History of the management of popliteal artery aneurysms

Management of popliteal aneurysms remains controversial. Debate continues as to when an asymptomatic popliteal aneurysm should be treated and, with concerns regarding the fate of a bypassed popliteal aneurysm and the advent of intravascular stents, what procedure is best. This paper reviews the history of popliteal artery aneurysm management with particular emphasis on treatment and results before the modern era of arterial reconstruction. The aim of treatment then was to induce thrombosis. Now it is to prevent thrombosis.

[Rendering surgical care for the wounded presenting with injuries to limb vessels]

The proffered paper provides the information about rendering surgical care for the wounded presenting with vascular injuries inflicted and sustained during wars Russia was engaged in, to be followed by a detailed description of the haemorrhage-arresting methods and techniques used in N. I. Pirogov's time, during World War I, the Great Patriotic War, as well as in local military conflicts and combat operations. Also depicted herein is the role surgeons of Russia have played in the development of vascular surgery, and, finally, due coverage is given to the statistical data concerning the methods of rendering care for those having suffered firearm wounds and injuries involving vascular lesions.

Emergency intervention for thrombosed popliteal artery aneurysm: can the limb be salvaged?

We present a review and our own experience of the demographic aspects of popliteal artery aneurysms (PAAs), their clinical presentation, the treatment alternatives and associated outcome. The incidence of PAA:s varies between 0,1-1%. 95% of the patients are male. 50% are asymptomatic at the time of diagnosis. Annually, 5-24% of PAAs develop symptoms. The clinical presentation varies widely with an amputation rate of up to 78% in acute ischemic cases. The main indication for PAA repair is prevention of embolisation but acute revascularisation is the primary task in the emergency setting. Open surgery and endovascular techniques are described and can be combined with intraarterial thrombolysis as pre- or intraoperative treatment. The literature proves often inconclusive due to small numbers of heterogenous cases. Each case, therefore, needs to be assessed individually and offered the most suitable treatment.

History of endovascular surgery: personal accounts of the evolution

Endovascular therapy has continuously evolved since it was first described in 1904. It was first used as a technique to inject particles to follow the flow into vascular lesions, and from the mid-seventies on, microballoons were developed to reach targets in the arterial vascular tree. Arteriovenous malformations were approached with catheters, the tip mounted by calibrated leak balloons. The embolizing material injected was cyanoacrylate labeled with Lipiodol (Lafayette Pharmacal, Lafayette, IN), a technique that is similar to what we use today. Flow-guided microballoons placed and detached in brain aneurysms eventually became unstable, making reperfusion and rupture possible. With the introduction of guidewire-supported microcatheters, controlled navigation in the endovascular tree became possible, allowing the injection of particles, liquid embolizing agents, or free coils. In 1991, detachable coils became available and brought new therapeutic concepts. Having learned that detachable coils could not be used to treat aneurysms, which were difficult to treat surgically, the neurosurgical community accepted this new technology primarily for patients in poor condition following aneurysmal subarachnoid hemorrhage. Increased experience led to better clinical results, and Guglielmi detachable coiling therapy began to be accepted also for patients with posterior circulation aneurysms. Recent controlled trials and new technologies improving the endovascular feasibility have raised the acceptance of endovascular therapy for brain aneurysms. The elegance of the endovascular approach was an important argument for this technology from its inception, but in early years, restricted endovascular efficacy limited the efficiency of embolizations. Increasing experience and exploding new technologies have made endovascular techniques not only safer but also as effective as microsurgery. The number of vascular pathologies where microsurgery is the only option is decreasing, and training in vascular neurosurgery may become the privilege of specialized centers in the future.

Historical perspectives: the microsurgical and endovascular treatment of aneurysms

The history of aneurysm therapy is rich in parallelisms that exist between the once-fledgling field of aneurysm surgery and the now-growing field of endovascular aneurysm treatment. The treatment of aneurysms has had a cyclic progression. The indirect and safest approach to the treatment of aneurysms was seen in the development and use of Hunterian ligation in the 19th century. During the past few decades, nascent technology and a better understanding of the pathophysiology of aneurysms resulted in a more direct intracranial, extravascular approach to aneurysm therapy, with the focal point being the use of the aneurysm clip to secure an aneurysm at its neck. Interestingly, alternative and, arguably, even more direct approaches to aneurysm therapy developed in the surgical suites. These techniques became the seeds for the birth of direct endovascular aneurysm treatment in particular and endovascular surgery in general. As endovascular technology continues to develop, somewhat more sophisticated, indirect approaches to aneurysm therapy (the use of stents to modify flow, for example) are being investigated. The treatment of intracranial aneurysms has a rich history. First thought to be inoperable lesions, aneurysms have challenged neurosurgeons and their colleagues since they were first recognized in the 18th century. Treatment for these lesions did not begin until the 19th century with the use of Hunterian ligation. This review describes the many milestones in the field of aneurysm surgery and endovascular surgery, tracing the many parallelisms contained within the birth and growth of each field and their respective significance.

