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2 Chapter 1/Historical Introduction
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A
B
FIGURE 1.1 A) The famous illustration used by Harvey in his De motu
cordis (1661) showing the direction of fl ow into the veins and B) the plate
published 60 years before by Hyeronimus Fabricius of Acquapendente
(1603).
complete until 1661, when Marcello Malpighi demonstrated
by microscopy the existence of the capillaries in his De
Pulmonibus (see Figure 1.2).
VENOUS ANATOMY
The fi rst systematic description of the venous system was
given by André Vesale (alias Vesalius) in De humanis cor-
poris fabrica (1543). Vesalius’ venous anatomy was almost
complete (see Figure 1.3) containing some omissions, like
venous valves and perforating veins. In addition, Vesalius
furnished a good description of the structure of the venous
wall. He differentiated the internal coat of the veins in two
layers. The internal one contained contractile fi bers, though
“dissimilar from those of skeletal muscles, arranged, from
within outwards, circularly, obliquely and longitudinally.”
The outer coat was formed by a loose network borrowed
from surrounding structures.
FIGURE 1.2 The original Malpighi’s representation of the lung capillary
bed (De Pulmonibus, 1661).
VESALIUS’S OMISSION I: VENOUS VALVES
Giovanni Battista Canano from Ferrara, was the fi rst to
describe venous valves in 1540 (“ostiola sive opercula”), in
the renal, azygos, and external iliac veins. According to
Franck Cockett, “. . . he identifi ed correctly the function of
the valves, i.e., to avoid blood refl ux . . .” Further sporadical
descriptions of venous valves were given by the Spanish
anatomist Ludovicus Vassaeus (1544) and, one year later,
by Charles Estienne (apophyses membranarum). Valves in
the veins of the lower limbs fi rst were reported by Sylvius
Ambianus in 1555, and their fi rst illustrations appeared in
the Salomon Alberti’s De valvulis membraneis vasorum
(1585). Finally, Hyeronimus Fabricius of Acquapendente
published in 1603 an exhaustive description of the valves of
the veins with magnifi cent fi gures (see Figure 1.4), which
were used by his pupil Harvey to demonstrate the direction
of fl ow (see Figure 1.1). Four centuries passed before it was
demonstrated that venous valves do not only steer blood
return and prevent refl ux; according to Lurie et al., they also
act as a venous fl ow modulator.
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FIGURE 1.3 The Venous System according to Vesalius (1545).
VESALIUS’S OMISSION II:
PERFORATING VEINS
The second Vesalius’s gap was fi lled at the beginning of
the nineteenth century (1803), when the anatomist Justus
Christian Von Loder represented exactly the more important
perforating veins of the human body (see Figure 1.5). Von
Loder omitted a description of their function; that was clarifi ed only in 1855 when Aristide August Verneuil described
the presence of valves within perforating veins and the
direction of blood fl ow in them.
THE RETURN OF THE VENOUS BLOOD
The mechanisms allowing blood to fl ow centripetally
along the veins were described more than two hundreds
years ago (see Table 1.1). The “vis a tergo” was described
in 1670 by Richard Lower: “. . . the return of the venous
blood is the result of the impulse given to the arterial
blood . . .” Furthermore, Lower acknowledged an important
role to the “venarum tono” in venous return, and described
the effects of the muscular pumping. Antonio Valsalva,
FIGURE 1.4 The Sapheno-Femoral Junction according to Fabricius
(1603).
FIGURE 1.5 The fi rst representation of perforating veins in Von Loder’s
Anatomische Tafeln (1803).
