Treatment of venous disease – The innovators
1994; Elsevier BV; Volume: 20; Issue: 5 Linguagem: Inglês
10.1016/s0741-5214(94)70153-9
ISSN1097-6809
Autores Tópico(s)Peripheral Artery Disease Management
ResumoAdvances in the management of any disease cannot be graphically represented by a straight line. If one plots advances versus time, there are a variety of ways that the resulting line might take shape. There could be an early period of gradual improvement in care followed by a sharp upswing. A period of time may then occur without any advances only to be followed by another sharp upswing. A period of negativism may follow with deterioration in care once again followed by a sharp upswing. Multiple possibilities for the shape of the line exist. The reason for the sharp upswings in this line, of course, is that something new has occurred. An innovation has been introduced. I have selected four innovations that I believe have been responsible for significant advances in the management of venous diseases during the twentieth century. There are others. These innovations may also fit the definition of inventions, but I selected innovations because that term more fairly suggests that previous discoveries also have been helpful to the responsible innovator. The four innovations that I have selected are the anticoagulant heparin, intraluminal partial venous interruption, balloon thrombectomy catheters, and pressure gradient stockings. Venous thrombosis may occur in the superficial veins of the leg but is more commonly found in the deep veins as a result of trauma, stasis, or hypercoagulability. Early morbidity of deep venous thrombosis consists of pain, swelling, and the threat of pulmonary embolism. With a radioiodinated fibrinogen test, Kakkar 1Kakkar V The diagnosis of deep vein thrombosis using the 125I fibrinogen test.Surgery. 1972; 104: 152-156Google Scholar found thrombi in the soleal and deep veins of the calf in greater than 25% of patients after elective surgery. Without anticoagulation 10% of these patients will have propagation of the thrombi, and 3.4% will have pulmonary emboli. 2Solis MM Ranval TV Barnes RW et al.Is anticoagulation indicated for asymptomatic postoperative calf vein thrombosis?.J VASC SURG. 1992; 16: 414-419Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar Late morbidity of venous thrombosis consists of deep vein valvular insufficiency and ulceration. Gay 3Gay J On varicose diseases of the lower extremities.in: The Lettsomian Lectures of 1867. Churchill, London1868Google Scholar recognized the relationship between venous thrombosis and subsequent ulceration in 1867. Homans in 1917 4Homans J The etiology of treatment of varicose ulcer of the leg.Surg Gynecol Obstet. 1917; 24: 300-308Google Scholar identified the postthrombotic valvular insufficiency as the cause of the ulcers. Bauer 5Bauer G A roentgenological and clinical study of the sequels of thrombus.Acta Chir Scand. 1942; 86: 1-11Google Scholar noted the delayed occurrence of the ulcers after thrombosis with an incidence of 20% at 5 years, 52% at 10 years, and 79% at times later than 10 years. In the early 1900s the usual treatment for venous thrombosis, when recognized, was bed rest and elevation of the legs. There was no anticoagulation available to prevent propagation of the thrombus and pulmonary embolization. Charles H. Best, 6Best CH Preparation of heparin and its use in the first clinical cases.Circulation. 1959; 19: 79-86Crossref PubMed Scopus (65) Google Scholar in describing the discovery of heparin, stated, "In 1912 Doyan published a paper in which he describes an attempt to isolate and characterize an anticoagulant released by the injection of peptone in a dog. There are a number of other intriguing findings in the literature, but their significance could only be appreciated after the discovery of heparin." We come then to our first innovation, the anticoagulant heparin, and the innovator, Jay McLean (Fig. 1). 7Mclean J The discovery of heparin.Circulation. 