Peripheral vascular disease.

There is little doubt that one of the greatest advances in the field of peripheral arterial disease was our ability to visualize problems wherever they occurred. This was possible because of the development of arteriography. One of the dramatic developments that made this possible was the observation by Forsmann1 in 1929 that a catheter could be threaded through a peripheral vein into the right heart. He also suggested the possibility of injecting a contrast agent through the catheter for imaging purposes. Because of this contribution, he was awarded the Nobel prize in 1953. Seldinger2 in 1953 pushed this concept even further by showing that it was possible to replace an intra-arterial needle with a catheter that could be manipulated within the arterial system. These developments, along with the realization that arteries could be replaced, led to many of the early advances. One of the first methods used to replace segments of abdominal aorta was the use of homografts. Dubost et al3 in 1952 reported the replacement of an aortic aneurysm with a homograft. This procedure was rapidly followed by similar efforts in the United States by Julian et al4 and Debakey et al.5 These homografts were initially used for the treatment of abdominal aortic aneurysms but did have serious problems related to size, according to the anatomy of the patient and late breakdown of the grafts themselves.6 Once it became obvious that arterial homografts were not an answer to the problem of arterial replacement, development of alternative methods moved ahead rapidly. Vorhees et al7 in 1952 reported the first application of an artificial prosthetic device for arterial replacement. This led to the development of other prosthetic materials such as Dacron, Teflon, and polytetrafluoroethylene.8 These grafts were and still are in widespread use for treatment of arterial problems. All of these methods, for both the exposure of diseased anatomy and its correction, were developed in this time frame and remain in place even today. In the early phases of applying grafting techniques, one of the most difficult problems was related to the management of abdominal aortic aneurysms. The landmark study of Estes9 in 1950 pointed out the lethal nature of these lesions if left untreated. Although these lesions became recognized as a cause of death, it required the surgical application of developed techniques to show that resectional therapy was beneficial. Experience over the past 50 years has clearly demonstrated an improvement in long-term survival after aneurysm resection and replacement with prosthetic grafts.10 These grafts were also developed for bypassing areas of occlusion, both in the aortoiliac area and for femoral-popliteal occlusive disease.11 A parallel advancement of great importance was the use of autogenous tissue to bypass areas of occlusion. The experience in the Korean conflict showed that limb survival secondary to arterial injury could be greatly improved by use of the saphenous vein as the bypass conduit.12 The saphenous vein was not only superior in terms of long-term patency but also was not as prone to infection as prosthetic devices when placed under less-than-optimal circumstances. The use of autogenous veins for bypass grafting was applied with increasing frequency, particularly in areas distal to the inguinal ligament, where prosthetic grafts did not function as well in the long term. The concept of in situ versus reversed saphenous vein also emerged in this time frame.13,14 Using veins as reversed conduits, one did not have to deal with the issue of venous valves. However, when used in the in situ position, the valves had to be disrupted to permit unimpeded arterial flow. Although argument continues regarding the superiority of reversed saphenous vein over the in situ method, it is clear that when the vein is used to bypass lesions well below the knee, the in situ method offers some advantages in terms of sizing the anastomoses. It should be noted that during this era there were also advances that at first glance did not appear to be very important, but in reality were a big influence on how these surgical procedures were successfully carried out. An obvious advance was the use of magnification in dealing with suturing blood vessels to ensure optimal coaptation. In addition, development of a variety of atraumatic vascular clamps represented a major advance. The development of monofilament vascular sutures also was a major advance in terms of ease of handling, with multiple sizes being available to fit the needs of the operative procedure at hand. Each of these technical innovations made the satisfactory performance of direct arterial surgery much simpler and better. During this rapidly developing technological era with new approaches to aneurysmal and occlusive disease, the method of patient identification depended entirely on a well-taken history, palpation of pulses, and listening for