A History of Vascular Surgery - part 9 ppsx

The Lindbergh pump provided the groundwork foreventual development of modern pump oxygenators and the mechanical heartFigure 17.5.Alexis Carrel 181 Figure 17.5 Charles Lindbergh and Alex

In 1913, Alexis Carrel was made Knight of the Legion of Honor by the Frenchgovernment In the latter part of that year he married a long-time friend, AnnMarie de la Meyrei.

When World War I broke out, Carrel was vacationing in France As a Frenchcitizen he was bound to serve his country when ordered to report to Lyon (Figure 17.4) The terrible infections spawned on the battlefields of Europe dur-ing this conflict rekindled Carrel’s interest in wound healing

Carrel sought ways to treat advanced infections and through contacts at theRockefeller Institute he was introduced to a chemist named Henry Dakin After testing hundreds of antiseptic solutions, the two devised a means of irri-gating wounds with the solution that still bears Dakin’s name and remains incommon use

Alexis Carrel 179

Figure 17.3 Examination of tissue cultures by Carrel (courtesy of the Rockefeller University

Archives).

In 1915, Carrel became Commander in the French Army’s Legion of Honor Inthe following year, he received the Order of Leopold from King Albert of Belgium Carrel also received the Order of the Northern Star of Sweden and wasmade a companion of the Order of St Michael and St George.

In 1917, the first mobile army hospital was opened under Carrel’s direction.This was a forerunner of the MASH units that would play a vital role in Koreaand Vietnam, and contribute significantly to the advancement of vascular surgery

Following the war, Carrel returned to New York and devoted his attention todevelopment of a perfusion pump for organ preservation He was introduced tothe great aviator Charles Lindbergh, who professed a similar interest followingthe severe respiratory illness of a relative affecting the heart Working together,

180 Chapter 17

Figure 17.4 Carrel in the French Army (courtesy of the Rockefeller University Archives).

they constructed a Pyrex pump in 1935 that sustained a cat thyroid gland for 18days Preservation of hearts, ovaries, fallopian tubes, spleens, kidneys, and pan-creases soon followed The Lindbergh pump provided the groundwork foreventual development of modern pump oxygenators and the mechanical heart(Figure 17.5).

Alexis Carrel 181

Figure 17.5 Charles Lindbergh and Alexis Carrel with their perfusion pump, on the cover of TIME

magazine, June 13, 1938 (reprinted by permission from TIME).

In 1939, Carrel was forced into mandatory retirement from the Rockefeller Institute; he was 65 His bitterness gave rise to denunciation of the Institute and

of science in general Carrel and his wife left the United States and returned

to France

During the early 1940s, Carrel devoted himself to the creation of an “Institute

of Man,” the realization of a long-held dream In 1941, the “Fondation FrancaisePour l’Etude des Problemes Humains” was sanctioned by law and chargedwith: “ researching all practical solutions and proceeding with all demonstra-tions in view of improving the physiological, mental, and social condition of thepopulation.” Carrel eschewed all political issues and functions during WorldWar II, preferring instead to promote the cause of his foundation

In 1943, amid accusations of Nazi collaboration, Carrel suffered his first heartattack Carrel had met with the Germans to insure the safety of his Institute, andthis probably incited the charges He eventually recovered and returned to thefoundation until his second heart attack 1 year later This left Carrel severely dis-abled and, following the liberation of France, the vituperations against him in-tensified Even the French government, which had lavished some of its greatesthonors upon Carrel, sought ways to implicate him in the German nightmare.Carrel’s physical condition deteriorated rapidly, and on November 5, 1944, at8p.m., French radio broadcasted that Carrel had fled his home to avoid beingtried for collaborating with the Nazis Carrel had, in fact, died 9 hours prior tothis radio message Proof of the alleged collaboration was never produced.The tragic events of Carrel’s final months were a bitter denouement to the life

of one of the most ingenious and prescient figures in the history of surgery Thereare few innovations in cardiac and vascular surgery today that do not have roots

in his work The epithet “Father of Vascular Surgery” is justly applied to AlexisCarrel

Bing RJ Carrel A personal reminiscence JAMA 1983; 250:3297.

Bouchet A Les pionniers Lyonnais de la chirurgie vasculaire: M Jaboulay, A Carrel, E Villard

et R Leriche Hist Sci Med 1994; 28:223.

Carrel A La technique opératiore des anastomoses vasculaires et la transplantation des

vis-cères Lyon Méd 1902; 98:88.