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TABLE 1.1 Mechanisms of Venous Propulsion
1670 Richard Lower Propulsive Vis a tergo
1670 Richard Lower Muscle pump
1670 Richard Lower Tone of the venous wall
1710 Antonio Valsalva Aspirative Vis a fronte
1728 Giovanni Lancisi Contraction of the venous wall
1793 John Hunter Pulsation of neighboring arteries
pupil of Malpighi, described in 1710 the aspiratory forces
that enhance venous return to the heart: the “vis a fronte”
due to the rhythmic respiratory changes of thoracoabdominal pressure. In 1728, Giovanni Lancisi demonstrated
experimentally the spontaneous rhythmical contraction of
larger veins. Finally, John Hunter suggested in 1793 that the
pulsation of arteries assists the blood return in certain veins.
J.F. Palmer, the editor of the posthumous Hunterian Of the
Vascular System (1837), added a footnote: “. . . especially
when a common sheath exists . . .”
ETIOLOGY AND PATHOGENESIS
OF VARICOSE VEINS
Hippocrates was the fi rst to deal with the pathogenesis
and epidemiology of varicose disease when he affi rmed that
varicose veins were more frequent in Scythians due to the
prolonged time spent on the horseback with the legs hanging
down. In 1514, Marianus Sanctus noted that varicose veins
were more frequent after pregnancy and in longtime standing peoples (“. . . standing too much before kings . . .”). In
1545, Ambroise Paré related varicose veins to pregnancy
and long travelling and affi rmed that they are more frequent
in melancholic subjects. Ten years later, Jean Fernel (1554),
Professor of Medicine at Paris, stated that varicose veins can
develop after an effort or a trauma: “. . . the varix comes also
from a blow (?), from a contusion, from an effort . . .”
Virchow (1846) was the fi rst to point out the hereditary
tendency to varicose veins. Finally, the rare syndrome due
to congenital absence of venous valves was fi rst reported by
Josephus Luke in 1941.
The fi rst to attribute the onset of varicose veins to valvular incompetence was Hyeronimus Fabricius (1603). The
parietal theory fi rst was promulgated by Richard Lower,
who in 1670 affi rmed that a “relaxatio venarum tono” (wall
muscular looseness) is the cause of venous stasis and
dilation. Pierre Dionis credited in 1707 an important role to
mechanical compression of large trunks in the development
of varicose veins, whereas Jean Louis Petit (1774), the
eminent French surgeon, reported their possible occurrence
during obstruction of proximal veins. According to these
two authors, the clinical syndromes due to compression of
the left common iliac vein were described by the Canadian
McMurrich in 1906, and of the popliteal vein by Rich and
Hughes in 1967. Al Sadr described in 1950 the compression of the left renal vein by the aorta and the superior
mesenteric artery. Paul Briquet was the fi rst to affi rm in
1824 that varicose veins are due to abnormal fl ow coming
from deep veins via the perforators. In 1944, Malan described
the occurrence of varicose veins in limbs with abnormal
arteriovenous connections. The theory of a subclinical
parietal phlogosis inducing venous valve disruption has
been proposed only recently by Ono, Bergan, and SchmidSchonbein.
2
VENOUS THROMBOSIS
In 1544 the Spanish anatomist Ludovicus Vassaeus fi rst
identifi ed the “vascular dessication” described by
Hippocratic medicine with the phenomena of “coagulation,”
that is, loss of the liquid state of the blood. One year later,
Paré fi rst described superfi cial phlebitis (“. . . a swollen vein,
with jelly blood, spontaneously painful . . .”). In 1793, John
Hunter introduced the term Phlebothrombosis and affi rmed
that infl ammation of the venous wall is always accompanied
by the formation of a clot. Matthew Baillie (1793), in contrast to Hunter, considered fl ow deceleration the cause of
thrombosis. Rudolf Virchow, the greatest pathologist of all
times, defi ned in 1846 the famous triad of conditions essential for development of thrombosis: slowing of fl ow or its
cessation, excess of circulating thrombogenic factors, and
disruption of the endothelial lining. Only one century later
(1946), MacFarlane and Biggs described the “cascade”
mechanism for coagulation.
