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U L T R A S O N I C V E N O U S F L O W
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EVALUATION AND IMAGING
e history of ultrasound in venous medicine started in
1961, when Stegall and Rushmer described the rst Doppler
instrument and the basis for its practical use. Are 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. e technique to evaluate valvular competence
was deeply investigated in 1970 by Folse and Alexander.
e 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
6
Szendro, Nicolaides, Myers, Malouf etal
7
Luizy, Franceschi, and Franco.
OTHER DIAGNOSTIC TECHNIQUES
and by that of
Other techniques have been proposed in the daily clinical
evaluation of venous disorders (see Table1.2).
COMPRESSION THERAPY
It has been well known since ancient civilizations that compression is the main therapeutic option for the conservative
management of limbs a icted with chronic venous insuf ciency. Henry de Mondeville (1260–1320) a rmed that
“compression expels bad humors that in ltrate legs and
ulcers.” e e ectiveness of compression was explained in
1824 by Sir Astley Paston Cooper, who a rmed that it
allows the venous valves to regain their competence. Clinical
and hemodynamic e ects of compression and bandages in
Table1.2 PROPOSALS FOR EVALUATION OF VENOUS
DISORDERS
1948 Pollack and Wood Dynamic measurement of venous
1953 Whitney Impedance plethysmography
1960 Hobbs and Davies Detection of thrombi by radioactive
1968 Dahn Strain gauge plethysmography
1969 Webber Detection of thrombi by radioactive
1971 Rosenthal Radionuclide venography
1973 Norgren and
ulesius
1973 Cranley Phleborheography
1979 Abramovitz Photoplethysmography
1987 Van Rijn Air plethysmography
pressure
iodium
technetium
Foot volumetry
the eld of treatment of any form of venous insu ciency
8
and of phlebitis are still deeply investigated.
Techniques of bandaging changed minimally over the
course of the centuries. In the h century , Hippocrates
meticulously described how to apply leg bandages and how
to obtain an eccentric compression by placing a sponge under
the bandage. Giovanni Michele Savonarola (grandfather of
the theologian Girolamo Savonarola) in 1440 recommended
extending the application of bandages to the thigh. Bell
(1778) proposed associating bandaging with bed rest, and
Underwood (1787) with deambulation. In 1849, omas
Hunt warned that bandages must be applied only by surgeons.
e 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 bene cial e ects. Intermittent compression for the prevention
of DVT and of its sequelae was proposed in 1971 bySabri.
Materials for bandages varied greatly over the centuries.
Celsus used linen rollers, Galen preferred wool, as well as split
and sewn bandages. Aetius put bandages in an 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 rst used an elastic bandage obtained with
a Welsh annel. At the same time (1797) Baynton introduced
the eponymous 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 rst mechanical device for compression of the
limb. anks 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 obtaining 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. e rst seamless compression stocking is dated 1904,
the rst rubber-free in 1917. Ultrathin rubber strings were
introduced in the late1930s.
In 1902, Ho meister 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 rst sequential pressure pneumatic
device furnished with fourteen compartments.
S C L E R O T H E R A P Y
e beginning of sclerotherapy is commonly dated back to
the invention of the syringe by Pravaz (1831), and of the
hypodermic needle by Rynd (1845). However, earlier phlebologists could not wait for Rynd’s and Pravaz’s discoveries.
8 • BASIC CONSIDERATIONS
In fact, the rst endovenous treatment goes back to 1665,
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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 rst to perform sclerotherapy in 1682, by injecting
acid into varicose veins. e rationale of sclerotherapy was
furnished by Joseph Hodgson (1815) who noted rst that
“thrombosis extinguished varicose veins.” In the second half
of the eighteenth century, various substances were used (see
Table1.3), 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 rmly stopped. e adoption of
safer sclerosants allowed, primarily in Europe, the renaissance
of sclerotherapy at the beginning of the twentieth century.
e renaissance of sclerotherapy was also due to safer
techniques and to its use in combination with surgery.
Tavel (1904) injected varicose veins a er 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 a er saphenous interruption (see Figure1.9).
Linser (1916) suggested using compression to reduce complication and to enhance the e ects of the therapy. Ungher
(1927) used a urethral catheter to perfuse varicose veins
with sclerosing agents. Mc Ausland in 1939 recommended
emptying the vein to be injected by elevating the leg and
bandaging the leg a er treatment.