1959; 19: 75-78Crossref PubMed Scopus (151) Google Scholar, 8Bigelow WG Discovery of heparin.in: Mysterious heparin. McGraw-Hill Ryerson, Toronto-Montreal1990: 7-16Google Scholar John T. (Jay) McLean was born in 1890 in California. His father died when Jay was 4 years old, and he was raised by his mother and stepfather. The family suffered the loss of their house and source of livelihood in the San Francisco earthquake and fire of 1906. Jay was able to be partially supported for 2 years of college at the University of California at Berkeley. His stepfather offered similar support for 4 years of medical school but only at the University of California Medical School. Jay was convinced, however, that Johns Hopkins offered him the best preparation for research, teaching, and an academic surgical career. He spent 15 months working at the Mojave gold mine and completed the third year of college required by Johns Hopkins, which was concurrently the first year of medical school. He worked another 15 months in the oil fields, and, although his application for Johns Hopkins had been rejected, he boarded a train for Baltimore in 1915. When settled he visited the medical school and introduced himself to the registrar and dean. Although they were surprised to see him, the next day the dean informed McLean there was an unexpected vacancy, and he was admitted to the school. Jay had used W. H. Howell's Textbook of Physiology at the University of California and was "fascinated with the subject and its research possibilities." 7Mclean J The discovery of heparin.Circulation. 1959; 19: 75-78Crossref PubMed Scopus (151) Google Scholar Having learned of his admission he immediately contacted Dr. Howell and requested the opportunity of spending a year in research in his laboratory. He told Howell "that I wanted a problem I could reasonably hope to finish and publish in one academic year entirely by myself." 7Mclean J The discovery of heparin.Circulation. 1959; 19: 75-78Crossref PubMed Scopus (151) Google Scholar Howell suggested that McLean study cephalin, a crude ether and alcohol extract of brain, which was a powerful thromboplastic agent that Howell used in blood clotting experiments. The cephalin precipitate decayed within 3 months. McLean found articles in the German literature, which described extracts of liver and heart resulting from a process similar to that for obtaining cephalin from the brain. They had been named heparphosphatide (from the liver) and courin (from the heart). McLean found that the resulting extracts did not accelerate the clotting of blood as well as cephalin, suggesting there was something else in the extracts other than cephalin. Fortuitously he made large batches of all of the extracts and periodically tested the thromboplastic activity of the extracts. He found that when exposed to air for about 3 months, all three extracts lost their thromboplastic activity. The miraculous finding was that the resulting extracts of liver had a strong anticoagulant action. Heparin was discovered! McLean accomplished this in 1915 to 1916 at the age of 24 and while still a medical student. McLean continued his pursuit of academic surgery. He graduated from medical school at Johns Hopkins in 1919, served on its surgical housestaff 1919 to 1921, and was a member of the surgical faculty and research laboratories at Johns Hopkins, University of California, and Ohio State University. He did not continue his research on heparin. Howell and Holt 10Howell WH Holt E The purification of heparin and its chemical and physiologic reactions.Bull Johns Hopkins Hosp. 1928; 42: 199-207Google Scholar did pursue heparin and in 1928 published a detailed report of its chemical and physiologic reactions. It was Charles H. Best and his associates 6Best CH Preparation of heparin and its use in the first clinical cases.Circulation. 1959; 19: 79-86Crossref PubMed Scopus (65) Google Scholar who developed the purification of and production of heparin and established its experimental and clinical usage. He accomplished this in his laboratories at the University of Toronto, and also with the Connaught Laboratories with whom he "had been intimately concerned with the preparation of insulin and of liver extract." 6Best CH Preparation of heparin and its use in the first clinical cases.Circulation. 1959; 19: 79-86Crossref PubMed Scopus (65) Google Scholar Much of the early clinical work was performed in the Department of Surgery at the University of Toronto, where Gordon F. Murray 11Murray G Heparin in thrombosis and blood vessel surgery.Surg Gynecol Obstet. 