The “white swelling” of the lower limb or phlegmasia
alba dolens was accounted for by Charles White in 1784. In
1857, Jean Baptiste Cruveilhier described the “phlébite
bleue” (phlegmasia coerulea dolens) and affi rmed it is due
to the thrombosis of all the veins with patency of the arteries (see Figures 1.6 and 1.7). Sir James Paget investigated
the pathogenesis of phlebitis and described in 1866 a great
number of possible causes: traumatic phlebitis; distension
phlebitis; phlebitis occurring in exhaustion or during either
acute or chronic disease; phlebitis due to extension of infl ammation from an ulcer; idiopathic, puerperal, and pyemial
phlebitis, and fi nally, phlebitis occurring in varicose limbs.
A clear nosologic discrimination between phlebothrombosis
and thrombophlebitis was fi nally indicated by Ochsner and
De Bakey in 1939. The possible occurrence of venous
thrombosis of the leg due to prolonged sitting was fi rst
described by John Homans (1954). Incorrectly, the association of prolonged sitting and venous thrombosis was then
limited to air travel and assumed the name of “Economy
Class Syndrome.”
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FIGURE 1.6 Ileocaval thrombosis (Cruveilhier, 1857).
DIAGNOSIS OF VENOUS DISORDERS
Clinical Semiotics
Clinical semiotics started in 1806 when the Swiss surgeon
Tommaso Rima described a simple test for the diagnosis of
saphenous refl ux. In 1846, Sir Benjamin Brodie described a
method of testing for incompetent valves by constriction of
the limb and palpation. These two tests were reproposed by
Friedrich Trendelenburg in 1890. In 1896, Georg Perthes of
Bonn described the famous test to verify the patency of the
deep veins. Finally, in 1938, John Homans described a test
for detection of deep venous obstruction based upon foot
dorsifl exion. Surprisingly, these tests and maneuvers still
appear in modern texts of vascular medicine and venous
surgery.
FIGURE 1.7 Post-thrombotic varicose veins (Cruveilhier, 1857).
Phlebography
The history of phlebography started in 1923, when
Berberich and Hirsch described the technique to demonstrate the venous system in living humans by infusion of
strontium bromide. One year later, Sicard and Forestier performed the fi rst phlebography in humans using Lipiodol. In
1929, McPheeters and Rice performed the fi rst dynamic
varicography and described the movement of blood in the
varicose veins. Further developments were due to Ratschow
(who in 1930 introduced water soluble contrast media for
angiography), Dos Santos (who demonstrated in 1938 the
utility of direct ascending contrast venography to detect
deep venous thrombosis), and Farinas (who performed the
fi rst pelvic venography in 1947). Intraosseus phlebography
was then proposed by Schobinger in 1960 and refi ned by
Lea Thomas in 1970. Finally, Dow described in 1973 the
technique to perform retrograde phlebography.
Traditional venography is even less used in daily practice
due to the achievement of duplex sonography. However,
radiologic venous imaging recently improved due to the
introduction of computed tomography (CT) and magnetic
resonance (MR) techniques. CT was introduced in 1980 to
demonstrate venous thrombosis by Zerhouni. Multislice CT,
proposed fi rst in 1994 by Stehling to evaluate the venous
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TABLE 1.2 Proposals for Evaluation of Venous Disorders
1948 Pollack and Wood Dynamic measurement of venous
pressure
1953 Whitney Impedance plethysmography
1960 Hobbs and Davies Detection of thrombi by radioactive
iodium
1968 Dahn Strain gauge plethysmography
1969 Webber Detection of thrombi by radioactive
technetium
1971 Rosenthal Radionuclide venography
1973 Norgren and Thulesius Foot volumetry
1973 Cranley Phlebo-rheography
1979 Abramovitz Photo-plethysmography
1987 Van Rijn Air plethysmography
Other techniques have been proposed in the daily clinical
evaluation of venous disorders (see Table 1.2).