[Josef Koncz (1916-1988)--pioneer of cardiac surgery]

Josef Koncz (1916-1988) was until given emeritus status in 1982 director of the Department of Cardiothoracic and Vascular Surgery, which was specifically founded for him in Goettingen, Germany. By the fusion of three different surgical branches the University hospital of Goettingen took over the role of a pacemaker and initiated a standard in the development of this new specialty in Germany. The scientific and clinical work done by the Department of Cardiothoracic and Vascular Surgery was shaped by the personality of the surgeon and scientist Josef Koncz. He was a successful surgeon and innovative pioneer in one person. Already in 1956, he started open-heart surgery and proceeded this technique in an impressing series. In 1965 he was the first in Germany who operated upon the transposition of the great vessels by Mustard's method and developed together with his long-standing assistant, Huschang Rastan, an operation technique to extend the left-ventricular outflow tract combined with tunnel-shaped subvalvular aortic valve stenosis. Another essential element of his work is related to the establishment of the Cardiothoracic and Vascular Surgery as an independent specialty, ending in the foundation of the German Society for Thoracic and Cardiovascular Surgery in 1971.

Fifty Years of Thoracic Aortic Surgery: Lessons Learned and Future Directions

During the past 50 years, the genetic basis and natural history of aortic disease has been defined. Surgical methods evolved to reduce mortality and morbidity from bleeding, renal impairment, cerebral injury, and paraplegia. Aortic surgery is now a specialty in itself. Experienced groups achieve a mortality rate of less than 2% for root operations and less than 15% for arch surgery and aortic dissection. The introduction of stent grafts has changed the approach to vascular pathology. These are less intimidating for the patient but have unsolved risks with uncertain long-term outcome. In the future, an evidence-based balance between conventional surgical procedures versus interventional strategies is required.

[Surgical treatment of the lower extremities varicose veins throughout the ages]

The authors describe a historical review of surgical treatment of varicose veins from antiques to modern methods. Diseases of the veins have been recognized and attempts of their surgical resection have been described since antiquity. Hippocrates wrote about surgical treatment of varicose veins, Celsus and also Galien himself described varicose veins ligatures. The end of 19th century with Trendelenburg and Madelung was a start of modern period of varicose vein surgery. Parallel to surgical the less invasive methods of varicose veins treatment developed and gave a base for modern sclerotherapy.

Upper extremity arterial combat injury management

Traumatic hemorrhage and vascular injury management have been concerns for both civilian and military physicians. During the 20th century, advances in technique allowed surgeons to focus on vascular repair, restoration of perfusion, limb salvage, and life preservation. Military surgeons such as Makins, DeBakey, Hughes, Rich, and others made significant contributions to the field of surgery in general and vascular surgery in particular. Casualties from combat in Afghanistan and Iraq confront physicians and surgeons with devastating injuries. The current generation of providers is challenged with applying contemporary care while expanding upon the lessons taught by our predecessors. The objective of this report is to review the historical experience with managing military upper extremity arterial injuries and compare that experience with current management.

New Training Paradigms and Program Requirements

Specialized training in vascular surgery evolved over the second half of the 20th century and continues to do so in 2006. Apprenticeship-style training in the 1960s and 1970s gave way to formal curriculum- and case-based programs created in the 1980s to improve the quality and consistency of vascular care. Recent developments have resulted in the Accreditation Council for Graduate Medical Education's approval of additional training pathways leading to certification by the American Board of Surgery. This article summarizes the history of vascular surgery training in the United States and describes the four types of currently approved programs--Standard, Early Specialization, Independent, and Integrated--for specialty training in vascular surgery. These are the only programs that can lead to American Board of Surgery certification in vascular surgery.