Carrel A Les anastomoses vasculares et leur technique opératoire Union Med Can 1904; 33:521 Carrel A Transplantation des vaisseaux conserves au froid pendant plusieurs jours Comptes Rendu Soc Biol 1906; 2:57.

Carrel A Au sujet de la conservation des artères en “cold storage.” Comptes Rendu Soc Biol 1907;

62:1178.

Carrel A Résultats éloignés de la transplantation des veines sur les artères Rev Chir 1910;

XVL:987.

182 Chapter 17

Carrel A On the experimental surgery of the thoracic aorta and the heart Ann Surg 1910; 52:83 Carrel A Graft of the vena cava on the abdominal aorta Ann Surg 1910; 52:462.

Carrel A The preservation of tissues and its applications in surgery JAMA 1912; 59:523 Carrel A Experimental operations on the orifices of the heart Ann Surg 1914; 60:1.

Carrel A Experimental operations on the sigmoid valves of the pulmonary artery J Exp Med

Carrel A, Lindbergh CA The Culture of Organs New York: Paul B Hoeber, Inc., 1938.

Carrel A, Morel Anastomose bout à bout de la jugulaire et de la carotide primitive Lyon Méd

Hallowell C Charles Lindbergh Am Heritage Inv Tech 1985; Fall:58.

Hardy JD Transplantation of blood vessels, organs and limbs JAMA 1983; 250:954.

Jaboulay M, Briau E Recherches expérimentales sur la suture et la greffe artérielles Lyon Med

1896; 81:97.

Kunlin J Le traitement de l’artèrite oblitérante par la greffe veineuse Arch Mal Coeur 1949;

42:371.

Malt RA, McKhann CF Replantation of severed arms JAMA 1964; 189:716.

Murphy JB Resection of arteries and veins injured in continuity – End-to-end suture

– Experimental and clinical research Med Rec 1897; 51:73.

Murray JE, Merrill JP, Harrison JH Renal homotransplantation in identical twins Surg Forum

1955; 6:432.

Najafi H Dr Alexis Carrel and tissue culture JAMA 1983; 250:1086.

Payr E Zur frage der circulaeren vereingung von blutgefaessen mit resorbibaren prothesen.

Arch Klin Chir 1900; 62:67.

ShawR, Stubenbord WT Alexis Carrel MD Contribution to kidney transplantation and

preser-vation NY State J Med 1980; 8:1438.

Tuffier T, Carrel A Patching and section of the pulmonary orifice of the heart J Exp Med 1914;

20:3.

Alexis Carrel 183

René Leriche was born in October 1879 in Roanne, France As a boy, he dreamed

of becoming a soldier, but eventually he developed an interest in medicine Heattended medical school at the University of Lyon and received his degree in

1906 His thesis was entitled “The Surgical Treatment of Cancer of the Stomach.”Leriche’s choice of surgery was influenced by his contact with several of thefield’s luminaries Mathieu Jaboulay was one of his instructors, Leriche had sev-eral opportunities to assist Antonin Poncet with surgery, and Alexis Carrel was

a chief resident when Leriche was a medical student Leriche and Carrel workedtogether for 6 months and they resided in the same boarding house Leriche wasalways grateful to Carrel for his friendship and for teaching him the importance

of observation

Carrel left France in 1904 and continually encouraged Leriche to visit othercountries Leriche eventually arrived in the United States while Carrel was atthe Rockefeller Institute In New York Leriche met Simon Flexner and visited theRoosevelt and German hospitals; in Chicago he met John Murphy and EvartsGraham; and in Boston he met Harvey Cushing The highlight of his trip, how-ever, was several days spent with William Halstead in Baltimore

Carrel continued to pressure Leriche into emigrating to the United States In

1914, Leriche was on the verge of doing so when World War I began Leriche mained in France and became a surgeon at La Houleuse camp, where woundedsoldiers were cared for Leriche gained much experience in treating skeletal, andcentral and peripheral nerve injuries, and here his interest in the sympatheticnervous system and various pain syndromes began He received accoladesfrom the French and Belgian governments for his work during the war

re-In 1917, Leriche and Jean Heitz demonstrated the benefits of arteriectomy fore the Society of Biology They proposed that resection of an obstructed arteryresulted in “reheating” of the extremity and the disappearance of pain,cyanosis, and edema Leriche also described ulcer healing from arteriectomy

be-In 1924, at the age of 45, Leriche became Professor of Clinical Surgery at Strasbourg, succeeding Louis Sencert He directed a large surgical service at theHôpital Civil, one of the oldest in Europe Leriche distinguished himself by hisphysiologic approach to surgery, also espoused by Cushing and Halstead in theUnited States He was particularly interested in the vasomotor, humoral, andhematologic consequences of surgery