1941; 72: 340-344Google Scholar made clinical trials beginning in April 1935. In 1941 he reported 700 patients treated with heparin. A large number were treated with prophylactic, and no pulmonary embolism occurred. Forty-six patients were treated after their first pulmonary embolus with no deaths and only two questionable pulmonary emboli. One hundred twenty-five patients were treated for phlebitis with no pulmonary emboli. 11Murray G Heparin in thrombosis and blood vessel surgery.Surg Gynecol Obstet. 1941; 72: 340-344Google Scholar Craaford 12Craaford C Preliminary report on postoperative treatment with heparin as a preventive of thrombosis.Acta Chir Scandiav. 1937; 79: 162-169Google Scholar reported similar results in 1937. Additional controlled and comparative studies have confirmed that heparin therapy followed by coumarin derivatives is superior to no anticoagulation. 13Barritt DW Jordan SC Anticoagulant drugs in the treatment of pulmonary embolism: a controlled trial.Lancet. 1960; 1: 309-311PubMed Google Scholar, 14Coon WW Willis III, PW Symons MJ Assessment of anticoagulant treatment of venous thromboembolism.Ann Surg. 1969; 170: 559-568Crossref PubMed Scopus (102) Google Scholar In most centers the current treatment for deep venous thrombosis is bed rest, elevation of the leg, intravenous heparin for 4 to 7 days, followed by oral warfarin (Coumadin) for 6 weeks to 6 months. Nonfatal and fatal emboli may still occur in 0.9% to 7.7% of patients treated with anticoagulants. 15DeWeese JA Venous and lymphatic diseases.in: 4th ed. Principles of Surgery. McGraw-Hill, New York1984: 981Google Scholar A fatal pulmonary embolus is the most feared complication of venous thrombosis. Although warning signs may be present, 27% of 606 patients who died of pulmonary emboli had no warning signs or symptoms in an autopsy study reported by Coon and Coller. 16Coon WW Coller FA Clinicopathologic correlation in thromboembolism.Surg Gynecol Obstet. 1959; 109: 259-267PubMed Google Scholar Before the availability of heparin, ligation of the venous system was the only treatment available for prevention of pulmonary emboli. It remained available for patients with recurrent emboli while receiving heparin or when heparin was contraindicated. Femoral vein ligations were popular in the 1940s and 1950s but fell into disfavor because of reports of a 5% to 8% rate of fatal recurrent embolism. 17Homans J Deep quiet venous thrombosis in the lower limb.Surg Gynecol Obstet. 1944; 79: 70-82Google Scholar, 18Greenfield LJ Evolution of venous interruption for pulmonary thromboembolism.Arch Surg. 1992; 127: 622-626Crossref PubMed Scopus (36) Google Scholar Inferior vena caval ligation became the procedure of choice. Vena caval ligation has possible undesirable sequelae. Shock occurs in many patients because of the sudden decrease in venous return. Venous thrombosis progresses as a result of venous stasis. Recurrent emboli can still occur through collateral vessels. Postthrombotic chronic venous insufficiency occurs in as many as 35% of patients. Before 1958 there were reports of inducing temporary occlusion by ligation of the vena cava with absorbable catgut or removable metal clips in hopes of reducing the incidence of late postthrombotic sequelae, but the problems of total occlusion still existed. 19Moretz WH Naisbitt PF Stevenson GP Experimental studies on temporary occlusion of the inferior vena cava.Surgery. 1954; 36: 384-398PubMed Google Scholar, 20Dale WA Pualwan F Bauer FM Ligation of the inferior vena cava with absorbable gut.Surg Gynecol Obstet. 1956; 102: 517-530PubMed Google Scholar, 21Stretuer MA Paine JR Temporary occlusion of the inferior vena cava suggested as a means of treatment in thromboembolism requiring cava ligation.Surgery. 