Modern sclerotherapy developed in the 1960s. e tactics
and the techniques to obtain even safer and more e ective
Table1.3 SOME OF THE SCLEROSANT AGENTSUSED
1840 Monteggio Absolute alcohol
1853 Pravaz Iron perchloride
1855 Desgranges Iodotannin
1880 Negretti Iron chloride
1894 Medical Congress of Lyon:to stop sclerotherapy!
1904 Tavel Phenol + surgery
1909 Schiassi Iodine and potassium iodide +
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 Imho and Sigg Stabilized polyiodated ions
1966 Henschel and
Eichenberg
surgery
Polidocanol
Figure1.9 Schiassi’s method to inject the GSV at the same time of its
interruption (1909).
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. ese techniques di ered
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; and
(5)size of the needle and modalities of injection.
In early 1990s, the safety and accuracy of sclerotherapy
were greatly enhanced by the introduction of real-time
control of needle position and wall reaction by echotomography (“echosclerosis,” according to Schadeck). In the
late 1990s to early 200s, the e ectiveness of sclerotherapy
was 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 ancient civilizations, surgery of “serpent-shaped dilatations of lower limb veins” was advised to avoid dangerous
hemorrhages and death (Papyrus of Ebers, 1550 ). 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). is detracting theory persisted through the centuries. As an example,
Wiseman (1676) discouraged surgery of varicose veins
HISTORICAL INTRODUCTION • 9
“unless they were painful, formed a large tumour, ulcerated,
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or bled” or when “purging and bleeding, not once or twice,
but o en 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 ultrashort stripping of varicose
veins. Agreat boost to varicose vein surgery come from the
Byzantine physician Oribasius of Pergamum (325–405 ),
who devoted three chapters of his book to the treatment of
varicose veins, an operation using a special hook called a cir-
sulce. Many of his recommendations are stillvalid:
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 rst, then at thethigh.
5. Remove clots by external compression of thelimb.
Further important contributions were from Paulus of
Aegina (seventh century), who described the main anatomy
of varicose veins and identi ed the great saphenous vein
(GSV) as their source. He isolated the varicose veins at the
thigh by a longitudinal incision, and, a er bloodletting,
ligated them at both ends. e tied-o portion was excised
or allowed to slough o 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 rst
to use an external stripper. William of Saliceto advocated
in his Cyrurg ia (1476) the reintroduction of the knife into
surgery and, a few decades later, Amboise Paré (1545) abandoned de 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 ow to varicose veins and
ll any ulcer.” Asimilar technique was used by Sir Benjamin
Collins Brodie (1816):“a er 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. e wound was then bandaged and compressed. is
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. Atwisted suture is then applied round the
two ends of the pin, so as to compress the vein su ciently
Figure1.10 Techniques for venous obliteration from Davat (1), Velpeau (2), Sanson (3), Beclard (4), Wise (5), Fricke (6), and Richerand (7) . Courtesy
of Doctor Michel Georgiev.
AU: Okay?
10 • BASIC CONSIDERATIONS
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Figure1.11 Velpeau’s method (1826).
Figure1.13 Rind eish intervention (le ) and its sequelae (1908) (right).
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 GSV just below a healthy femoral valve. In the same
year, Madelung proposed a complete excision of the GSV (see
Figure 1.12) through a long incision much like those used
today in vein harvest for coronary bypass. On the contrary,
in the operation proposed by Rind eish and Friedel in 1908,
the incision was spiral (see Figure1.13) and the lancet plunged
deep to the fascia. Saphenous ligation followed by sclerotherapy (see Figure1.14) was proposed by Tavel (1904), whereas
Schiassi (1905) injected varicose veins at the time of surgery
(see Figure1.9).
MODERN SURGERY OF
SUPERFICI ALVEINS
Modern surgery of varicose veins started in 1806, when
Tommaso Rima proposed a hemodynamic treatment with
ligation of the upper GSV. is operation was reproposed
in 1890 by Friedrich Trendelenburg:“the saphenous re ux
must be the rst step in control distal varicosities.” It consisted of a double ligation of the GSV just 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 re 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, elwall
omas emphasized the importance of ligation and division
of all branches at the saphenofemoral junction.
SAPHENOUS STRIPPING
e stripping technique was introduced by Charles Mayo
(1904), who used an extraluminal device. In 1905, Keller
described an intraluminal stripper to extirpate the GSV (see
Figure1.15). Atwisted and rigid wire was passed into the
A
B
C
Figure1.12 GSV excision according to Madelung (1884).
ED
Figure1.14 Saphenous interruption and its incannulation with the
instrument called a pagoda .