Other Diagnostic Techniques
FIGURE 1.8 The fi rst contrastless 3D venography by multislice CT
(Caggiati, 1999).
bed of the lower limb, also is indicated for the contemporary
evaluation of the pulmonary vessels. More recently, multislice CT has been proposed to obtain 3D images (see
Figure 1.8) of superfi cial veins3 with special reference to the
preoperative evaluation of varicose limbs.4 MR was introduced in the fi eld of the diagnosis of DVT in 1986 by
Erdman. MR venous imaging improved since 2001, when
the group of Jorge Debatin proposed the technique called
“low-dose, direct-contrast-injection 3D MR venography.”
5
Ultrasonic Venous Flow Evaluation
and Imaging
The history of ultrasounds in venous medicine started in
1961 when Stegall and Rushmer described the fi rst Doppler
instrument and the basis for its practical use. A refi nement
of the Doppler techniques for venous investigations was
made in 1967 by Sigel and coworkers. One year later, fundamentals of Doppler investigation of deep venous thrombosis were furnished separately by Evans and Cockett, and
Sumner and Strandness. The technique to evaluate valvular
competence was deeply investigated in 1970 by Folse and
Alexander.
The history of venous echotomography started in 1976,
when Day focused the possible role of B-mode imaging of
venous thrombi. Duplex scanning was proposed for the
diagnosis of venous disorders in 1986 by the group of
Szendro, Nicolaides, Myers, Malouf et al.6 and by that of
Luizy, Franceschi, and Franco.
7
COMPRESSION THERAPY
It was well known since ancient civilizations that compression is the main therapeutic option for the conservative
management of limbs affl icted with chronic venous insuffi ciency. Henry de Mondeville (1260–1320) affi rmed that
“. . . compression expels bad humors that infi ltrate legs and
ulcers . . .” The effectiveness of compression was explained
in 1824 by Sir Astley Paston Cooper, who affi rmed that it
allows the venous valves to regain their competence.
Cli nical and hemodynamic effects of compression and bandages in the fi eld of treatment of any form of venous
insuffi ciency and of phlebitis are still deeply investigated.
Techniques of bandaging changed poorly along the
course of the centuries. Since the fi fth century bc,
Hippocrates meticulously described how to perform leg bandages and how to obtain an eccentric compression by placing
a sponge under the bandage. Giovanni Michele Savonarola
(grandfather of the theologician Girolamo Savonarola) recommended in 1440 to extend the application of bandages to
the thigh. Bell (1778) proposed to associate bandage to bed
rest, whereas Underwood (1787), to deambulation. In 1849,
Thomas Hunt warned that bandages must be done only by
surgeons.
The use of compressive bandaging was extended to treatment of acute phlebitis in 1826 by Alfred Armand Louis
Marie Velpeau, and associated with immediate mobilization
by Einrich Fisher in 1910 in order to enhance its benefi cial
effects. Intermittent compression for the prevention of DVT
and of its sequelae was proposed in 1971 by Sabri.
Materials for bandages varied greatly along centuries.
Celsus used linen rollers, Galen preferred wool, as well as
split and sewn bandages. Aetius put bandages in an
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ear-of-corn shaped fashion. Fabricius introduced laced
stockings made from dog’s skin. At the end of the eighteenth
century, dog skin was abandoned and laced stockings were
made with linen. In 1783, Underwood fi rst used an elastic
bandage obtained with a Welsh fl annel. At the same time
(1797) Baynton introduced the homonymous bandage done
with small plasters of pitch, resin, and lithargyre. Adhesive
bandaging was introduced by Dickson Wright in 1830. Five
years later, Muray and Claney described the fi rst mechanical
device for compression of the limb. Thanks to the introduction of rubber vulcanization in 1839 by Goodyear, elastic
stockings were ideated and patented by William Brown in
1848. In 1878 Martin proposed to obtain elastic compression
with rubber bandages. In 1896, Paul Gerson Unna combined
local treatment with compression for treatment of venous
ulcer by incorporating emollient compounds in a dressing
that becomes increasingly rigid. The fi rst seamless compression stocking is dated 1904, the fi rst rubber-free in 1917.
