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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3953_Библиотеки_им_академика_М_И_Перельмана
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Linda de Cossart Countess of Chester, NHS Foundation Trust, Chester, U.K.
Walter N. Dura
´
n New Jersey Medical School, Newark, New Jersey, U.S.A.
Ronald K. G. Eifell Department of Vascular and General Surgery, Queen Elizabeth
Hospital, Gateshead, U.K.
Bo Eklo
¨
f Department of Vascular Diseases, Lund University, Lund, Sweden
Anna Falanga Department of Haematology–Oncology, Ospedali Riuniti,
Bergamo, Italy
F. G. R. Fowkes Wolfson Unit for Prevention of Peripheral Vascular Diseases,
University of Edinburgh, Edinburgh, U.K.
George Geroulakos Vascular Unit, Ealing Hospital, Southall, and Department of
Vascular Surgery, Imperial College, London, U.K.
Athanasios D. Giannoukas University of Thessaly Medical School and Division of
Vascular Surgery, University Hospital of Larissa, Larissa, Greece
Jonathan Golledge School of Medicine, James Cook University, Townsville,
Queensland, Australia
Hany Hafez St. Richard’s Hospital, Chichester, U.K.
George Hamilton University Department of Surgery, Royal Free Hospital, UCL and
Royal Free Medical School, London, U.K.
Denis W. Harkin Regional Vascular Surgery Unit, Royal Victoria Hospital,
Belfast, Northern Ireland
Olivier Hartung Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire
Nord, Marseille, France
Anil Hingorani Division of Vascular Surgery, Department of Surgery,
Maimonides Medical Center, Brooklyn, New York, U.S.A.
Claude Juhan Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Nord,
Marseille, France
Stavros K. Kakkos Vascular Unit, Ealing Hospital, Southall, U.K.
Steven S. Kang South Miami Heart Center, Miami, Florida, U.S.A.
Patrick Kesteven Department of Haematology, Freeman Hospital, Newcastle upon
Tyne, U.K.
Shankat N. Khan Northern Vascular Centre, Freeman Hospital, Newcastle
upon Tyne, U.K.
Contributorsxviii
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Nicos Labropoulos Vascular Laboratory, Division of Vascular Surgery, New Jersey
Medical School, Newark, New Jersey, U.S.A.
Brajesh K. Lal New Jersey Medical School, Newark, New Jersey, U.S.A.
Tim A. Lees Department of Vascular Surgery, Freeman Hospital, Newcastle upon
Tyne, U.K.
Luis Leon Division of Vascular Surgery, Loyola University Medical Center, Maywood,
Illinois, U.S.A.
Sumaira Macdonald Northern Vascular Centre and the Department of Radiology,
Freeman Hospital, Newcastle upon Tyne, U.K.
Derek Manas Hepatic Surgery Unit, Freeman Hospital, Newcastle upon
Tyne, U.K.
James E. McCaslin Department of Vascular and General Surgery, Queen Elizabeth
Hospital, Gateshead, U.K.
Jonathan Michaels Department of Vascular Surgery, University of Sheffield, Sheffield,
U.K.
Peter Negle
´
n River Oaks Hospital and University of Mississippi Medical Center,
Jackson, Mississippi, U.S.A.
Ian Nichol Department of Vascular Surgery, The James Cook University Hospital,
Middlesbrough, U.K.
Klaus Overbeck Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne,
U.K.
Frank T. Padberg, Jr. New Jersey Health Care System–Veterans Affairs Medical
Center, East Orange, New Jersey, U.S.A.
Simon Palfreyman Department of Vascular Surgery, University of Sheffield, Sheffield,
U.K.
Peter J. Pappas New Jersey Medical School, Newark, New Jersey, U.S.A.
Michel Perrin University of Lyon, Lyon, France
Andrea Piccioli Department of Medical and Surgical Sciences, University of Padua,
Padua, Italy
Paolo Prandoni Department of Medical and Surgical Sciences, University of Padua,
Padua, Italy
Seshadri Raju River Oaks Hospital and University of Mississippi Medical Center,
Jackson, Mississippi, U.S.A.
Contributors xix
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Jill Robson Freeman Hospital, Newcastle upon Tyne, U.K.
Frank C. T. Smith Bristol Royal Infirmary, Bristol, U.K.
Philip D. Coleridge Smith Royal Free and University College Medical School,
London, U.K.
Gerard Stansby University of Newcastle upon Tyne, Newcastle upon Tyne, U.K.
Sriram Subramonia Northern Vascular Centre, Freeman Hospital, Newcastle
upon Tyne, U.K.
Alok Tiwari University Department of Surgery, Royal Free Hospital, UCL
and Royal Free Medical School, London, U.K.
Fiona J. Tsang West of London Vascular Service, Charing Cross Hospital,
London, U.K.
