By Dr Ananya Mandal, MD
Earliest records of abdominal aorta aneurysm in history come from Ancient Rome in the 2nd century AD. Greek surgeon Antyllus tried to treat the aneurysm with proximal and distal ligature, central incision and removal of thrombotic material from the aneurysm. The surgical management of aneurysms however dates back to 3000 years.
Surgery was unsuccessful until 1923. In that year, Rudolph Matas performed the first successful aortic ligation on a human. Other non conventional methods that were tried included wrapping the aorta with polyethene cellophane, which induced fibrosis and restricted the growth of the aneurysm.
Over the course of surgical history arose three landmark developments in aortic surgery. These were :-
Ligation or tying up of the aorta
Open repair of the bulging artery
Endovascular repair of the artery
Records of knowledge of aneurysms
The word aneurysm is derived from the Greek aneurysma which means “widening”. The earliest records were found in the ‘Book of Hearts’ from the Eber Scolls of ancient Egypt, dating back to 1550 BC. It was termed tumor of the arteries. India’s Sushruta (sometime around 800 and 600 BC) called aneurysms ‘Granthi’, in chapter 17 of his great medical text ‘Sushruta Samhita’.
Galen (126-216 AD), a surgeon of ancient Rome, first formally described these ‘tumors’ as localised swellings that disappear with pressure. He was the first to draw anatomical diagrams of the heart and great vessels.
Antyllus during this time performed his surgeries of ligating or tying up the aneurysms. Antyllus’s method was not very successful and often led to death but the methods remained in practice until the late nineteenth century.
In 1554 Vesalius (1514-1564) studied anatomy for the first time using cadaveric dissections in his treatise ‘De Humani Corporis Fabrica.’ A year later he made the first accurate diagnosis and illustrations of abdominal aorta aneurysm pathology. Vesalius corrected over 200 of Galen’s anatomical mistakes and was called the father of modern anatomy.
Ambroise Pare (1510-1590) attributed the presence and development of aneurysms to syphilis. Morgagni (1682-1771) described in detail ruptured sacular aortic aneurysms in syphilitic prostitutes. Monro (1697-1767) went on to find the intima, media and adventitia of arterial walls.
William Hunter (1718-1783) and John Hunter (1728-1793) next developed the modern definitions of true, false and mixed aneurysms based on the existing knowledge. Aneurysms were now accepted to be caused by ‘a disproportion between the force of the blood and the strength of the artery’.
In 1817, Cooper first ligated the aortic bifurcation or division into two for a ruptured left external iliac aneurysm in a 38 year old man. Although the patient died, the method held on. In 1923, that Matas performed the first successful complete ligation of the aorta for aneurysm. The patient survived seventeen months and died of tuberculosis. Matas also developed the technique of endoaneurysmorrhaphy. This involved tying the aneurysmal sac upon itself to restore normal blood flow to the lower limbs. This was the first recorded technique aiming to allow blood flow and was the basis for development of homograft, synthetic graft and endovascular techniques.
Alexis Carrel conducted the first saphenous vein bypass in 1948. Carrel also helped develop the techniques of arterial grafting, used when vessel connections was not possible.
Arthur Voorhees (1921-1992) was credited for the invention of synthetic arterial prosthetics. Voorhees tested a wide variety of materials for synthetic tube grafts and came upon vinyon-N. Vinyon-N proved robust, and was introduced by Voorhees, Jaretski and Blakemore.
In 1952 Voorhees inserted the first synthetic graft into a ruptured abdominal aorta aneurysm. By 1954, Voorhees had successfully implanted 17 such implants. Similar materials with improved tensile strength are used in open abdominal aneurysm repair and these include Teflon, Dacron and expanded Polytetrafluoroethylene (PTFE).
Juan Parodi with Julio Palmaz and Héctor Barone in the late 1980s developed the first catheter-based arterial approach to abdominal aorta aneurysm and this led to the endovascular approach to surgery.
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)