Ultra-thin rubber strings were introduced in the late 1930s.
In 1902, Hoffmeister described the principles of mercury
compression obtained by placing the edematous limb in a
reservoir with 50 ml of mercury. Pneumatic devices with
laced chambers adaptable to any form of extremities were
proposed in 1955 by Brush and, in the same year, Samson
and Kirby described the fi rst sequential pressure pneumatic
device furnished with 14 compartments.
TABLE 1.3 Some of the Sclerosant Agents Used
1840 Monteggio Absolute alcohol
1853 Pravaz Iron perchloride
1855 Desgranges Iodotannin
1880 Negretti Iron chloride
1894 Medical Congress of Lyon: to stop sclerotheraphy!
1904 Tavel Phenol + surgery
1909 Schiassi Iodine and potassium iodide +
surgery
1917 Kaush Inverted sugar
1919 Sicard Sodium salicilate
1926 Linser Hypertonic saline
1930 Higgins and Kittel Sodium morruate
1933 Jausion Chromated glycerine
1946 Reiner Sodium tetradecyl sulphate
1959 Imhoff and Sigg Stabilized polyiodated ions
1966 Henschel and Eichenberg Polidocanol
SCLEROTHERAPY
The beginning of sclerotherapy commonly is dated back
to the invention of the the syringe by Pravaz (1831), and of
the hypodermic needle by Rynd (1845). However, antique
phlebologists could not wait for Rynd’s and Pravaz’s discoveries. In fact, the fi rst endovenous treatment goes back
to 1665 when Sigismond Johann Elsholz treated venous
ulcers by irrigating them with intravenous injection of distilled water and essences from plants using a chicken bone
as a needle and a bladder of pigeon as a syringe. Some
authors credit Zolliker as the fi rst to perform sclerotheraphy
in 1682, by injecting acid into varicose veins. The rationale
of sclerotherapy was furnished by Joseph Hodgson (1815)
who noted fi rst that “thrombosis extinguished varicose
veins.” In the second half of the eighteenth century, various
substances were used (see Table 1.3), but adverse sequelae
(local tissue necrosis, extravasation, pulmonary embolism,
and scarring caused by poor technique and causticity of
solutions) were so frequent and serious that, in 1894, at the
Medical Congress of Lyon, sclerotherapy of varicose veins
was fi rmly stopped. The adoption of safer sclerosants
allowed, primarily in Europe, the renaissance of sclerotherapy at the beginning of the twentieth century.
Renaissance of sclerotheraphy was also due to safer techniques and to association to surgery. Tavel (1904) injected
FIGURE 1.9 Schiassi’s method to inject the Great Saphenous Vein at
the same time of its interruption (1909).
varicose veins after high ligation of the saphena. In order to
avoid innumerable skin incisions, Benedetto Schiassi, from
Bologna (1909), performed multiple injections of a combined iodine and potassium iodide immediately after saphenous interruption (see Figure 1.9). Linser (1916) suggested
to use compression to reduce complication and to enhance
the effects of the therapy. Ungher (1927) used a urethral
catheter to perfuse varicose veins with sclerosing agents. Mc
Ausland recommended in 1939 to empty the vein to be
injected by elevating the leg and to bandage the leg after
treatment.
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Modern sclerotherapy developed in the 1960s. The tactics
and the techniques to obtain even safer and more effective
venous obliterations varied greatly between countries: the
Swiss technique was proposed by Sigg; the French method
by Tournay; Fegan popularized the so-called Irish technique
and Hobbs the English method. These techniques differed
with relation to: 1) position of the patient; 2) progression of
injections (from larger to smaller veins, or vice versa); 3)
sclerosant agents, their concentrations, and quantity; 4)
modalities, duration, extension, and strength of compression; 5) size of the needle and modalities of injection.
