advance in the treatment of aneurysm since the days of Antyllus.
painstaking basic research spanning the decade beginning in 1901, Carrel (Fig. 2), working first with Morel at Lyons University and later with Guthrie at the University of Chicago, laid the foundations of modern vascular suturing techniques, as well as pioneering the field of tissue and organ transplantation. The principles of his technique remain as sound today as when he first described them, almost 70 years ago: . . . The results of the present blood-vessel surgery will be enhanced by the use of our methods of temporary hemostasis, of (gently) handling the vessels, of washing them with isotonic sodium chloride solution, of impregnating the threads and coating the vascular wall with vaseline, of exactly approximating the internal layers without invagination, and of suturing with very fine needles while the wall is somewhat stretched.4
The work of Carrel and Guthrie was widely reported in the world medical literature and Carrel was honored in 1912 with the Nobel Prize for Physiology and Medicine. Important clinical advances followed closely on the heels of Carrel's discoveries. In June of 1906, Jose Goyanes of Spain (Fig. 3) performed what was to this author's knowledge the first successful interposition of a venous graft for an aneurysmal arterial segment in man.9 Well versed in the experimental work of Jaboulay,12 Carrel, Murphy and others, Goyanes provides a brief history of vascular surgery and suturing techniques in his two-part paper and credits his teacher, Professor San Martin, with the concept of substituting a venous graft for an excised segment of artery. In the first section of his paper, Goyanes re-
Alexis Carrel,
FIG
2
field
of vascular surgery,
1873-1944.
Carrel
Medicine and Physiology in 1912.
For his basic contributions to the was
awarded
the
Nobel
Prize in
Vol. 183oNo. 2
VENOUS AUTOGRAFTS
103
clinical case. A segment of the greater saphenous vein some 10 centimeters in length was removed from the patient's leg and used to join the ends of the bisected axillary artery. Although the graft functioned beautifully, the patient died of delirium tremens on the fifth postoperative day. Lexer performed the postmortem examination himself and noted that the graft was patent. Although there was a small, non-occluding thrombus on the inner wall of the axillary artery where a clamp had been applied, the suture lines were free of thrombus. Lexer reported this patient at the Thirty-sixth Congress of the G-Yerman Society for Surgery in April 1907, and published it in that same year in the prestigious Archiv fur klinische Chirurgie. 13 The journal was read assiduously by a number of prominent surgeons in the United States, as well as virtually the entire European surgical community. Among those Americans who read Professor Lexer's article was William S. Halsted, Professor of Surgery at the Johns Hopkins Hospital and generally recognized as the foremost scholar of American surgery. Halsted was an admirer of Lexer, as he was of German surgeons in general, and he suggested to his associate, Bertram Bernheim, that he pursue this technique experimentally in animals. Bernheim (Fig. 5), son of a wealthy Kentucky distilling family, had graduated from Johns Hopkins Medical School in 1905, after which he had chosen to
FIG. 3. Jose Goyanes, 1876- . In 1906, Goyanes reported the first use of an autologous vein graft as an arterial substitute in man.
6 months, however, Erich Lexer (Fig. 4), Professor of Surgery at Konigsberg, faced a similar problem. He, too, was familiar with the experimental work of Carrel, Murphy and of Stich, for whom Lexer had particular esteem. The patient was a 69-year-old man who had suffered a subcoracoid dislocation of the shoulder 9 weeks previously. An attempt to reduce the dislocation had resulted in an injury to the axillary artery and the formation of a large false aneurysm in the axilla. Several months before, Lexer had been successful in resecting a popliteal aneurysm with primary reanastomosis of the artery using a modification of Payr's magnesium vessel prosthesis. When confronted with a hiatus of some 8 centimeters between the severed ends of the axillary and brachial arteries, however, Lexer recognized that a primary anastomosis was not possible. Fearing that the size and traumatic etiology of the aneurysm had not allowed development of adequate collateral flow to susFIG. 4. Erich Lexer, 1867-1937. An early genius in the field of recontain the arm if the artery were simply ligated, Lexer structive surgery, Lexer independently demonstrated the feasibility chose to apply the experimental work of Stich23 to this of venous arterial grafts within a year of the report by Goyanes.