HISTORICAL INTRODUCTION • 11
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Figure1.15 Keller’s operation for saphenous extraction (1905).
vein lumen. e 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
asthe vein was extracted. is technique was then re ned
by van der Stricht in 1963. In 1907, Babcock modi ed
Keller’s technique and proposed using an acorn tip and a
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 limiting saphenectomy to the tract
located between the groin and the knee. In 1930, De Takats
re ned the technique of Schiassi by proposing the ambulatory treatment of saphenous vein insu ciency followed by
sclerotherapy. In 1947, Myers and Smith further re ned the
endoluminal exible stripper.
10
early disease, as demonstrated by Corcos etal in 1997.
11
procedure was re ned in 2002 by Yamaki,
who associated
is
valvuloplasty of the subterminal valve combined to the axial
transposition of a competent tributaryvein.
ENDOVASCULAR TECHNIQUES
e rst to use endovascular techniques for treatment of the
varicose saphena was Gaetano Conti from Naples, who in
1854 proposed a complex method based on “electropuncture and cauterizations of varicose veins” (see Figure1.16).
Modern endovascular techniques developed beginning in
1964 with Werner and McPheeters (“electrofulguration”)
and Politowski (“endovenous electrosurgical dessication”).
Asimilar 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 insu ciency. is technique was
re ned in 1997 by Constantin, who combined ligation and
division of the saphenous junction with saphenous trunk
removal by a cryoprobe. e eld of physical sclerotherapy
was drastically revolutionized by two innovative techniques
BEYOND STRIPPING
Many e ective techniques alternative to stripping were proposed in the second half of the twentieth century. First of
all, the ancient art of hook phlebectomy was so improved
by Robert Muller (1956) that it became possible to operate,
with local anesthesia and small incisions, on both saphenae
for their entire length. Muller’s stab avulsion technique was
further re ned and di used worldwide in 1995 by Ricci,
Georgiev, and Goldman.
posed a minimally invasive surgical approach (conservatrice
et hemodynamique de l’insu sance veineuse en ambulatoire
[CHIVA]) aimed to a hemodynamic correction, more than
to a radical avulsion of the varicose bed, based on 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
9
In 1988, Claude Franceschi pro-
12 • BASIC CONSIDERATIONS
Figure1.16 Gaetano Conti’s method for endovascular fulguration of the
GSV (1854). Courtesy of Doctor Michel Georgiev.
that obtained the obliteration of the varicose trunks by
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endovascular radiofrequency and laser. Endovascular radiofrequency di used in the late 1990s, and the rst positive
results were reported by Mitchell Goldman in 2000. e use
of endovenous laser in the treatment of the varicose saphena
was proposed rst by Puglisi at the IUP World Congress of
1989 held in Strasbourg. Endovenous laser technique was
deeply re ned and di used worldwide in 1999 by Bone.
Many centers are still at work to evaluate exact indications
and results of these techniques.
Historically, removal of the GSV from super cial circulation has been considered the rst essential step in treating
primary varicose veins. While the newer endovenous thermal and chemical ablation procedures also accomplish this,
the need to ablate the saphenous vein is increasingly being
questioned, as discussed in more detail in Chapter25 .
lter for the prevention of pulmonary embolism. is
instrument was then re ned by Green eld, who introduced
a steel lter. One year later, Eichelter and Schenk proposed a
temporary caval ltration with a removable balloon.
In order to control symptoms of venous insu ciency,
Parona in 1894 suggested ligating the popliteal vein, whereas
Linton in 1948 suggested interrupting the femoralvein.
Fundamentals of reconstructive venous surgery were
developed during the nineteenth century, and in 1912,
Carrel and Guthrie received the Nobel Prize for their
improvements to vascular surgery techniques. However,
safe and e ective venous interventions for venous obstructions of the trunk and limbs developed only a er World
War II (see Table1.4).
THROMBECTOMY
PERFORATING VEIN SURGERY
e 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 lig ature 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 those of Albanese
(1965) and Edwards (1976). e use of endoscopy to interrupt perforators in the subfascial space goes back to 1985 by
Hauer, but only extensive technical improvements allowed
12
its even wider and safer use.
Despite new techniques and
instrumentations, the problem still remains open: Which
13,14
perforators must be treated? And when?