In the last years, safety and accuracy of sclerotherapy
greatly enhanced thanks to the introduction of real-time
control of needle position and wall reaction by echotomography (echosclerosis, according to Schadeck). More
recently, the effectiveness of sclerotherapy further improved
thanks to the use of sclerosing foams, obtained by mixing
slerosants with air (Tessari, Monfreux) or inert gas (Cabrera).
However, the use of gas-sclerosant mixtures dates back to
1939 (Stuard Mc Ausland) and to 1944 (the “air-block technique” of Egmont James Orbach).
SURGERY OF SUPERFICIAL
VEINS—THE DETRACTORS
In older civilizations, surgery of “serpent-shaped dilatations of lower limb veins” was advised to avoid dangerous
hemorrhages and death (Papyrus of Ebers, 1550 bc). Only
minimally invasive procedures were performed: “. . . the
varix itself is to be punctured in many places, as circumstances may indicate . . .” in order to avoid that “. . . large
ulcers be the consequence of the incisions . . .” (Hippocrates).
This detracting convincement persisted along the centuries.
As an example, Wiseman (1676) discommended surgery of
varicose veins “. . . unless they were painful, formed a large
tumour, ulcerated, or bled . . .” or when “. . . purging and
bleeding, not once or twice, but often repeated, fail . . .”
SURGERY OF SUPERFICIAL
VEINS—FORERUNNERS
First described by the Roman Celsus, hook extraction of
the varicose vein, double ligation, and venectomy (or
cautery) is the rough operation performed for centuries.
Galenum used the hook to perform multiple ultra-short stripping of varicose veins. Great boost to varicose vein surgery
come from the Byzantine physician Oribasius of Pergamum
(325–405 ad), who devoted three chapters of his book to the
treatment of varicose veins, operated by a special hook,
called cirsulce. Many of his recommendations are still
valid:
1. Remove the veins, because if only ligated, they can
form new varices.
2. Shave and bathe the leg to be operated.
3. When the leg is still warm, the surgeon has to mark
varicose veins with the patient standing.
4. Extirpate varicose veins of the leg fi rst, then at the
thigh.
5. Remove clots by external compression of the limb.
Further important contributions were from Paulus of Aegina
(seventh century), who described the main anatomy of varicose veins and identifi ed the great saphenous as their source.
He isolated the varicose veins at the thigh by a longitudinal
incision, and, after bloodletting, ligated them at both ends.
The tied-off portion was excised or allowed to slough off
later with the ligatures.
In Arab medicine, treatment of varicose veins was
dominated by cautery. However, the Spanish El Zahrawi
(Albucasis of Cordova) (936–1013) is credited by Anning
as the fi rst to use an external stripper. Williams of Saliceto
advocated in his Cyrurgia (1476) the reintroduction of the
knife into surgery and, a few decades later, Amboise Paré
(1545) abandoned defi nitively external cauterization of varicose veins to reintroduce their ligation: “. . . the incision
must be placed a little above the knee, where a varicose vein
is usually found to develop . . . Ligature was needed for the
purpose of cutting the channel and making a barrier against
the blood and the humors contained within it which fl ow to
varicose veins and fi ll any ulcer . . .” A similar technique
was used by Sir Benjamin Collins Brodie (1816): “. . . after
the skin over a varix was incised, the varix was divided with
a curved bistoury and pressure was applied to prevent haemorrhage . . .” Lorenz Heister (1718) placed a wax thread
transcutaneously around the distal end of a varicose vein.
Eight to ten ounces of the grumous and viscid blood was
allowed to escape as the varix was laid open longitudinally.