104
Ann. Surg. * February 1976
HARRISON
tive, so the presumed diagnosis was a syphilitic aneurysm of the popliteal artery. Before operating on the patient, Bernheim performed the Moszkowicz test,* the results of which indicated that insufficient collateral circulation had developed to prevent loss of the leg if permanent interruption of the popliteal blood flow proved to be necessary. On the morning of September 3, 1915, at the Union Protestant Infirmary in Baltimore, Bernheim exposed the aneurysm "prepared to do any operation that might be indicated."2 It was necessary to remove some 15 cm of popliteal artery, which he replaced with a 12 cm segment of saphenous vein. The patient enjoyed an uneventful recovery, and Bernheim presented the case before the Johns Hopkins Hospital Medical Society on October 18, 1915, where it received great acclaim from Dr. Halsted. Other cases followed, and the concept of vascular reconstructive surgery was on its way to becoming a reality. During the next 20 years (1915-1935), the last remaining obstacles to the development of vascular surgery as a * A clinical test used to assess the extent of collateral circulation in an extremity.17
FIG. 5. Bertram M. Bernheim, 1880-1957. Though always in the shadow of Halsted and Cushing, Bermheim made important contributions in the areas of blood transfusion and vascular reconstruction. He was the first American to substitute a segment of vein for an artery in man.
spend a period of 18 months in Germany working in hospitals in Baden, Freiburg and Berlin. Returning briefly to his home in Kentucky, Bernheim felt the need of further surgical training and applied to Dr. Halsted for a position. Halsted afforded him the opportunity of working in the Hunterian Laboratory under the direction of Harvey Cushing. Acting upon Dr. Halsted's suggestion that he attempt to duplicate Lexer's work in the laboratory, Bernheim soon found he had an affinity for meticulous vascular work. In 1909, Halsted called upon Bentheim to attempt a long venous graft (12-14 cm) to repair a defect in the popliteal artery created by removal of a sarcoma in the popliteal space. In this case the graft failed because of thrombosis; however, Bernheim continued his work and by 1913 was able to publish an authoritative monograph on vascular surgical techniques, in which he made significant early contributions.1 Bernheim apparently achieved recognition as a vascular surgeon because of this monograph, and in August 1915, a patient was referred to him by Dr. William Bruce of Sydney, Nova Scotia. The patient was a 43-year-old man who had over the course of three months developed a painful swelling in the right popliteal fossa. The patient had a FIG.
history of syphilis and his Wassermann reaction was posi-
6
Wilhelm Konrad
radiation
Rntgen, 1845-1923. Discoverer of gamma Rontgen was awarded the Nobel Prize in Physics for 1901.
Vol. 183 . No. 2
VENOUS AUTOGRAFTS
full-fledged discipline were overcome. These obstacles centered on the problems of accurate preoperative diagnosis and prevention of thrombosis in the intraoperative period. With aneurysms of the extremities, diagnosis posed no particular problem, for the site of the pathological lesion was clinically manifest. In the case of atherosclerotic lesions, which were considerably more common than aneurysms, there were no surface indicators of the precise location of the lesion. The problem was a difficult one and required the birth of a completely new clinical science to overcome it. On November 8, 1895, a relatively obscure physicist performing basic research at the Institute of Physics, Wurzburg University, first observed the new rays which were to become a cornerstone of the diagnostic armamentarium in virtually every branch of medicine.20 The man's name, of course, was Wilhelm Konrad Rontgen (Fig. 6), and in his discovery lay the key to accurate diagnosis of vascular lesions. I'n 1918, D. F. Cameron published a paper on the use of iodide salts as a contrast medium in roentgenography.3 This work stimulated Sicard and Forestier who are credited with the develo'pment of an iodized poppyseed oil (Lipiodol) which was the first vascular contrast medium to be used in humans.21 With Forssmann's report of the first successful cardiac catheterization in 1929,7 virtually every segment of the vascular'circuit was opened to diagnostic examination. The solution to the problem of thrombosis lay in basic research, and the man who almost single-handedly solved it was William Henry Howell. Born in Baltimore and a product of Johns Hopkins, Howell and Jay MacLean, a medical student, working in Howell's laboratory, happened upon an anticoagulant which they extracted from liver while trying to isolate thromboplastin.14 Howell named this substance "heparin,"11 and with the discovery by Charles and Scott of a means for large scale extraction of heparin from beef liver and lung in 1933,5 the problem of intraoperative thrombosis was solved. While basic and clinical research was providing the means for peripheral vascular surgery, the World Wars demonstrated the need. According to Matas, one-fourth of the wounded treated at the front in World War I required special attention for injuries of the blood vessels, and at the base hospitals 2% of the wounded were admitted for the treatment of traumatic aneurysms."8 If the first World War demonstrated the need, it also demonstrated the fact that most surgeons were inadequately trained in vascular techniques to fill that need. The improved results obtained in the treatment of vascular combat injuries in World War II and the Korean War were attributable to several factors, among them better evacuation methods, improved treatment of hemorrhagic shock, blood banking and the advent of antibiotics. In large part, however, this was a result of increased skill and better training in vascular surgical techniques.