1953; 94: 20-27Google Scholar The time was set for our second innovation, intraluminal partial venous interruption, and its innovator, M. S. DeWeese (Fig. 2). Marion Spencer (Bill) DeWeese was born in Corydon, Indiana, in 1915. His family moved to Kent, Ohio when he was 8 years old. He grew up across the street from the campus of what became Kent State University. He completed his high school and college training on that campus. His father was a physician, and Bill knew at an early age that he wished to follow in his father's footsteps. He graduated from the University of Michigan Medical School in 1939 and entered the surgical residency program at University Hospital, which he completed in 1948, after having spent 1941 to 1945 in the United States Army Medical Corps. As a general surgeon with a special interest in vascular surgery, DeWeese had personally seen and treated patients after caval ligation in whom swelling, induration, and recurrent ulceration of their lower extremity had developed. In hopes of decreasing the morbidity after caval ligation, DeWeese 22DeWeese MS Hunter Jr, DC A vena cava filter for the prevention of pulmonary emboli.Bulletin De La Societe Internationale De Chirurgie. 1958; 1: 1-9Google Scholar stated "We conceived that it might be feasible to construct an intraluminal filter of textile filaments within the vena cava. Such a filter could potentially block the transit of emboli without significantly disturbing the function or dynamics of the venous system." He selected silk for his filter because of Voorhees' 23Voorhees AB Jaretzki III, A Blakemore AH The use of tubes constructed from Vinyon "N" cloth in bridging arterial defects.Ann Surg. 1952; 135: 332-336Crossref PubMed Scopus (321) Google Scholar observation "that a simple strand of silk suture traversing the chamber of the right ventricle of the heart of a dog became coated in a few months throughout its length by a glistening film free of macroscopic thrombi." No one, however, had ever tested the thrombogenicity of such materials in the venous system or explored the possibility of partially interrupting venous blood flow to prevent fatal pulmonary emboli. DeWeese 22DeWeese MS Hunter Jr, DC A vena cava filter for the prevention of pulmonary emboli.Bulletin De La Societe Internationale De Chirurgie. 1958; 1: 1-9Google Scholar constructed intraluminal "harpgrid" filters in canine vena cavae by placing mattress stitches of 5-0 or 6-0 silk sutures on an atraumatic needle obliquely across the infrarenal vena cava. The sutures were carefully tied to prevent narrowing of the lumen. Control animals underwent autopsy at periodic intervals, and only one was found to have "minute 1 × 1 × 2 mm thrombi on the threads one day after operation but no other thrombi were seen and the threads were covered with intima by 1 - 3 weeks." Standard fibrinogen emboli introduced into the femoral veins of control animals caused death within 5 minutes, and autopsies revealed emboli in the pulmonary arteries. All animals with filters survived injection of thrombi into the femoral vein. Six of 30 animals at autopsy had small pulmonary emboli without detectable symptoms. Autopsies on animals in which clots were trapped by the filter demonstrated lysis or complete organization of the thrombi with recanalization in all animals. The clinical efficacy of the filter was later confirmed in 112 patients. 24DeWeese MS Kraft RO Nichols WK et al.Fifteen-year clinical experience with vena cava filter.Ann Surg. 1973; 178: 247-257Crossref PubMed Scopus (13) Google Scholar None of the patients who had partial caval interruption died of pulmonary emboli. There was a 6.2% incidence of small nonfatal emboli. Since DeWeese first demonstrated that intraluminal partial venous interruption was feasible and effective, there have continued to be significant advances in available devices and techniques of insertion, an example of a continuation in the sharp increase shown on the line of advances that follow an innovation. The next advance was the development of devices that could be placed in the inferior vena cava through short venotomies in the femoral or jugular vein. The devices were single wires, umbrella-like plastics, or cone-shaped wire devices that were usually passed up the cava in removable sheaths. When the sheaths were removed, the devices sprung open. The Pate wire stretched the wall of the cava to produce a 3 mm slit. 25Pate JW Melvin D Cheek RC A new form of vena caval interruption.Ann Surg. 1969; 169: 873-880Crossref PubMed Scopus (21) Google Scholar The Eichelter umbrella-tipped catheter could be tied to the femoral vein and later removed. 26Eichelter P Schenk Jr, WG Prophylaxis of pulmonary embolism.Arch Surg. 1968; 97: 348-364Crossref PubMed Scopus (30) Google Scholar The Mobin-Uddin and Greenfield filters remained fixed to the wall of the cava by hooks. 