SURGERY OF THE DEEPVEINS
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 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 nally, Pate by a detachable
clip (1969). Mobin-Huddin described in 1967 an umbrella
Paré was probably the rst to perform a super cial vein
thrombectomy, in 1545:He suggested performing an incision along the vein and squeezing it to expel the thrombus.
e rst thrombectomy of deep veins was performed by
Table1.4 VENOUS RECONSTRUCTIVE SURGERY
e Pioneers of Venous Reconstructive Surgery
1816 Travers Sutured a traumatic lesion of the femoral
1830 Guthrie Sutured a traumatic lesion of the jugular
1872 Eck Portacaval anastomosis
1878 Agnew Lateral suture of traumatized veins
1889 Kummel First termino-terminal anastomosis of
1901 Clermont First termino-terminal anastomosis of
1912 Carrel &
Guthrie
Main Steps in Venous Reconstructive Surgery
1950 Wanke Surgical decompression of the le
1953 Kunlin Venovenous gra ing
1954 Warren & ayer GSV bypass of obstructed femoral veins
1958 Palma & Esperón Cross-pubic bypass for iliac vein
1964 Stansel Synthetic gra for caval reconstruction
1970 Husni Saphenopopliteal bypass for femoral
1982 Fiore Reconstruction with prosthetic gra s of
1984 Gloviczki; Dale Reconstruction with prosthetic gra s of
1988 Zolliker Endovascular disobliteration and
vein
vein
the femoral vein
the inferior vena cava
Nobel prize for improvements of vascular
surgery techniques
common iliac vein
occlusion
venous obstruction
superior vena cava
inferior vena cava
stenting
HISTORICAL INTRODUCTION • 13
Lawen in 1937. In 1939, Leriche and Geisendorf associ-
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ated a periarterial sympathectomy of the nonpulsatile but
unoccluded femoral artery to a successful thrombectomy
of the femoral vein in a patient with phlegmasia coerulea
dolens. In 1966, Fogarthy described how to remove vascular obstruction by a catheter and a rmed this is the “most
rationale, most e ective and safest way of dealing with iliofemoral thrombosis.”
SURGERY OFVALVES
e rst attempt to restore valvular function was performed in 1953 by Eisemann and Malette, who proposed
producing valve-like structures by gathering folds at two
sites of the venous wall opposite each other. In 1963,
Psathakis proposed entwining the tendon of the gracilis
muscle between the popliteal artery and vein in order to
obtain the compression of the vein during contraction of
the muscle. Afew years later, Ferris and Kistner proposed
a transvalvular approach for internal repair of venous valve
(1968). In 1984, Raju modi ed this technique by using a
supravalvular approach. Finally, Sottiurai (1988) proposed
an internal approach, modifying the original technique of
Raju for supravalvular repair of the incompetent venous
valves. In 1972, Hallberg proposed the external banding
of the incompetent valves of deep veins by sheathing the
region with a plastic tube. An extravenous valve substitute
in the popliteal space was described by Psathakis in 1984.
In 1982, Taheri proposed transferring a valvulated segment
of the axillary vein into the lower femoral vein to treat
chronic venous insu ciency. In 1986, Jessup and Lane
developed an external technique of banding incompetent
valves with a silastic cu . One year later, Kistner developed
an external suture technique to “band” incompetent valves.
Reparative or substitutive surgery of venous valves continued to improve greatly. In 1999, Dalsing introduced the
use of cryopreserved venous valve allogra s for the treat-
15
ment of chronic deep venous insu ciency.
16
later, Raju, Berry, and Neglen
described a variation of
One year
closed external venous valve repair (transcommissural valvuloplasty). In 2001, Tripathy and Ktenidis reported a new
technique of exposure of the valve commissure, called the
17
“trapdoor” internal valvuloplasty.
In 2003, Pavcnik experimented with small-intestinal submucosa square-stent bicuspid venous valve in sheep jugular veins and in three patients.
18
In the same year, Corcos
proposed a monocuspid valve
reconstruction obtained with an intimal ap.
VENOUS ULCERSWHY TO
TREATTHEM
Spender (1866) categorized ulcers of venous origins
as “varicose ulcers” and “venous ulcers” (“ulcers of the
varicose type without varicose veins”), attributing the
latter to failure of deep veins. One year later, John Gay
rst identi ed induration and bronzing of the skin as circulatory complications of venous disorders, and, having
noted that varicose veins can be present for many years
without any ulcer or bronzing of the skin, a rmed that
“ulceration is not a direct consequence of varicosity, but
all of other conditions of the venous system with which
varicosity is not infrequently a complication.” Gay’s intuitions had already been explained by Fabricius (1603),
who a rmed that varicose veins carry “fecaloid humours”
that cause skin damage. e “bad humours” could be the
hemosiderin that spreads from the capillary bed into the
19
interstitium,
capillary brin cu , poorly permeable to gases,
or other substances that produce a peri-
20
or that
induce leukocyte trapping, migration, and release of cyto-
21
toxic substances.
