|Year : 2020 | Volume
| Issue : 2 | Page : 181-184
Peripheral Bypass – Looking back into the past
Sunil Rajendran, Harishankar Ramachandran Nair
Department of Vascular and Endovascular Surgery, Starcare Hospital, Kozhikode, Kerala, India
|Date of Submission||04-Apr-2020|
|Date of Acceptance||10-Apr-2020|
|Date of Web Publication||17-Jun-2020|
Dr. Sunil Rajendran
Department of Vascular and Endovascular Surgery, Starcare Hospital, Kozhikode, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rajendran S, Nair HR. Peripheral Bypass – Looking back into the past. Indian J Vasc Endovasc Surg 2020;7:181-4
Bypass surgeries, like many surgical procedures, have a long history of evolution spanning about 50 years when in 1948, Jean Kunlin finally did the first successful femoropopliteal bypass using reversed saphenous vein. The epicenter of major landmarks in the development of vascular bypass was Lyon, France. Lyon's tradition of vascular innovations led by Mathieu Jaboulay, influenced surgeons such as Alexis Carrel, Rene Leriche, Cid dos Santos, and Kunlin, who made significant contributions from the conception to the refinement of this technique. In a quest to perfect their ideas, these great surgeons who were also great innovators spent significant time in their careers in animal experiments alongside their clinical work.
Mathieu Jaboulay (1860–1913) [Figure 1] was born in 1860 at Saint-Genis-Laval near the French city of Lyon. He studied and practiced medicine in Lyon and was appointed as a professor of clinical surgery at the Lyon medical school in 1902. Long before he took this chair, in the 1890s, Jaboulay had already experimented with techniques of vascular suturing, which were perfected over time to the present-day continuous suture technique for arterial repair. In 1896, he published an article on end-to-end anastomosis of blood vessels, a time when Alexis Carrel was doing his internship at the same university.
In the early 20th century, the pathophysiology of chronic limb ischemia was less understood, and the natural history of chronic occlusions was not implicated to a vaguely understood atherosclerosis. At that time, claudication was recognized as just a symptom, while end-stage gangrene was identified as an important clinical finding and was called “gangrene senile.” Jaboulay had pointed out that, distal warming was produced when the main artery of an extremity was dissected for a ligation procedure. This was attributed to the removal of peri-arterial sympathetic nerves, and limb ischemia was mainly attributed to a less understood “neurogenic” pathology.
Alexis Carrel (1873–1944) [Figure 2] was also born in Lyon, France, in 1873. He graduated from the University of Lyon Medical School in 1889 and subsequently did his internship under Jaboulay. It appears that he was attracted by the work on vascular anastomosis being done by his professor. Under the guidance of the finest embroiderist in Lyon, Carrel developed his tiny needles and used silk sutures lubricated with Vaseline to prevent trauma to the vessel wall. In 1902 at Lyon, he published his early work on the triangulation technique of blood vessel anastomosis, in which he described a technique of adventitial-muscular suturing to avoid violation of intima., In the same year, at a seminar on arterial sutures, Jaboulay was quick to give Carrel credit for his accomplishment.
In 1904, unhappy over being denied a University appointment at Lyon, Carrel decided to migrate to the United States to further his experimental work in vascular surgery. He was invited by Karl Beck to work with Charles Claude Guthrie at the University of Chicago. Together with Guthrie, he continued the work started in Lyon and where he worked on further perfecting the techniques of vascular repair. Unfortunately, the results of their initial experiments were disappointing until Guthrie suggested all layer suturing technique, including the intima. Ten years after he left Lyon, Carrel seemed to agree that “old Lyon technique” gave better results than his own technique. He and Guthrie emphasized the importance of gentle handling of tissues and copious use of saline during anastomosis. Their work also included the use of vein grafts in the arterial system and tissue preservation techniques, which had influenced the further development of bypass surgeries.
Carrel's association with Guthrie lasted only 2 years, and in 1906, he moved to the Rockefeller Institute in New York, and further, he went on to receive the Nobel Prize in 1912. However, he became increasingly controversial due to his self-centered approach towards his achievements. Unlike his teacher, he failed to acknowledge contributions of Jaboulay in his work, and in later years, he even branded the latter's ideas as “irrational.” Guthrie too was not happy for not having been given due credit to his contributions toward Carrel's work.