27Mobin-Uddin K McLean R June JR A new catheter technique of interruption of inferior vena cava for prevention of pulmonary embolism.Am Surg. 1969; 35: 889-894PubMed Google Scholar, 28Greenfield LJ McCurdy JR Brown PP et al.A new intracaval filter permitting continued flow and resolution of emboli.Surgery. 1973; 73: 599-606PubMed Google Scholar The latest advance has been the percutaneous introduction of the filters. This has been made possible by the development of stainless steel Bird's Nest filters (Cook, Inc., Bloomington, Ind.) and titanium Greenfield filters, which can be housed in a 12F sheath dilator as compared with the previous 28F sheaths. 18Greenfield LJ Evolution of venous interruption for pulmonary thromboembolism.Arch Surg. 1992; 127: 622-626Crossref PubMed Scopus (36) Google Scholar, 29Roehm Jr, JOF Johnsrude IS Barth MH et al.The Birds Nest inferior vena caval filter: progress report.Radiology. 1988; 168: 745-749PubMed Google Scholar Ligation of the inferior vena cava was associated with an operative mortality rate of 14%, recurrent pulmonary embolism rates of 6%, and a fatal recurrent pulmonary embolism rate of 2%. 18Greenfield LJ Evolution of venous interruption for pulmonary thromboembolism.Arch Surg. 1992; 127: 622-626Crossref PubMed Scopus (36) Google Scholar Recent experience with the Greenfield filter has resulted in operative mortality rates of 0% recurrent pulmonary embolism rates of 3%, and recurrent fatal pulmonary embolism rates of less than 2%. 18Greenfield LJ Evolution of venous interruption for pulmonary thromboembolism.Arch Surg. 1992; 127: 622-626Crossref PubMed Scopus (36) Google Scholar Partial vena caval interruption with extraluminal techniques has also flourished since DeWeese described his innovation. In 1959 Moretz et al. 30Moretz WH Rhode CM Shephard MH Prevention of pulmonary emboli by partial occlusion of the inferior vena cava.Am Surg. 1959; 25: 617-623PubMed Google Scholar introduced a smooth U-shaped Teflon clip to narrow the cava. In 1964 Miles et al. 31Miles RM Chapell F Rennet O A partially occluding vena caval clip for prevention of pulmonary embolism.Am Surg. 1964; 30: 40-46PubMed Google Scholar used a clip with serrated edges that also compartmentalized the cava. In 1966 Adams and DeWeese 32Adams JT DeWeese JA Partial interruption of the inferior vena cava with a new plastic clip.Surg Gynecol Obstet. 1966; 123: 1087-1088PubMed Google Scholar modified the Miles clip by making one limb serrated and the other smooth, which facilitated the passage of the clip around the cava. In 1960 Spencer 33Spencer FC An experimental evaluation of partitioning of the inferior vena cava to prevent pulmonary embolism.Surg Forum. 1960; 10: 680-682PubMed Google Scholar plicated the cava by dividing it into compartments, with mattress sutures passed through the anterior and posterior wall of the cava, which divided it into channels 3 to 4 mm in diameter. Ravitch et al. 34Ravitch MM Snodgrass E McEnany T et al.A compartmentalization of the vena cava with the mechanical stapler.Surg Gynecol Obstet. 1966; 122: 561-564PubMed Google Scholar accomplished compartmentalization with the mechanical stapler. All of these techniques have been successfully evaluated clinically and are still used by some surgeons, particularly when vena caval interruption is indicated prophylactically for a patient undergoing laparotomy. Massive iliofemoral venous thrombosis is associated with significant morbidity. Although the thrombosis may have ascended through the deep veins, it usually originates in the iliac veins or the greater saphenous vein. Phlebograms frequently reveal occlusion of the iliac vein with patent, normal-appearing distal veins. Even with heparin therapy, decrease in pain and swelling is slow, venous gangrene may occur, fatal as opposed to nonfatal pulmonary embolism is more likely, and the postphlebitic syndrome is common. In hopes of minimizing these complications, Lawen in 1938 35Lawen A Weltere Erfahrungen uber operative thrombenentfernung bei venenthrombose.Arch Klin Chir. 1938; 193: 723Google Scholar performed the "ideal" thrombectomy through a femoral venotomy, followed by closure of the venotomy without ligation of the femoral veins as performed by others. Mahorner et al. 36Mahorner H Castleberry JW Coleman WD Attempts to restore function in major veins which are the site of massive thrombosis.Ann Surg. 1957; 146: 510-518PubMed Google Scholar and Fontaine 37Fontaine R Remarks concerning venous thrombosis and its sequelae.Surgery. 