AND WHY NOT TO HEALTHEM
A few authors devoted to the Pythagorean theory of
the four humours argued against healing ulcers, because
they are considered as beneficial in expelling dangerous
substances. Galen of Pergamum (130–200 ) believed
that black bile would be trapped by a healing ulcer. Thus,
black bile could leak outside while the ulcer remains
unhealed. If the ulcer heals, madness and other disasters would follow. Avicenna even proposed reopening
varicose ulcers if these spontaneously closed. In modern times, among those reluctant to treat ulcers were
Lorenz Heister (1718) and Henry Françoise Le Dran
(1731). Both of them considered the ulcer to be a drain
for humors that caused severe illness if not expelled.
Laufman stated:“A number of British surgeons took up
the same cry in the eighteenth century and even into the
nineteenth century.”
U L C E R T H E R A P Y
Modern ulcer therapy is based on (1) topical medications, (2) compressive bandaging, and (3) surgery of
related veins. e same was true more than two thousand
yearsago.
In fact, for many centuries, venous ulcers have been
treated by topical applications of substances (like the g
poultice used by the Prophet Isaiah) and combined with bandages (Celsus) and local hygienic treatments (Hippocrates).
Principles of local treatments were meticulously described
in 1446 by an anonymous surgical textbook (quoted by
Partsch, 2002), which treated extensively (9,000 words) the
treatment of leg ulcers. Four steps are reported:(1)enlargement of the ulcer mouth, to obtain drainage; (2) mor-
ti cation (debridement); (3) mundi cation (cleansing);
(4) eshing (production of granulation tissue).
14 • BASIC CONSIDERATIONS
Ulcer therapies based only on topical remedies were
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strongly criticized in 1797 by Everard Home: “It must
appear obvious, that there is no probability that any one
medicine can ever be discovered which, whether internally administered or locally applied, shall have powers adapted to the cure of all ulcer on the legs; and it
would appear, the idea that such a medicine may exist,
has retarded very considerably, the advancement of our
knowledge in the treatment of ulcers.” In addition, Brodie
(1846) warned against the frequent occurrence of cutaneous sensitization due to drugs and other remedies used
topically to treat ulcers.
e importance of using bandages along with local
treatment of ulcers was well known since Hippocrates, and
in 1676, the Englishman Richard Wiseman warned that
venous ulcers healed by compression usually recur once the
compression is discontinued. In 1771 Else tried to determine
what compression therapy would do in old ulcers of the leg,
without administering any internal medicine, and found
it so exceedingly e cacious that he believed it will seldom
fail where there is no carious bone. It has been discussed at
length, whether bandaged patients must walk or if it is better
that they rest in bed (see Table1.5). Besides clinical argumentations, ambulatory treatment of venous ulcers was justi ed by the analysis of the costs of hospitalization reported by
Underwood in 1783 and by Philip Boyers in1831.
Besides topical treatments, surgery of the varicose veins,
when present, has been recommended since old times.
Hyeronimus Fabricius of Acquapendente (1603) suggested
combining compression with double ligation and division
of the varix above the ulcer. In turn, John Gay (1867) randomly divided all the veins around the ulcers by several
incisions. It was only one century later that selective interruption of perforating veins below the ulcer was emphasized
by Franck Cockett. Currently, sclerotherapy is used to obliterate periulcerative varicose veins. Nevertheless, the rst to
perform an endovenous treatment of ulcers was Sigismond
Johann Elsholz in 1665, using a chicken bone as a needle
and a bladder of pigeon as a syringe.
Other suggestions included using a “divine factor” to
heal ulcers (Fabricius, 1603)or the “delicate massages from
sweet maiden or boy, according with own preferences,” proposed by the Roman physician Asclepiade.
Table1.5 WALKING OR BED REST TO HEAL ULCERS?
