Once You Pop, You Can’t Stop (Bleeding): Aortic Aneurysms and their Management...

Once You Pop, You Can’t Stop (Bleeding):

Aortic Aneurysms and their Management from

the 18th to the 21st Century

Justin BarrDuke University

Bullitt Club, University of North Carolina, 2016

3 = aorta

Aneurysms

• Ancient Egypt• Ancient Greece

Ebers Papyrus

The Ancient World

Antyllus and Aneurysm Surgery

Make a straight incision through the skin in the direction of the length of the vessel...After having introduced beneath the artery a probe, we

pass…a needle armed with a double thread such that this thread finds itself placed beneath the artery…seizing, then, the two ends of one of

these threads, we bring it gently toward one of the two extremities of the aneurysm, tying it carefully; in like manner also we bring the other thread toward the opposite extremity, and in this place tie the artery. Thus the whole aneurysm is between the two ligatures. We open then the middle of the tumor by a small incision: in this manner all which it contains will

be evacuated. – Antyllus, ~100 AD

Aneurysms


• Arabic medicine• Medieval

Peripheral aneurysmsMinimal change in management

Ebers Papyrus

Aneurysms



• Early Modernity• Vesalius

• 1st to identify aortic dissecting aneurysm

• William Harvey, 1628

Aneurysms



• Early Modernity• Vesalius

• 1st to identify aortic dissecting aneurysm

• William Harvey, 1628• Lancisi, 1728

Early Modern: Rise of Syphilis

• Appears ~1500• Before abx,

#1 cause of aortic aneurysms• Matas:

80% of non-traumaAneurysms = syphilitic

Lancisi

Early Modern: Systemic Approach

Antonio Valsalva & Rene Laennec• Reduce pressure on walls of

aneurysm => less likely to rupture

• Blood is what exerts pressure on aneurysm walls

• Routinely bleed patient……12-20 oz. initially and 6-8 oz. periodically


Jolliffe Tufnell (Pres. Royal College Surgeons, Ireland) and O’B. Bellingham• Same idea of decreasing blood

pressure• Increase viscosity• Starvation diet: 10 oz food and

8 oz drink each day + strict bedrest


• Persistent• Valsalva: 1720s• Bellingham: 1870s

• Popular• Sophisticated understanding of

circulation and fluid mechanics• “whole body” approach to local

problem – manipulate the global to affect the local

Surgical Approach

• John Hunter, 1785• Proximal ligation• Rapid & broad popularity

Surgical Approach

• John Hunter, 1785• Proximal ligation

• Astley Cooper, 1817• Aortic ligation“As I was quitting the patient’s bed,” wrote Cooper, “I felt a

great regret…that the patient should be left to perish without giving him the only chance which remained of preventing his

immediate dissolution from haemorrhage, by tying the aorta.”

Surgical ApproachAortic Ligation

Surgeon Date Outcome

Cooper 1817 Death

James 1825 Death

Murray 1834 Death

Montiero 1842 Death

South 1856 Death

McGuire 1868 Death

Stokes 1869 Death

Watson 1869 Death

Czerny 1870 Death

Czerny 1879 Death

Milton 1890 Death

Keen 1899 Death

Korte 1899 Death

Tillaux 1900 Death

Morris 1901 Death

Scott 1905 Death

Halsted 1906 Death

Halsted 1909 Death


Halsted 1909 Death

Hamann 1917 Death

Vaughan 1920 Lived 2 years

Watts 1923 Lived 3.5 years

Matas 1925 Lived 1.5 years

Brooks 1926 Death

La Roque 1929 Lived 14+ months

Elkin 1939 Lived 11+ months

Adopted from Elkin, “Aneurysm of the Abdominal Aorta,” Annals of Surgery, (1940): 895

Surgical Approach

William Halsted

Surgical ApproachAortic Ligation


Cooper 1817 Death

James 1825 Death

Murray 1834 Death

Montiero 1842 Death

South 1856 Death

McGuire 1868 Death

Stokes 1869 Death

Watson 1869 Death

Czerny 1870 Death

Czerny 1879 Death

Milton 1890 Death

Keen 1899 Death

Korte 1899 Death

Tillaux 1900 Death

Morris 1901 Death

Scott 1905 Death

Halsted 1906 Death

Halsted 1909 Death


Halsted 1909 Death

Hamann 1917 Death

Vaughan 1920 Lived 2 years

Watts 1923 Lived 3.5 years

Matas 1925 Lived 1.5 years

Brooks 1926 Death

La Roque 1929 Lived 14+ months

Elkin 1939 Lived 11+ months

Adopted from Elkin, “Aneurysm of the Abdominal Aorta,” Annals of Surgery, (1940): 895

Surgical Approach

• Local approach to a local problem

• Reflected increasing reliance or surgical interventions to cure medical problems in the late 19th century

• (c.f. appendectomy, thyroidectomy, hysterectomy, etc)

Quasi-Surgical Approaches or,the attempts to clot-off an aneurysm

clot


William MacEwen and intimal disruption• Pin inserted from exterior to

scratch/abrade inside of blood aorta• Inflammatory process creates “white

clot” that occludes aorta• Based off animal experiments by

Benjamin Phillips, 1832• “A Series of Experiments Performed for the

Purpose of Shewing that Arteries May Be Obliterated without Ligature, Compression, or the Knife”


William MacEwen and intimal disruption• Pin inserted from exterior to

scratch/abrade inside of blood aorta• 4 cases on humans

Bilateral femoral aneurysms, right filled with clot after pin technique


Foreign bodies in aneurysm sac• Guido Bacelli, 1878


Foreign bodies in aneurysm sac• Gelatin• Dastre and Floresco, 1896

• Proof of concept• Presented to French Academy of

Medicine, 1898• Widely adopted Europe and USA

• Osler: 9 patients; no cures; 7 symptomatic relief

• Aneurysms huge!! 9cm, 11 cm, etc


Moore-Corradi Method• Charles Moore, 1864: fill

aneurysm with thin metal wire• 1st case: 78 feet!