1957; 41: 6-11PubMed Google Scholar reported series of such operations followed by heparin anticoagulation in 1957. The iliac thrombi were removed by abdominal pressure or by passage of tubes through the femoral venotomy, which were then attached to suction. The suction tubes were made of glass, metal, or flexible polyethylene. 38Dale WA Endovascular suction catheters.J Thorac Cardiovasc Surg. 1962; 44: 557-558PubMed Google Scholar These large catheters usually could not be passed into the vena cava because they met obstruction at the point where the iliac vein angulated medially and anteriorly over the sacrum. 39DeWeese JA Jones TI Lyon J et al.Evaluation of thrombectomy in the management of iliofemoral venous thrombosis.Surgery. 1960; 47: 140-159PubMed Google Scholar They could not be passed distally into the femoral vein without destroying the venous valves. The distal clots were removed by massaging the leg or by elevating and compressing the legs with rubber elastic bandages. Good early results after thrombectomy were reported. 40DeWeese JA Thrombectomy for acute iliofemoral venous thrombosis.J Cardiov Surg. 1964; 5: 703-712PubMed Google Scholar However, the occasional fatal intraoperative embolism, the inability to completely remove the thrombus with the methods available and the high rethrombosis rate discouraged most surgeons from performing thrombectomies. There was a need for an improved method for the extraction of venous thrombi. This brings us to our third innovation, the balloon thrombectomy catheter, and its innovator, Thomas J. Fogarty (Fig. 3). 41Friedman SG The Fogarty catheter.in: A history of vascular surgery. Futura, Mount Kisco, NY1989: 198-202Google ScholarThomas Fogarty was born in 1934 in Cincinnati, Ohio. His father died when Tom was very young, and it was necessary for him to work to help support the family. He delivered newspapers and mowed lawns and, while still in the eighth grade, was able to get a job in the central supply room of the Good Samaritan Hospital. While still in high school he became an operating room technician, where he first met Dr. John Cranley, a vascular surgeon. Cranley encouraged Tom and hired him to be his private technician. Tom at that time was not a good student and did not have his principal's strong recommendation for college. He was admitted to Xavier University on probation and quickly learned how to study and got good grades. He continued to work part-time for Dr. Cranley throughout college. Early in his operating room experiences Tom noticed that embolectomies and thrombectomies were frequently unsuccessful. He thought about it for some time, and finally in his junior year of college he experimented with the construction of some balloon catheters out of some old ureteral catheters and thin-walled latex tubing. 41Friedman SG The Fogarty catheter.in: A history of vascular surgery. Futura, Mount Kisco, NY1989: 198-202Google Scholar Three years later, while taking a 1-year fellowship with Dr. Cranley and his group, he was finally able to fully evaluate clinically a new balloon catheter. He was still making the device himself. It consisted of a semirigid plastic catheter to which a syringe could be attached. At the other end there were side holes in the catheter in an area where latex tubing was secured. Instillation of air or saline solution resulted in a ballooning out of the latex tubing. He first used his balloon catheter in the arteries of cadavers. He found that the tip of the catheters passed either between the wall of the artery and clots or through the softer portion of clots and that it was impossible to push the clots up the artery. Fogarty stated, "only with force exerted far beyond the usual surgical caution is one able to bring about dissection of plaques or arterial perforation in the cadaver." 42Fogarty TJ Cranley JJ Krause RJ et al.A method for extraction of arterial emboli and thrombi.Surg Gynecol Obstet. 