Dereck W. Wentworth U.S. Medical Affairs, New York, New York, U.S.A.
Robert W. Zickler UMDNJ–New Jersey Medical School, Newark, New Jersey and
New Jersey Health Care System–Veterans Affairs Medical Center, East Orange, New
Jersey, U.S.A.
Contributorsxx
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SECTION A: BACKGROUND DATA
1
Historical Background
Alberto Caggiati
Department of Anatomy, University “La Sapienza,” Rome, Italy
Venous disorders have been recognized since ancient times, although real knowledge
came only with an understanding of the anatomy of the venous and lymphatic systems
developed over many centuries. This hard-won knowledge still underpins any modern
study of venous and lymphatic function in both health and disease.
THE “DISCOVERY” OF THE VENOUS DRAINING SYSTEMS
Meticulous but partial descriptions of the venous system are to be found in the works of
Aristotle (384–322
BC), who described the vena cava and the superficial veins of the upper
extremities. However, the real beginning of the study of vascular and lymphatic anatomy
is due to Herophilus of Chalcedon (300–250
BC), a Greek physician living in Egypt.
He practiced in Alexandria, where human dissections were permitted, even performing
some in public. Herophilus furnished the first anatomical and functional discrimination
between arteries and veins. In addition, he was the first to note and describe lacteals, which
he observed in the mesentery of man. Galen of Pergamum (130–200
AD) subsequently
described the course of the veins of the whole body and called the smallest vessels
“tricoide
´
,” i.e., “hair-like.” He confirmed that these small vessels connect arteries and
veins throughout the body. He believed that blood originated in the liver and moved back
and forth through the body, passing through the heart, where it was mixed with air
(“pneuma”) by pores in the septum. Galen also introduced the concept of the “spirit”
system, consisting of natural spirit or “pneuma” (he thought air was found in the arteries),
vital spirit (blood mixed with air found in the arteries), and animal spirit (which he
believed to be found in the nervous system). The first complete and systematic description
of the whole venous system was finally furnished by Andre
´
Vesale (1514–1564) in the De
Humanis Corporis Fabrica, illustrated by the magnificent drawings of Jan Stefan van
Kalkan (Fig. 1).
A depiction of venous valves did not appear in the original Fabrica. They were
first described in the renal, azygos, and external iliac veins by Giovanni Battista Canano
(1515–1579) from Ferrara in 1540. They were included in the subsequent editions of the
Fabrica. Many decades later, Hyeronimus Fabricius of Acquapendente (1533–1619) was
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the first to furnish a good description of the valves of the veins and of their role (Fig. 2).
He was Harvey’s teacher at Padua and undoubtedly must have stimulated his interest in
the circulation of the blood.
A description of the perforating veins did not appear until two centuries later.
In 1803, they were first described by Justus Christian Von Loder (Fig. 3). In 1824, Paul
Briquet described the anatomy of the calf venous pump but believed that blood would be
pushed by the calf pump from deep to superficial veins via the perforators. The correct
hemodynamic role of perforators was finally stated by Aristide August Verneuil, a French
surgeon, in 1855.
LYMPHATIC VESSELS
Herophilus (third century
BC) mentioned the existence of the lymphatics. Bartolomeus
Eustachii (1500–1574), Professor at La Sapienza University of Rome, described in 1563
the thoracic duct nearly a century before Pecquet (1651); “.a whitish canal going
from the clavicular area to lower parts..” Sixty years later (1622) Gaspare Aselli
(1581–1626) described the lymphatics. In a posthumous account published in 1627, he
stated that lacteals contained milky or creamy fluid. Aselli described also the valves placed
along lymphatics, especially at their confluences. His book De Lactibus Sive Lacteis Venis
Figure 1 The venous system as represented by Vesale in his Fabrica.
Caggiati2
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was published just before the De Motu of Harvey, who had not appreciated Aselli’s
discovery and perhaps was not aware of it. Paolo Mascagni (1752–1815) was prosector in
anatomy at the University of Siena (Italy). In 1787, Mascagni published a large folio
volume entitled Vasorum lymphaticorum corporis humani historia et iconographia. This
important monograph contained the first systematic and definitive description of the
human lymphatic system (Fig. 4). Mascagni has been credited with discovering some 50%
of the lymphatic vessels.
THE “DISCOVERY” OF THE CIRCULATION OF THE BLOOD
William Harvey (1578–1657) is correctly credited with the “discovery” of the circulation
of the blood. He proved that the heart receives and expels blood during each cycle by
observing the action of the heart in small animals and fishes. By compressing the visible
veins of the forearm, he simply but persuasively confirmed Fabricius’ observation that
the venous valves permitted flow in only one direction, toward the heart. But the concept
of blood circulation was not new. In fact, Wang Shu So reported in the Mei Ching
(China, third century
AD) that “the heart regulates all the blood in the body.The blood
Figure 2 Valves of the sapheno-femoral junction as represented by Fabricius in 1603.