Leriche’s Alsatian period lasted 8 years In 1932, he returned to Lyon to come Chairman of External Pathology and surgeon at the Hotel-Dieu During

be-the inauguration of be-the new Grange-Blanche hospital be-the following year,Edouard Herriot, the mayor of Lyon, honored Leriche as a pioneer in surgery.Ever restless, Leriche soon returned to Strasbourg for 2 more years In 1936, hereplaced Charles Nicolle as Professor of Experimental Medicine at the Collège

de France Leriche’s annual Chairman’s lectures were eventually published in

The Surgery of Pain The book enjoyed several editions and multiple translations.

Leriche had no clinical service in Paris, and operated instead at the AmericanHospital in Neuilly

René Leriche 185

Figure 18.1 René Leriche (from Callow AD Historical development of vascular grafts In: Sawyer

PN, Kaplitt MJ, eds Vascular Grafts New York: Appleton-Century-Crofts, 1978).

During World War II, Leriche returned to Lyon, where he directed Pavilion G

of the Edouard Herriot Hospital He described the syndrome that bears his

name in Presse Médicale, in 1940, although his earlier ruminations on this subject

appeared in 1923 Leriche speculated that: “the ideal treatment would be to remove the occluded zone and reestablish arterial patency.” He also added hisdoubt, however, that this would ever be possible

After the liberation of France, Leriche returned to the Collège de Francewhere he began a laboratory of experimental surgery with Jean Kunlin Lerichewas elected a member of the Academy of Sciences in 1945 and he retired frompractice 5 years later (Figure 18.1)

In 1951, he became president of the International Society of Surgery and

pub-lished another book, The Philosophy of Surgery Leriche eventually pubpub-lished

well over 1000 papers on all aspects of surgery and physiology He was an honorary fellow of the American College of Surgeons, the Royal College of Surgeons of England and Edinburgh, and the Royal Society of Medicine.Leriche received honorary doctorates from 13 universities, including Glasgowand Harvard

Leriche became severely ill during the last few years of his life and he returned to Cassis, in the south of France He died on December 28, 1955, at theage of 76

It is ironic that, despite Leriche’s many contributions to the physiology andphilosophy of surgery, he resolutely turned his back on reconstructive arterialsurgery Kunlin dared perform the first femoral–popliteal bypass in 1948 onlywhen Leriche was absent Nevertheless, of Leriche, Kunlin wrote:

He was for 30 years the head of an exceptional school for surgery, for he combined a very fertile imagination with a vast clinical experience from which he drew simple and clear rules The generations of physicians that he trained still remember him, for his les- sons were accompanied by striking examples Patient rounds were a feast for the mind, for they were often the occasion for a springing of extraordinary new ideas Certain were adopted, others were taken up again later, for at the time they were too advanced.

Bibliography

Bouchet A Les pionniers Lyonnais de la chirurgie vasculaire: M Jaboulay, A Carrel, E Villard

et R Leriche Hist Sci Med 1994; 28:223.

Jarrett F René Leriche (1879–1955): Father of vascular surgery Surgery 1979; 86:736.

Kieny R René Leriche and his work as time goes by Ann Vasc Surg 1990; 4:105.

Kunlin J Traitement de l’artérite oblitérante par la greffe veineuse Arch Mal Coeur 1949,

371.

Leriche R De la sympathectomie péri-artérielle et de ses resultants Presse Méd 1917; 25:513.

Leriche R Des obliterations artérielles hautes (oblitération de la terminaison de l’aorte) comme

cause des insuffisances circlatoires des membres inférueurs Bull Mém Soc Chir (Paris) 1923;

49:1404.

Leriche R Considération sur certaines types d’artérites oblitérantes, sur la claudication

inter-mittente bilatérale et sur le traitement précoce de certaines lesions artérielles Lyon Chir 1925;

22:521.

186 Chapter 18

Leriche R Données générales sur l’artérite oblitérante juvenile Résultat de leur traitement par

l’artériectomie et la surrénalectomie Bull Mém Soc Chir (Paris) 1928; 54:201.