105 After the War, experience gained in the management of traumatic lesions was applied to the problem of acquired obstructive disease. In 1950, Holden reported the use of a saphenous vein to bypass an atherosclerotic femoral artery occlusion, with prior angiographic demonstration of the site of the lesion.10 In the following year, Voorhees, Jaretzki and Blakemore opened further the horizons of vascular surgery with their report of a synthetic substitute for blood vessels, Vinyon "N.' '24 Although this original graft material did not withstand the test of time, its descendants are now a mainstay of vascular reconstructive
operations everywhere. The remaining achievement of this extraordinarily productive period in the history of vascular surgery was a logical extension of the techniques of catheterization and vein grafting. In 1958, at the Cleveland Clinic, Sones successfully performed selective coronary angiography, allowing forthe first time antemortem correlation of electrocardiographic' and hemodynamic parameters with specific alterations in myocardial perfusion.22 The logical extension of this work was the application of vein grafting techniques to the coronary circulation. In Baltimore in 19b2, a 41-year-old patient who had had a previous right coronary endarterectomy for angina pectoris returned with recurrence of symptoms. Coronary arteriography was performed and demonstrated complete occlusion of the previously endarterectomized segment. Faced with the obvious -shortcomings of the endarterectomy technique on the one hand and on the other with the incapacitating symptoms of the patient, Sabiston performed an aorta-to-right coronary artery graft using an autologous saphenous vein. Unfortunately, the patient suffered a cerebrovascular accident in the postoperative period and expired three days later. At autopsy, thrombus was present at the aortic anastomosis, and this was the presumed source of the fatal stroke. This complication discouraged further pursuit of the technique at that time. In 1964, Garrett and associates at Baylor performed a successful graft from the aorta to the left coronary artery and demonstrated patency 7 years later.8 The pioneering work of Rene Favaloro established the aorto-coronary bypass graft as a feasible proced9re.6 This work was accomplished at the Cleveland Clinic, where Sones had earlier perfected the diagnostic technique of selective coronary arteriography almost a decade before. The significance of this advance is indicated by the fact that over half of the procedures in which cardiopulmonary bypass was used in 1972 involved vein grafts to the coronary arteries. There have been many contributors to the field of vascular surgery whose work has been omitted from this brief survey only because a complete coverage of the subject would be impossible except in a major work. The justification for choosing the contributors and events of this particular period lies in' the fact that this represented
Ann. Surg. m February 1976 HARRISON a time of accelerated progress and, more importantly, 8. Garrett, H. E., Dennis, E. W. and DeBakey, M. E.: Aortocoronary Bypass with Saphenous Vein Graft. Seven-year that it is a classic example of the symbiotic relationship Follow-up. JAMA, 223:792, 1973. between basic and clinical research. This latter point is in 9. Goyanes, D. J.: Substitution Plastica de las Arterias por las Venas, 6 Arterioplastia Venosa, Aplicada, Como Nuevo Metodo, al danger of being forgotten in the current period of inTratamiento de los Aneurismas. El Siglo Medico, Sept. 1, 1906; creased demand for "clinical relevance" in the allocation p. 346; Sept. 8, 1906, p. 561. of our research support and efforts. Yet clinical investiga- 10. Holden, W. D.: Reconstruction of the Femoral Artery for Arteriosclerotic Thrombosis. Surgery, 27:417, 1950. tion without basic research grows rapidly sterile, and W. H. and Holt, E.: New Factors in Blood Coagulationbasic research without clinical application becomes 11. Howell, Heparin and Pro-antithrombin. Am. J. Physiol., 47:328, 1918. rapidly impotent. That this interplay between the research 12. Jaboulay, M.: Recherches Experimentales sur la Suture et la Greffe Arterielles. Lyons Med., 1896; p. 97. laboratory and the clinical situation is a sine qua non for E.: Die ideale Operation des Arteriellen und des Arteriellmedical progress is one of the lessons of history. The 13. Lexer, venosen Aneurysma. Archiv. Klin. Chir., 83:459, 1907. development of vascular surgery is clearly a striking 14. MacLean, J.: The Thromboplastic Action of Cephalin. Am. J. Physiol., 41:250, 1916. example.