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Figure 3 The first drawing in which perforators are reported (Van Loder, 1803).
Figure 4 The lymph trunks of the pelvis and of the abdomen as represented by Mascagni (1787).
Caggiati4
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current flows continuously in a circle and never stops.” The Spanish anatomist
Ludovicus Vassaeus in 1544depicted exactlythe anatomyof thecardiovascular systemand
the flow direction in the main vessels. The Spanish theologian Miguel Servede, alias
Servetus of Villanueva (1509–1553), described in1564 thepulmonary circulation: he stated
that the blood enters the lungs by the way of the pulmonary artery in greater quantities than
necessary for theirnutrition, mixes with the “pneuma” and returns byway of the pulmonary
veins. The discovery of Servetus did not disseminate to contemporary physicians, probably
because itwas reported in a theological work.Andrea Cesalpino (1519–1603) from Arezzo,
was Professor of Medicine at Pisa and at Rome. He first delineated that blood flows into the
heart (“.the blood enters the right ventricle by the vena cava.exit from the heart to open
into the lungs.from the left ventricle opens the orifice of the aorta.”). Furthermore,
Cesalpino identified the function of the valves (“.certain membranes placed at the
openings of the vessels prevent the blood from returning.”) and coined the term
“circulation” supposing the existence of “vasa in capillamenta resoluta.” Finally, Realdo
Colombo (c. 1510–1577) from Cremona, successor of Vesalius as the chair of anatomy in
Padua, furnished an exact description of the circulatory system, denying the previously
suggested existence of porosity in the interventricular septum.
Harvey’s theory of blood circulation was completely accepted only in 1661, when
the Italian Marcello Malpighi (1628–1694) demonstrated using rudimentary microscopes,
the existence and hemodynamic role of the capillaries. Mechanisms of venous return were
better defined by: (1) Richard Lower, who emphasized the role of the muscular pump and
theorized the vis a tergo: “the return of the venous blood is the result of the impulse given
to the arterial blood.,” (2) Antonio Maria Valsalva, pupil of Malpighi and teacher of
Morgagni, who in 1710 described the respiratory forces that enhance venous return to the
heart: the “vis a fronte,” and (3) Giovanni Lancisi, who in 1728 demonstrated
experimentally the spontaneous rhythmical contraction of the larger veins.
SCLEROTHERAPY
Sclerotherapy is based upon the observation reported in 1815 by Joseph Hodgson
(1788–1869) who noted that “thrombosis extinguished varicose veins.” Sclerotherapy
developed after the invention of the hypodermic needle in 1845 by Francis Rynd and of the
syringe by Pravaz in 1851. However, former attempts of venous cannulation were made by
Francesco Folli (1623–1685) who in 1654 accomplished artero-venous blood transfusion
by insertion of a silver tube into the artery of the donor and a bone cannula into the vein of
the recipient, uniting the two by means of a tube especially made from an animal blood
vessel. In 1665, Sigismond Johann Elsholz (1623–1688) used a chicken bone as a needle
and the bladder of a pigeon as a syringe to irrigate ulcers by intravenous injection of
distilled water or of essences from plants.
Many substances have been used to induce venous obstruction. Here are a few
examples: Monteggio and De Leroy d’Etoilles (1840) proposed absolute alcohol for
sclerotherapy. Pravaz (1851) used ferric chloride. Benedetto Schiassi from Bologna used a
combination of iodine and potassium iodide. Kausche (1917) proposed inverted sugar for
sclerotherapy of varicose veins. After having used sodium carbonate for 4 years, Sicard
came to prefer sodium salicylate because “it occluded varicose veins and, at the same
time, it mitigated the arthritis that occurred in so many patients with varicose veins.”
In 1921, Genevrier, a military surgeon, discovered that injection of quinine solution to
treat malarial crisis could cause venous sclerosis. He suggested injecting a concentrated
quinine solution in the diseased veins of malarial varicose patients thereby treating both
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diseases. In 1925, Linser of Dresden reported the use of a 20% solution of ordinary table
salt to sclerose varicose veins.
Different techniques of venipuncture and strategies for sclerotherapy developed in
the last century. Benedetto Schiassi from Bologna, was the first to perform intraoperative
injections. In 1944, Horbach introduced the technique called “air block” to enhance the
effects of sclerotherapy. In 1963, Fegan described his methods of sclerosing varicose veins
based upon tight post injective compression and in the 1990s Shadek introduced the
Duplex evaluation of the effect of sclerosing agents. Duplex monitoring has recently
allowed the use sclerosing foam obtained chemically (Juan Cabrera) or by a mechanical
procedure (Lorenzo Tessari).