The wound was then bandaged and compressed. This technique was reproposed one century later by Alfred Armand
Louis Marie Velpeau (1826) who “. . . introduced a pin or
needle through the skin, which is passed underneath the
vein, and at right angles to it. A twisted suture is then applied
round the two ends of the pin, so as to compress the vein
suffi ciently to produce its obliteration . . .” (see Figures 1.10
and 1.11). Max Schede in 1877 operated on varicose limbs
by multiple ligature or venesections and percutaneous ligations. Delbet described in 1884 the reimplantation of the
terminal portion of the great saphenous vein just below a
healthy femoral valve. In the same year, Madelung proposed
a complete excision of the great saphenous vein (see Figure
1.12) through a long incision much like those used today in
vein harvest for coronary bypass. On the contrary, the incision was spiral (see Figure 1.13) and the lancet plunged deep
to the fascia in the operation proposed by Rindfl eish and
Friedel in 1908. Saphenous ligation followed by
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FIGURE 1.10 Techniques for venous obliteration from Davat (1), Velpeau (2), Sanson (3), Beclard (4), Wise (5),
Fricke (6), and Richerand. Courtesy of Doctor Michel Georgiev.
FIGURE 1.11 Velpeau’s method (1826).
FIGURE 1.12 Great Saphenous Veins excision according to Madelung
(1884).
FIGURE 1.13 A) Rindfl eish intervention and B) its sequelae (1908).
sclerotherapy (see Figure 1.14) was proposed by Tavel
(1904), whereas Schiassi (1905) injected varicose veins at
the time of surgery (see Figure 1.9).
MODERN SURGERY OF
SUPERFICIAL VEINS
Modern surgery of varicose veins started in 1806, when
Tommaso Rima proposed a hemodynamic treatment with
ligation of the upper GSV. This operation was reproposed
in 1890 by Friedrich Trendelenburg: “. . . the saphenous
refl ux must be the fi rst step in control distal varicosities . . .”
It consisted of a double ligation of the great saphenous just
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FIGURE 1.15 Keller’s operation for saphenous extraction (1905).
FIGURE 1.14 Sapenous interruption and its incannulation with the
instrument called pagoda.
inferior to the saphenofemoral junction, thanks to a 3 cm
incision. He boasted that he could do “. . . the operation so
fast that no anaesthesia was required . . .” Trendelenburg
made it clear that this technique had to be applied only to
those limbs in which the compression tests, described by
Brodie in 1846, revealed the incompetency of the saphenofemoral valve. In 1896, Moore of Melbourne refi ned the
Trendelenburg operation, with the skin incision performed
parallel and close to the inguinal fold, almost exactly as it
is today. In the same year, Thelwall Thomas emphasized the
importance of ligation and division of all branches at the
saphenofemoral junction.
SAPHENOUS STRIPPING
Stripping technique was introduced by Charles Mayo
(1904) by using an extraluminal device. In 1905, Keller
described an intraluminal stripper to extirpate the GSV (see
Figure 1.15). A twisted and rigid wire was passed into the
vein lumen. The wire was brought throughout its lumen at
a site distal to the divided end of the vein. Its end was tied
to the ligated and divided end of the varicose vein. Extracting the wire distally inverted the end of the vein into itself
as the vein was extracted. This technique was then refi ned
by van der Stricht in 1963. In 1907, Babcock modifi ed
Keller’s technique and proposed to use an acorn tip and a
fl exible rod, which was more sophisticated than a twisted
wire. His operation avoided tearing of the vein at the tributary junction, which occurs in the inversion technique. In
1920, Cole suggested to limit saphenectomy to the tract
comprised between the groin and the knee. In 1930, De
Takats refi ned the technique of Schiassi by proposing the
ambulatory treatment of saphenous vein insuffi ciency followed by sclerotherapy. In 1947, Myers and Smith further
refi ned the endoluminal fl exible stripper.