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Acknowledgments The author wishes to thank Mrs. Bertram Bernheim for contributing biographical information concerning her husband, Professor Bernheim. Thanks are also due Kaye Townsend and Sandra Justice for assistance in preparing the manuscript.
References 1. Bernheim, B. M.: Surgery of the Vascular System. Phila. J. B. Lippincott Co., 1913. 2. Bernheim, B. M.: The Ideal Operation for Aneurysm of the Extremity. Report of a Case. Bull. Johns Hopkins Hosp., 27:93, 1916. 3. Cameron, D. F.: Aqueous Solutions of Potassium and Sodium Iodide as Opaque Medium in Roentgenography. JAMA, 70:754, 1918. 4. Carrel, A.: The Surgery of Blood Vessels. Bull. Johns Hopkins Hosp., 190:18, 1906. 5. Charles, A. F. and Scott, D. A.: Studies on Heparin. J. Biol. Chem., 102:425, 1933. 6. Favaloro, R.: Saphenous Vein Autograft Replacement of Severe Segmental Coronary Artery Occlusion. Ann. Thorac. Surg., 5:334, 1968. 7. Forssmann, W.: Die Sondierung des rechten Herzens. Klin. Wochnsch, 8:2085, 1929.
15. von Manteuffel, Z.: Demonstration eines Praparates von Aneurysma arteriovenosum ossificans der Arteria femoralis profunda. Chirurgencongress-Verhandlungen I, 1895; p. 167. 16. Matas, R.: An Operation for the Radical Cure of Aneurism Based Upon Arteriorrhaphy: With the Report of Four Cases Successfully Operated Upon by the Author. Trans. Am. Surg. Assoc., 20:396, 1902. 17. Matas, R.: Testing the Efficiency of the Collateral Circulation as a Preliminary to the Occlusion of the Great Surgical Arteries. JAMA, 63:1441, 1914. 18. Matas, R.: Endoaneurismorrhaphy. Surg. Gynecol. Obstet., 30: 456, 1920. 19. Murphy, J. B.: Resection of Arteries and Veins Injured in Continuity. Med. Rec., 51:73, 1897. 20. Rontgen, W. K.: Uber eine neue Art von Strahlen. (trans.) Nature, 53:274, 1896. 21. Sicard, A. and Forestier, J.: L'huile iodee en clinique; applications therapeutiques et diagnostiques. Bull. Mem. Hop. Par., 47:309, 1923. 22. Sones, F. M., Jr. and Shirey, E. K.: Cine Coronary Arteriography. Mod. Con. Cardiovasc. Dis., 31:735, 1962. 23. Stich, R., Makkas, M., and Dowman, C. E.: Beitrage zur Gefasschirurgie; cirkulare Arteriennaht und Gefasstransplantationen. Beitr. Klin. Chir., 53:113, 1907. 24. Voorhees, A. B., Jaretzski, A., III, and Blakemore, A. H.: The Use of Tubes Constructed from Vinyon "N" Cloth in Bridging Arterial Defects: A Preliminary Report. Am. Surg., 135:332, 1952.