Valentine Mott. American surgeon pioneer

Valentine Mott (1785-1865) was considered one of the most influential American surgical leaders of his time. Originally from Long Island, New York, he proceeded from a Quaker medical family and received a classical education from an elementary seminary. After completing an apprenticeship under his cousin, well-respected surgeon Valentine Seaman, he attended and received his medical degree from Columbia Medical College in 1806. Months later, he left for London, where he studied surgery under the superb guidance of the surgical star Sir Astley Cooper. Other noted English and Scottish surgeons actively participated in his education as well. By 1809, Valentine Mott returned to New York City. Various coveted surgical posts at Columbia, Rutgers Medical College of New Jersey, and University City of New York were occupied by Professor Mott. Valentine Mott was certainly the first American to ligate successfully a great number of large arteries. Because of Valentine Mott's extraordinary vascular surgery work, the distinguished surgeon and historian, Ira Rutkow, believes Mott should be named the father of American vascular surgery. I concur with his recommendation. In addition, Valentine Mott performed an incredible number of lithotomies with good results, and nearly 1000 amputations and other operations, such as surgery of the face, nose, and mandible. He was a continuously dedicated, highly committed, and skillful surgeon, who knew anatomy extremely well and was a considerate professional with his patients and colleagues-a great example for aspiring surgeons to follow.

FIFTY YEARS OF VASCULAR SURGERY IN AUSTRALIA AND NEW ZEALAND

Over the 50 years that vascular surgery has been practised in Australia and New Zealand there have been major advances and refinements of surgical techniques, particularly with the advent of endovascular surgery, spurred on especially with the introduction of endovascular aortic aneurysm stent grafting. At the same time, there has been a revolution in medical imaging, with the introduction of ultrasound, computed tomography scanning and magnetic resonance scanning. Vascular surgery in Australia and New Zealand was initially an interest of either general or cardiothoracic surgeons, but was recognized as a subspecialty of general surgery with the formation of the Section of Vascular Surgery within the Division of General Surgery of the Royal Australasian College of Surgeons in 1972. In 1981, a 2-year training programme in vascular surgery was established and in 1983 an Australian and New Zealand Chapter of the International Society for Cardiovascular Surgery was formed. In 1995, vascular surgery was recognized as a specialty in its own right with the formation of the Division of Vascular Surgery within the College. There has been a separate examination for Fellowship of the Royal Australasian College of Surgeons (Vascular) since 1997. In 2001, the Chapter changed its name to The Australian and New Zealand Society for Vascular Surgery and in 2002 it amalgamated with and took over the functions of the Division of Vascular Surgery, which was formally dissolved.

The transition from hunterian ligation to intracranial aneurysm clips: a historical perspective

The description of cerebral aneurysms dates back to antiquity. Little was known, however, about the pathological mechanisms of aneurysm formation and treatment options for this disease until 200 years ago. The modern era of aneurysm treatment began with the hunterian ligation of the proximal artery, followed by clip and coil occlusion. In this article, the authors describe the transition from conservative therapy to internal carotid artery (ICA) ligation and gradual occlusion of the ICA to the direct placement of clips on aneurysms. The driving forces and rationale behind each major advancement are summarized, and the authors attempt to predict what these innovations mean for the future of intracranial aneurysm management.

J. Lawrence Pool, M.D.: a pioneer in vascular neurosurgery

The authors detail the life and career of Dr. J. Lawrence Pool, as well as his significant contributions to the field of cerebrovascular neurosurgery. The discipline of cerebrovascular neurosurgery is a young and dynamic field, which underwent rapid and substantial growth during the middle of the twentieth century. As the chairman of the Department of Neurological Surgery at the Neurological Institute of New York, Dr. J. Lawrence Pool was instrumental in the development of new techniques and devices that would ultimately result in decreased mortality rates and improved results from complex cerebrovascular procedures. Passion, ingenuity, and a pioneering spirit fueled Dr. Pool, whose introduction of the operating microscope and use of temporary clip occlusion during aneurysm repair revolutionized the field of cerebrovascular neurosurgery.

Vascular Knowledge in Medieval Times was the Turning Point for the Humanistic Trend

OBJECTIVE

Knowledge of the history of our surgical specialty may broaden our viewpoint for everyday practice. We illustrate the scientific progress made in medieval times relevant to the vascular system and blood circulation, progress made despite prevailing religious and philosophical dogma.

METHODS

We located all articles concerning vascular knowledge and historical reviews in databases such as MEDLINE, EMBASE and the database of abstracts of reviews (DARE). We also explored the database of the register from the French National Library, the French Medical Inter-University (BIUM), the Italian National Library and the French and Italian Libraries in the Vatican. All data were collected and analysed in chronological order.

RESULTS

Medieval vascular knowledge was inherited from Greek via Byzantine and Arabic writings, the first controversies against the recognized vascular schema emanating from an Arabian physician in the 13th century. Dissection was forbidden and clerical rules instilled a fear of blood. Major contributions to scientific progress in the vascular field in medieval times came from Ibn-al-Nafis and Harvey.

CONCLUSION

Vascular specialists today may feel proud to recall that once religious dogma declined in early medieval times, vascular anatomic and physiological discoveries led the way to scientific progress.