• Corradi, 1881: pass electricity through wire

• Debates re: length, material, and ampage

• 10-20 feet, silver, 70 milliampere• Persisted through 1970s (Charles

Rob)


Moore-Corradi Method• Hunner, 1900:

• 12/14 Moore method died• 13/17 Moore-Corradi method

died

• Matas: “believed the bad results were in the main attributable to inherent dangers of the method itself apart from all questions of technique.” - 1900


• Sophisticated understating of blood vessel anatomy, inflammatory response, and coagulation

• Bench to bedside• Application of novel technology:

• Gelatin• Electricity

Pseudo-surgical was comboOf local and relying on global/systemic

Vessel Repair

Anesthesia & Anti/Asepsis

1846 1867

Innovations in Vessel Repair• Schede, 1882

• 1st successful repair of venous laceration

• Jassinowsky, 1889• Repaired longitudinal and transverse

arteriotomies in carotids of dogs• 22/26 successes

• After 100 days, no thrombosis, aneurysm

Innovations in Vessel Repair

Dorrance, “An Experimental Study of Suture of Arteries with a Description of a New Suture,” Annals of Surgery 1906

Vessel Anastomosis

Nikolai Eck

• Russian military surgeon• First vessel anastamosis: side-to-side

anastamosis between portal vein and vena cava

• Portocaval shunt sometimes called Eck fistula

Vessel Anastomosis• Robert Abbe, 1894: glass tube prostheses

• Magnesium, silver, pigeon bones…• “I do not expect that this version of surgical possibilities

will be realized soon, nor do I think enough has been proved to warrant much hope.”

Abbe, “The Surgery of the Hand,” The New York Medical Journal 1894.

Vessel AnastomosisJ. B. Murphy (1897)

• Chicago surgeon known best for “Murphy’s Sign”

• Pioneer surgeon• Developed invagination technique of

anastamosis

Murphy, “Resection of Arteries and Veins Injured in Continuity – End-to-End Suture – Experimental andClinical Research,” Medical Record 1897.

Vessel AnastamosisJ. B. Murphy (1897)- After 35 experiments on animals…- 1st arterial anastomosis in humans- 19 Sept 1896: 29 y/o M GSW to Scarpa’s triangle;

penetrated common femoral- 4 Oct: Murphy 1st examined pt- 7 Oct: operation

- 4 Jan 1897: pt walked out of hospital

Vessel Anastomosis

Murphy’s invagination and other methods had 2 main problems:1. Technique inherently prevented replacing any lengthy segment2. Frequently thrombosed or outright failed

Alexis Carrel

• Born 1873 in Lyons France• Assassination of Pres. Carnot in 1894 – galvanized Carrel • Medical degree (1900) from University of Lyons• Failed surgical boards

Vessel Repair

1912 Nobel Prize

Aortic Surgery• 1944: 1st excision of aortic aneurysm, Alexander and Byron

• 1944: Crafoord’s bypass of coarctation with subclavian (repeated by Gross, 1945)

• 1947: Shumacker resects aneurysm and re-anastamoses the aorta

Vessel Repair

• 1951, Charles Dubost – 1st AAA repair

• Resected aneurysm• Replaced conduit with arterial

homograft using Carrel technique

Vessel Repair

Successful AAA repairs:• Dubost, 1951• Julian, 1952• Brock, 1952• DeBakey and Cooley, 1952• Bahnson, 1953

Vessel Repair

• Limitations of arterial homograft• 1952, Arthur Voorhees & cloth

grafts

Vessel Repair

Post-World War II period of more advanced surgery• Cardiac surgery • Kidney transplant• Complex oncological operations

Endovascular Era

Endovascular Era

• Aortogram of 1st

successful endovascular AAA repair in human, 1990

• Juan Parodi, Argentina, 1990

Endovascular Era

unruptured

Dua, “Epidemiology of aortic aneurysm repair in the united states from 2000-2010,” JVS 59 (2014): 1512

Benefit of EVAR(?)

Meijenfeldt, “Differences in Mortality…” European J Vasc andEndovasc Surg (2014): 479.

“EVAR I” Lancet 365 (2005): 2179

Benefit of EVAR(?)

Endovascular Era

1991

Endovascular Era

• appendectomy

Sporn, “Laparoscopic Appendectomy,” JACS 20 (2009): 179.

Endovascular Era

• colorectal

Peterson, “The Prevalence of Laparoscopy and Patient Safety Outcomes,” Surg Endos 28 (2014): 608.

Endovascular Era

• General shift to minimally invasive surgery

• Microcosm of larger trends in the history of medicine

Conclusion

antiquity

present

Modern Era

2005 SAAVE Act to fund national screening for AAAs through Medicare

Conclusion

antiquity

present

Endovascular

Vessel repair

Starvation ligation Moore-Corradi

Questions?

Aortic Surgery

• 1944: 1st excision of aortic aneurysm, Alexander and Byron

Antyllus’ Operation

• Double ligation

Once You Pop, You Can’t Stop (Bleeding): Aortic Aneurysms and their Management...

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