SURGERY
Historically, venous surgery started in the second century
BC with Heliodorus. He gave the
first description of ligation and torsion of blood vessels to control hemorrhage. The Roman
Celsus extirpated varicose veins with a blunt hook and used cauterization with a red hot
iron. Oribasius of Pergamum (325–405
BC) was the first of the Byzantine surgeons who
dealt with varicose veins. He devoted three chapters of his Book XLV to this subject and
recommended: (1) shaving and bathing the leg to be operated, (2) with the leg still warm,
the surgeon has to mark varicose veins with the patient standing (they marked them by
small incisions!), (3) the use of a special hook, called a cirsulce, (4) to extirpate varicose
vein of the lower leg firstly, then at the thigh, (5) to remove the veins because, if only
ligated, they can form new varices.
“Open surgery” of varicose veins started with Paulus of Aegina (625–690).
He recommended isolation of varicose veins at the thigh by a longitudinal incision, and,
after bloodletting, to ligate them at both ends. The tied-off portion was excised or
allowed to slough off later with the ligatures. Arab surgeons operated on varicose veins
by cautery. Guglielmo Saliceti, from Piacenza (Italy), alias Williams of Saliceto
(1210–1277), had the great merit of reintroducing the use of the knife into surgery, which
had been abolished by the Arabs. Giovanni da Vigo (1460–1525), surgeon to Pope Julius
II, ligated the veins “.intromittendo acum sub vena desuper filium stringendo.” (by
introducing a needle beneath the vein and tightening the thread from above) (1514).
In 1545, Ambroise Pare
`
(1510–1590), after initially treating varicose veins by external
cauterization (Arab tradition), reintroduced the use of ligature of varicose veins.
Modern venoussurgery started with the Swiss surgeon Tommaso Rima (1777–1843),
who was the first to propose in 1806, a hemodynamic treatment of varicose veins with
ligation of the upper portion of the great saphenous vein, an operation generally credited to
Trendelemburg (1896). In 1816, Sir Benjamin Collins Brodie (1783–1862) operated on
varicose veins: “.after the skin over a varix was incised, the varix was divided with
a curved bistoury and pressure was applied to prevent haemorrhage...” Alfred Armand
Louis Marie Velpeau (1795–1864) introduced a pin or needle through the skin, which was
passed underneath the vein, and at right angles toit. A twisted suture was then appliedround
the two ends of the pin, so as to compress the vein sufficiently to produce its obliteration.
In 1877, Max Schede reported a technique for radical removal of varicosities based upon
multiple ligature or venesections and percutaneous ligations. In 1884, Madelung proposed
the complete excision of the great saphenous vein through a long incision much like those
used today in vein harvest for coronary bypass. In 1906, Delbet proposed to treat varicose
veins by re-implantation of the terminal portion of the great saphenous vein just below
a healthy femoral valve.
Caggiati6
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In 1905, W.L. Keller described a rigid intraluminal stripper to extirpate the Great
Saphenous Vein. Two years later, Babcock modified the technique of Keller and devised
the acorn tip and used a flexible rod. Finally, in 1907 Mayo proposed an extraluminal ring
stripper that was modified by Myers and Smith in 1947. In 1956, Robert Muller elaborated
a modern technique for ambulatory stab avulsion of varicose veins. In 1963, Jean Van der
Stricht described the “saphenectomy by invagination” refining similar techniques
proposed in the past. Utilizing Duplex preoperative evaluation of the varicose bed, in
1988 Claude Franceschi proposed a minimally-invasive and conservative treatment of
varicose veins designated with the acronym CHIVA (“conservative haemodynamic
treatment of incompetent and varicose veins in the ambulatory patient”).
Endovascular treatment of the Saphenous vein started in 1964 when Politowski
destroyed varicosities by endovenous electrosurgical dessication. In 1972 Watts described
the treatment of saphenous varicosities by endovenous diathermy. In 1981 Milleret and
Le-Pivert proposed a freezing technique to treat saphenous insufficiency. In 1989, Puglisi
and his colleagues of the School of Malan (Milan) firstly reported at the IUP Congress in
Strasbourg, the use of endovenous Laser to treat varicose saphenous veins. At the end of
the 1990s, radiofrequency probes were introduced into clinical practice to induce
endovenous obliteration of the Saphenous veins.
Selective surgery of perforating veins was proposed in 1938 by R.R. Linton, who
proposed a medial subfascial approach to treat incompetent perforating veins. In 1953,
Cockett and Jones proposed the epifascial ligature of medial ankle perforators. Two years
later, Felder recommended that subfascial incision for ligation of perforating veins should
be placed in the posterior midline of the calf 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. Bassi suggested avulsion of perforators by use of a hook. Finally,
in 1985, Hauer performed the first subfascial endoscopic interruption of perforating veins.
Historical Background 7
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