1778 Benjamin Bell Absolute bed rest
1783 Michel Underwood Immediate mobilization
1793 John Hunter Bed rest
1797 omas Baynton Walking
1799 Whately “to walk with no scruples”
1861 Hilton Bed rest
1886 Dechambre Walking
ADDENDUM:THE
INTERNATIONAL UNION OF
PHLEBOLOGYIUP
It was on March 24, 1959, at the Château de Meyrargues
in France near Aix-en-Provence, at the close of a joint
meeting of the responsible representatives of the four
existing Societies of Phlebology (the French Society
of Phlebology created in 1947, the Benelux Society of
Phlebology created in 1957, the German Society of
Phlebology created in 1958, and the Italian Society
of Phlebology, which came into being at the same time)
that the foundations of an International Union of
Phlebology were laid. Those responsible were Tournay
and Wallois (France), van der Molen (Benelux), Krieg
(Germany), and Bassi and Comel (Italy). Currently, the
IUP includes the phlebological societies of more than
forty countries
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1
HISTORICAL INTRODUCTION • 15
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16 • BASIC CONSIDERATIONS
2 .
https://t.me/med1917
VENOUS EMBRYOLOGY AND ANATOMY
Geza Mozes and Peter Gloviczki
INTRODUCTION
Substantial knowledge has accumulated in recent years on
development and anatomy of the venous system. Progress
in medical genetics resulted in identi cation of genes linked
to development of circulation and in recognition of growth
factors a ecting normal and abnormal development of
blood vessels. Perfection of ultrasound technology combined with an increasing clinical interest in venous disease
resulted in identi cation of new compartments and clinically important anatomic structures.
cally relevant anatomic terminology of the veins of the leg
and pelvis was introduced.
embryology of the venous system and present the most
frequent venous anomalies. We describe the histology of
large veins and present a detailed anatomy of the veins of
the trunk and the upper and lower limbs. Discussion of
the anatomy of the visceral and cervical veins is beyond the
scope of this review. e new terminology of veins will be
used in this chapter (see Table2.1).
E M B R Y O L O G Y
During embryogenesis the earliest veins develop from capillary plexuses; these carry blood into the sinus venosus, the
in ow end of the forming heart. e right and le common cardinal veins drain directly into the sinus venosus (see
Figure2.1). e common cardinal veins form at the junction of the anterior and posterior cardinal veins on both
sides. Between this junction and the heart the common
cardinal veins receive the vitelline and umbilical veins. e
vitelline veins initially drain the yolk sac and later the intestines. e right umbilical vein regresses completely, the le
drains the placenta.
e anterior cardinal veins drain the cranial part of the
embryo and are connected to each other by a large central anastomosing channel. e segment of the le anterior cardinal vein located proximal to the anastomosis will
regress. e oblique vein of the le atrium and the coronary
3,4
2
In this chapter we discuss the
1
Finally, a new, clini-
sinus develop from the regressed proximal segment of the
le anterior cardinal vein. e remaining distal segment
becomes the le internal jugular vein, and the anastomosis
between the anterior cardinal veins forms the le brachiocephalic vein. e right internal jugular and brachiocephalic veins develop from the proximal segment of the right
anterior cardinal vein. e external jugular veins develop
secondarily. Failure of the regression of the proximal le
anterior cardinal vein results in double superior vena cava
(SVC), whereas erroneous regression on the right side
results in le -sided SVC (see Figure2.2A andB).
e posterior cardinal veins run caudal to the heart
and distally develop an interconnecting iliac anastomosis.
Contrary to their anterior counterparts, the posterior cardinal veins regress almost completely. Only a small proximal
segment remains on the right side to form the azygos arch
and the iliac anastomosis to transform into the common,
external, and internal iliac and median sacralveins.
Most veins, caudal to the heart, develop from the suband supracardinal veins, which arise dorsal and ventral to
the regressed posterior cardinal veins, respectively. e
subcardinal veins anastomose with each other (subcardinal
anastomosis) and with the supracardinal veins (subsupracardinal anastomosis). e majority of the le -sided cardinal veins regress. e right subcardinal vein develops to
drain most of the upper, the right supracardinal vein most
of the lower part of the abdomen.
e majority of the azygos system develops from the
cranial part of the supracardinal veins. e infrarenal segment of the inferior vena cava (IVC) develops from the caudal right supracardinal vein. e renal segment of the IVC
arises from the subsupracardinal anastomosis, a venous network located circumferentially around the aorta (renal collar). Eventually, the posterior segment of the collar regresses
and the anterior part gives the le renal vein. Most of the
suprarenal segment of the IVC develops from the right subcardinal vein, except for the short hepatic segment, which
originates directly from hepatic sinusoids.
the complex development of IVC and le renal vein is not
uncommon. If the right subcardinal vein fails to connect to
5
Variation in
17
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