BEYOND STRIPPING
Many effective techniques alternative to stripping were
proposed in the second half of the twentieth century. First
of all, the antique art of hook phlebectomy was so improved
by Robert Muller (1956) to possibly operate on, with local
anesthesia and small incisions, both saphenae for their entire
length. Muller’s stab avulsion technique was further refi ned
and worldwide diffused in 1995 by Ricci, Georgiev, and
Goldman.9 In 1988, Claude Franceschi proposed a minimally invasive surgical approach (CHIVA) aimed to a
hemodynamic correction, more than to a radical avulsion of
the varicose bed, based upon a meticulous preoperative
Duplex examination. External banding of the terminal
saphena has been largely adopted by many centers, but its
results are good only if performed in limbs with early
disease, as demonstrated by Corcos et al. in 1997.
procedure was refi ned in 2002 by Yamaki,11 who associated
10
This
Surgery of the Deep Veins 11
https://t.me/med1917
removal by a cryoprobe. The fi eld of physical schlerotherapy was drastically revolutionized by two innovative tech-
niques, which obtained the obliteration of the varicose trunks
by endovascular radiofrequency and laser. Endovascular
radiofrequency diffused in the late 1990s, and the fi rst positive results were reported by Mitchell Goldman in 2000.
The use of endovenous laser in the treatment of the varicose
saphena was proposed fi rst by Puglisi at the IUP World
Congress of 1989 held in Strasbourg. Endovenous laser
technique was deeply refi ned and worldwide diffused in
1999 by Boné. Many centers are still at work to evaluate
exact indications and results of these techniques.
PERFORATING VEIN SURGERY
The fi rst to suggest selective interruption of perforators
to treat varicose veins was probably Remy in 1901. In 1938,
Linton proposed a medial subfascial approach to treat
incompetent perforators. In 1953, Cockett and Jones proposed the epifascial ligature of medial ankle perforators.
Two years later, Felder recommended that the fascial incision for perforating vein ligature should be placed in the
posterior midline of the calf in order to avoid placing the
lower end of the incision over the ulcer itself or in the compromised skin of the medial leg: the so-called “posterior
stocking seam approach.” Glauco Bassi and Robert Muller
used a hook for transcutaneous stripping of perforators
through small incisions. Special instruments have been proposed to facilitate subfascial perforator interruption, like
FIGURE 1.16 Gaetano Conti’s method for endovascular fulguration of
the Great Saphenous Vein (1854). Courtesy of Doctor Michel Georgiev.
valvuloplasty of the subterminal valve combined to the axial
transposition of a competent tributary vein.
those of Albanese (1965) and Edwards (1976). The use of
endoscopy to interrupt perforator in the subfascial space
goes back to 1985 by Hauer, but only extensive technical
improvements allowed its even wider and safer use.12 Despite
new techniques and instrumentations, the problem still
remains open: Which perforators must be treated? And
13,14
when?
ENDOVASCULAR TECHNIQUES
Forerunner of endovascular techniques for treatment of
the varicose saphena was Gaetano Conti from Naples, who,
in 1854, proposed a complex method based upon “electropuncture and cauterizations of varicose veins” (see
Figure 1.16). Modern endovascular techniques started in
1964 with Werner and McPheeters (“electrofulguration”)
and Politowski (“endovenous electrosurgical dessication”).
A similar technique was proposed by Watts (1972) to treat
saphenous varicosities by endovenous diathermy. In 1981,
a freezing technique was proposed by Milleret and Le-Pivert
to treat saphenous trunk insuffi ciency. This technique was
refi ned in 1997 by Constantin, who associated ligation and
division of the saphenous junction with saphenous trunk
SURGERY OF THE DEEP VEINS
Ochsner and De Bakey publicized in 1943 the interruption of the inferior vena cava to prevent embolic migration
from the leg. John Hunter is credited as the fi rst to ligate it
in 1739. Bottini (1893) and Trendelenburg (1910) also are
credited with performing this intervention. A temporary
caval ligation was proposed by Dale in 1958. In the same
year, De Weese and Hunter partially interrupted the inferior
vena cava by an intraluminal “hard grip.” Spencer obtained
caval interruption by suture plication (1965), Ravitch by
stappler plication (1966), and fi nally, Pate by a detachable
clip (1969). Mobin-Huddin described in 1967 an umbrella
fi lter for the prevention of pulmonary embolism. This instrument was then refi ned by Greenfi eld, who introduced a steel
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