Rene Leriche (1879–1955) [Figure 3], known as a great innovator of vascular surgery, was born in Roanne, France, in 1879. He also did his medical graduation at the University of Lyon in 1906 and worked under Jaboulay. He owed his interest in experimental surgery to Jaboulay, his professor and to Carrel, who was the chief surgical resident when Leriche was a medical student at the same university. Leriche was appointed as professor of surgery at Strasbourg University in 1924, and then in 1939, he took over as professor of Experimental Medicine at College de France. He was a prolific orator and a great teacher. Many great names in vascular surgery such as Michael DeBakey, Cid dos Santos, René Fontaine, and Jean Kunlin were his students.
Leriche was one of the earlier proponents, who believed that surgical diseases are not an aberration of local anatomy, but a result of the alteration of normal physiology and suggested a holistic approach toward patients with surgical disease. Being a keen observer and passionate experimenter in surgery, one of his followers remarked about him as follows:
“So acute are his powers of observation and deduction, so illuminating the flashes of inspiration which he directs upon his problems, that there are few—if any—surgeons of his generation who, having asked themselves 'why?' have been able to reply 'exactly thus' as often as has René Leriche.”
Jaboulay's work on the arterial system had a great influence on the experimental work of Leriche, who believed in the vasomotor theory of limb ischemia. He proposed that arterial occlusions induced distal vasospasm due to irritation by the proximal thrombosis. Leriche performed the first peri-arterial sympathectomy in 1913, in which the femoral artery was exposed, and adventitia was removed for a distance of 6 cm to 8 cm. This procedure resulted in increased warmth and return of peripheral pulses in some cases of chronic limb ischemia.
A few years later, Leriche observed that lesions in patients with painful trophic ulcers were segmental in nature, and he proposed “arterectomy,” wherein the thrombosed segment was excised. However, this procedure was still not done with intent to restore blood flow to the distal circulation, but probably for a more effective sympathetic denervation. In his initial years of practice, Leriche was not a proponent of the restoration of distal flow. Although not widely documented, in 1909 and 1912, he did attempt to restore the blood flow in a thrombosed artery, but had to abandon the procedure, as he could not delineate the distal end of the occlusion., However, over the years, he was gradually convinced about the role of reconstructive surgery, and in 1923, in a note to Surgery Society, he wrote: “The ideal treatment would be to remove the occluded zone and reestablish the arterial patency.” However, he added that he doubted “this would ever be possible.”, At this juncture, three factors stood as stumbling blocks in further progress toward a successful bypass surgery. These were the absence of anticoagulation, lack of definitive preoperative imaging, and nonavailability of suitable vascular conduits.
In 1916, Jay McLean, a 2nd-year medical student, while doing a research project under William Henry Howell, a renowned physiologist at John Hopkins University discovered Heparin. It took another 20 years of research by many scientists, when Charles Herbert Best Professor of Physiology in Toronto and J. Eric Jorpes Biochemist at Karolinska Institute, Stockholm, Sweden, finally succeeded in developing a pure form of Heparin. On April 16, 1937, Heparin was first used in humans, when Gordon Murray, a surgeon and an associate of Charles Best, used this as an infusion into the brachial artery. Despite the controversy surrounding the discovery of Heparin, its discovery ushered in a new era of reconstructive vascular surgery.
Joao Cid dos Santos (1907–1975), [Figure 4], a Portuguese Vascular Surgeon, born in 1907, was inspired by his father Reynaldo dos Santos, a physician himself to take up medicine. In 1933 after graduating from Lisbon, he started his surgical career at Arroios Hospital, established by his father. Reynaldo's one of the areas of interest being vascular surgery is credited with performing the first translumbar arteriogram for a patient with peripheral gangrene 1929. Subsequently, in 1935, Joao extended its use into experimental vascular surgery. In 1936, he traveled to Strasbourg to work with Rene Leriche for a year, where he made acquaintances with Jean Kunlin, Fontaine, and DeBakey among others. This one year was a turning point in the surgical career of Joao Cid dos Santos, and he had remarked, “Our practice with Leriche is a capital milestone in our life.”