1963; 116: 241-244PubMed Google Scholar He used the balloon catheter to remove thrombus from the iliac vein and proximal superficial femoral vein through a common femoral venotomy in patients with iliofemoral venous thrombosis and phlegmasia cerulea dolens. 43Fogarty TJ Cranley JJ Krause RJ et al.Surgical management of phlegmasia cerulea dolens.Arch Surg. 1963; 86: 256-263Crossref PubMed Scopus (20) Google Scholar, 44Fogarty TH Krippaehne WW Catheter technique for venous thrombectomy.Surg Gynecol Obstet. 1965; 121: 362-363PubMed Google Scholar Fogarty 45Fogarty TJ Hallen RW Temporary caval occlusion during venous thrombectomy.Surg Gynecol Obstet. 1966; : 1269-1272PubMed Google Scholar made further improvements in the performance of iliofemoral venous thrombectomy by the passage of a balloon catheter up the uninvolved iliac vein for the temporary occlusion of the cava during thrombectomy. He was also able to pass the catheter distally by the manipulation of the catheter past valves with intermittent inflation and deflation of the balloon. Edema was absent in 17 of 20 patients, and phlebograms demonstrated patency of 10 of 13 iliofemoral veins after operation. 46Fogarty TJ Dennis D Krippaehne WW Surgical management of iliofemoral venous thrombosis.Am J Surg. 1966; 112: 211-217Abstract Full Text PDF PubMed Scopus (26) Google Scholar The availability of thrombolytic therapy has decreased the use of thrombectomy for many patients with iliofemoral venous thrombosis. Venous thrombectomy by Fogarty balloon catheter technique is still, however, the treatment of choice for patients with phlegmasia cerulea dolens and threatened venous gangrene. The use of an arteriovenous fistula for the first few weeks after thrombectomy has improved the results. 47Neglen P Al-Hassan HKh Endrys J et al.Iliofemoral venous thrombectomy followed by percutaneous closure of the temporary arteriovenous fistula.Surgery. 1991; 110: 493-499PubMed Google Scholar Varicose veins have been recognized since antiquity, as recorded by ancient Greek sculptures. Hippocrates (460 – 377 BC) first recognized varicose veins as being associated with, if not the cause of, ulcers on the leg. 48Anning ST. The historical aspects. In the pathology and surgery of the veins of the lower limb. 6. E & S Livingstone Ltd, Edinburgh and London England1956: 27Google Scholar William Harvey described the circulation of blood in 1628. When he studied venous valves he appreciated their function of directing blood flow in one direction. It was not until the mid 1800s that J. Gay recognized that ulcers of the leg were related to venous thrombosis and not necessarily to varicose veins. 3Gay J On varicose diseases of the lower extremities.in: The Lettsomian Lectures of 1867. Churchill, London1868Google Scholar It has only been during this century that the importance of postthrombotic venous valvular insufficiency (particularly in the deep and perforating veins) and the effect of gravity and the muscle pump on venous and pressures about the ankle as a cause of ulcers, has been understood. 4Homans J The etiology of treatment of varicose ulcer of the leg.Surg Gynecol Obstet. 1917; 24: 300-308Google Scholar The value of compression in the treatment of venous ulcers has long been recognized. Hippocrates described the use of compression bandages in the fourth century BC. 48Anning ST. The historical aspects. In the pathology and surgery of the veins of the lower limb. 6. E & S Livingstone Ltd, Edinburgh and London England1956: 27Google Scholar Various materials and medicaments and methods of application have been used to the present time. Wiseman in 1676 compressed the leg with a leather laced stocking for the healing of ulcers. 48Anning ST. The historical aspects. In the pathology and surgery of the veins of the lower limb. 6. E & S Livingstone Ltd, Edinburgh and London England1956: 27Google Scholar The development of stockings made of elastic materials is a product of the twentieth century. The elastic stockings available in the 1940s were of varying strength and weight. They were made in only a few sizes. No attempt was made to vary the tension of the circumferential fibers of the stocking at various levels of the leg. A patient with a very thin ankle and thick calf could actually have higher compressio
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