Leriche R De la resection du carrefour aorto-illiaque avec double sympathectomie lombaire

pour thrombose aortique Le syndrome de l’oblitération termino-aortique par artérite Press Méd 1940; 486:1.

Leriche R, Morel A Considèrations sur le traitement des arterites et des embolies artérielles.

Lyon Méd 1933; 151:393.

Leriche R, Stricker P Artéruectinue dans les Artérites Oblitérantes Paris: Masson, 1933:198 Wertheimer P L’œuvre de René Leriche Lyon Chir 1956; 52:21.

René Leriche 187

Prior to World War II, Kunlin was Chief Surgeon of the Hôpital Meurthe etMoselle When the war began, Kunlin moved to Paris and met up again withLeriche Kunlin pursued a dual role as practicing surgeon at the American Hos-pital, and as a researcher at the College de France, and then the Val de Grace Inthe laboratory, his interests included extracorporeal circulation, gas embolism,venous reconstructive surgery, microanastomoses (1–2 mm vessels), and otheraspects of vascular surgery Some of these techniques were eventually used forportal–caval shunts and distal lower extremity vein grafts in humans.

In 1947, Cid Dos Santos traveled to Paris to be reunited with Leriche and Kunlin He demonstrated his revolutionary thromboendarterectomy, and attributed his success to the use of heparin Surgeons in Paris began performingthis procedure, and Kunlin sought ways to improve it in the laboratory His initial attempts at modifying the suturing technique were unsuccessful, and heattributed this to the absence of the endothelium These failures undoubtedlyprompted Kunlin to attempt the first saphenous vein bypass

In 1948, Kunlin was still collaborating with Leriche in the experimental gery laboratory of the Collège de France, and at the American hospital where thedepartment of surgery had 11 beds It was here that Kunlin encountered a 54-year-old man with a 3-month history of ischemic rest pain The patient had undergone a great-toe amputation, which led to gangrene of the dorsal surface of the foot A lumbar sympathectomy and femoral arteriectomy had already been performed, precluding endarterectomy An arteriogram revealed

sur-a psur-atent poplitesur-al sur-artery with posterior tibisur-al runoff Kunlin proposed sur-afemoral–popliteal bypass with saphenous vein; Leriche proposed continuingmedical treatment

At the end of May 1948, Leriche left for Holland Kunlin’s patient was about

to lose his leg so he agreed to Kunlin’s proposal The operation was performed

on June 3, 1948 Instead of performing end-to-end anastomoses, Kunlin’s

proposal utilized an end-to-side technique, reasoning that collaterals could bepreserved and the anastomoses would be easier Within 3 weeks of the bypass,the patient’s foot ulcer had healed.

Upon his return from Holland, Leriche was astonished that the procedurehad been successful Nevertheless, he encouraged Kunlin to continue his work.Kunlin’s first patient underwent a contralateral bypass several months later,and survived for 1 year, until he suffered a stroke

Kunlin’s second patient was a 40-year-old man whose bypass remainedpatent for 8 years Kunlin’s third patient underwent bilateral femoral–popliteal

Jean Kunlin 189

Figure 19.1 Jean Kunlin (from Callow AD Historical development of vascular grafts In: Sawyer PN,

Kaplitt MJ, eds Vascular Grafts New York: Appleton-Century-Crofts, 1978).

bypasses that remained patent for 28 and 25 years, with the aid of several tional procedures.

addi-Kunlin (Figure 19.1) presented his first eight cases to the Academy of Sciences

in November 1948, and his technique was soon adopted by surgeons around theworld (Figure 19.2)

In 1962, Kunlin was appointed to the Hôpital Foch, in Paris, where he oped a department of vascular surgery Soon after, he received the René Lericheaward from the International Society of Surgery

devel-Kunlin retired 10 years later but continued his research activity in the HôpitalFoch Laboratory In 1981, he was awarded the Vermeil Medal of Paris Kunlindied in Paris on September 11, 1991, after a brief illness; he was 87

Bibliography

Cid Dos Santos J From embolectomy to endarterectomy or the fall of a myth J Cardiovasc Surg

1976; 17:113.

190 Chapter 19

Figure 19.2 Title page of Kunlin’s account of the clinical use of venous bypass grafts (from Kunlin J.

Le traitement de l’ischémie artéritique par la greffe veineuse longue Rev Chir 1951; 70:206).