After the return from Strasbourg, Cid dos Santos continued his experimental work in vascular surgery and submitted a doctoral thesis titled “General pathology of ischemia in limbs” to the Faculty of Medicine of Lisbon. Gradual advancements in the techniques of arteriography uncovered the segmental nature of lesions in various territories of the arterial tree. In the early 20th century, removal of such lesions by many surgeons had always met with failures, which further upheld the long-held myth of “inviolability of the intima.” Cid dos Santos, however, was very focused on developing a surgical cure for such focal lesions and continued experimental work to improve and reproduce the results of classic experiments of Carrel and Guthrie.
By the early 1940s, Heparin became available for clinical use, and Cid dos Santos initially attempted peripheral “desobstruction” procedures in a few terminally ill patients, under cover of this drug. The histopathology of the specimen thus removed and revealed intimal and medial layers of the artery along with the centrally organized thrombus. Arteries of such patients were patent till their death, and he attributed this to the ability of Heparin to prevent thrombosis over the exposed media of the arterial wall, thereby disproving the long-held “intimal myth.” Finally, on August 27, 1946, Cid dos Santos performed the first endarterectomy of the femoral artery, first such an attempt to re-establish blood flow in a patient with a chronic arterial occlusion.
Jean Kunlin (1904–1991), [Figure 5] was born in Schiltigheim, near Strasbourg. He studied medicine, interned, and worked in the experimental surgery laboratory at Mount Saint Martin's Hospital in Strasbourg under Rene Leriche. Working with Leriche, he grew his interest in vascular surgery as one of the most loyal pupils of his teacher and worked with him till Leriche's death except between 1938 and 1942.
In 1942 Leriche was invited to occupy the Chair of Experimental Medicine at College de France, where he invited Kunlin to collaborate with him. During this period, both continued their clinical work at the 11-bedded surgical unit at the American hospital in Paris. He was a very modest person and worshipped Leriche like a father and would not venture into a new technique without his approval. Kunlin had spent considerable time developing a technique to bypass long arterial occlusion with an autologous vein and had almost perfected it in his experimental laboratory. However, he could not convince his mentor, Leriche to use this in a suitable patient. In 1947, his friend Cid dos Santos visited Paris to show his then-revolutionary technique of thromboendarterectomy, and he developed an interest in this procedure. Over the next few months, Kunlin spent some time experimenting to perfect this procedure. He modified the technique by placing a tacking suture at the distal end of the endarterectomy, but could not reproduce results of Cid dos Santos, further prompting him to get back to his technique of vein bypass between undiseased segments of an artery.
In 1948, a patient was admitted at the American hospital, under the care of Leriche, with ischemic rest pain and gangrene. He had already undergone amputation of the first toe and had subsequently been subjected to lumbar sympathectomy and arterectomy of the thrombosed superficial femoral artery, which was the optimal treatment of those days. While Leriche was on a long vacation to Holland, the patient's condition deteriorated, and as amputation was imminent, he agreed to Kunlin's proposal of vein bypass to a patent popliteal artery below. On June 3rd, first femoropopliteal bypass was done that involved an end-to-side anastomosis of the reversed saphenous vein to normal segments of arteries above and below the long occlusion [Figure 6]. The patient did well after the procedure, and his ulcer healed within 3 weeks 1. On his return, Leriche was astonished by the “unconventional” procedure done but was slowly convinced. Kunlin went on to do similar procedures and presented his series of 17 vein bypasses enumerating technical details involved.
Kunlin continued to be a very modest person and never sought the honors or recognition, he would have been entitled to. While paying tribute to this great person at the Annual Meeting of the French Vascular Surgery Society in 1994, a former colleague of Kunlin, J. Testart stated:
“In making his decision to perform bypass, Kunlin must have been torn between his scientific objectivity and his affection and loyalty to his mentor. Kunlin denies having forsaken his mentor's ideas and even claims to have been in complete agreement with Leriche, since his ultimate goal was to gain an understanding of pain and thus be better able to treat it.”
Bypass surgery is the cornerstone of many vascular surgical procedures. We the modern-day vascular surgeons owe greatly to all these stalwarts of yesteryears from Mathieu Jaboulay to Jean Kunlin, who were all innovators par excellence, for their role in laying a strong foundation to the present-day practice of vascular surgery.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]