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History of Varicose Vein Surgery

The word " varicose" is an old one. The origin of the word comes from the Greek "grapelike". It was probably first used as a medical description by Hippocrates in 460 BC.

Indeed, since the beginning of written history, mankind has suffered from - and devised many treatments for varicose veins. Methods of treatment have been under development for more than 2000 years, but until the present era, relatively little weight was given to the cosmetic outcome.

Below is the history of varicose veins treatments throughout various ages in the world:

The Egyptians

Varicose veins were first described in the Ebers papyrus over 3500 years ago. This ancient Egyptian work described 'serpentine windings' which were not to be operated on because the patients would be 'head to the ground'. This is the first description of what must have been a failed attempt at surgery to treat varicose veins, implying that the use of incisions lead to fatal haemorrhage.

The Greeks

Hippocrates wrote some of the earliest medical descriptions of varicose veins. The Hippocratic Treatises, written in 460 BC, took treatment one step further and whilst he did not recommend the excision of varicose veins, he prescribed compression following multiple punctures. He also believed in cautery and is quoted as saying 'what cannot be cured by medicaments is cured by the knife, what cannot be cured by the knife is cured by the searing iron, whatever this cannot cure must be considered incurable'.

The Greek, Paulus Aegineta (A.D. 625-690), favoured ligation of the long saphenous vein long before Trendelenburg 200 years later. He wrote: 'Varices of the leg may be operated upon in a manner similar to that for varicocele, making the attempt upon those in the inner parts of the thigh where they gradually arise, for below this they are divided into many ramifications. A tourniquet is placed upon the thigh, and the patient walks. When the vein becomes distended a mark is made with writing ink or collyrium. Having placed the man in a reclining position with his leg extended we apply another tourniquet above the knee, and where the vein is distended we make an incision through the skin. The vein is freed and tourniquets are removed. A double thread is introduced under the vein and so cut as to make two ligatures, and the vein is opened in the middle, and as much blood as is required is evacuated. The wound is dressed with a pledget in it and with an oblong compress soaked in wine and oil. It is then bandaged.'

The Romans

In a medical treatise De Medicina, a Roman physician named Celcus (25 BC - AD 14) described the ligation and excision surgeries, as well as possible complications. Another description of varicose veins was provided by Galen (AD 131 - 201), who also promoted the use of severing the connection of the arteries to veins in order to reduce pain and avoid spreading gangrene. Celsus and Galen were possibly the first to describe 'phlebectomies', a technique still used today. Celsus, who described the 4 cardinal signs of inflammation, made multiple incisions 4 fingerbreadths apart, then touched the vein with cautery, grasped it and extracted as much of the vein as possible, double damping and dividing the vein between ligatures. Galen described making 3-6 incisions with a hook and then bandaging the leg. Roman surgeons carried scalpels with blunt handles that could be used for dissecting varicose veins, a procedure that was done without any form of anaesthetic. The Roman tyrant Caius Marius who died in 86 B.C. underwent varicose vein surgery. After treatment on one leg he declined surgery to the other leg saying 'I see the cure is not worth the pain'.

Oribasius of Pergamum (c325-405ce), a Byzantine physician, devoted 3 chapters of text to varices. His description of the surgery for varicose veins of the legs included shaving and bathing the leg, followed by marking all of the swellings with small incisions in order that when the veins became invisible on lying down their sites would still be apparent . The vein was identified by drawing 1 or 2 hooks along the leg through a small incision in the skin. The vein was encircled and a feather placed underneath it. This was repeated along the length of the leg. The great saphenous vein (GSV) at the ankle was then cut and pulled from each sequential, proximal incision. Pressure was then applied to the leg to remove all thrombus in order to prevent infection.

Similarly, Paul of Aegina (607-690) who trained in Alexandria , recognised that ligation and removal of the GSV was important.

Arab

Perhaps the most famous physician and surgeon of the era was 'Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi' known to the west as Albucasis (930 AD to 1013 AD). His full name is Abu-Al-Qasim Khalaf Ibn'Abbas Al-Zahrawi. He had been known in the Western World as Abulcasis, Bucasis or Alzahravius. He was born in Al-Zahra, a suburb of Cordoba (Cordova) in 930 A.D .He attended the University of Cordoba which had already been established for one and a half centuries. At that time Cordoba had a population of one. It was the magnificent capital of Al-Andalus where culture and science were at their peak in Europe . Al-Zahrawi became an eminent surgeon. He was appointed as the Court-Physician of King Abdel-Rahman III. He spent a productive life in practicing medicine, especially in surgery and medical writings. He died at the venerable age of 83.

He wrote a major compendium of extant medical knowledge called 'Tasrif'. It comprised of thirty volumes. One of them is "Al-Tastif Liman Ajiz'an Al-Ta'lif' which is the best medieval surgical encyclopaedia recorded. The last volume is perhaps the most important in that it deals with all aspects of Surgery. It was the first textbook of Surgery with illustration of instruments used in Surgery to be ever published. It gained such greart fame that it became the standard testbook of surgery in prestigious universities in the west and was most widely read. He emphasised that knowledge of Anatomy and physiology was essential prior to undertaking any surgery. It was used in Europe until the 17th century. Al-Zahrawi described the ligature of arteries long before Ambrose Pare . Al-Zahrawi also used cautery to control bleeding. He showed evidence of great experience from details of clinical picture and surgical procedures e.g. his description of varicose veins stripping, even after ten centuries, is almost like modern surgery "... Have the leg shaved if it is much hairy. The patient gets a bath and his leg is kept in hot water until it becomes red and the veins dilate; or he exercises vigorously. Incise the skin opposite the varicose vein longitudinally either at the ankle or at the knee. Keep the skin opened by hooks. Expose, dissect, and separate the vein. Introduce a spatula underneath it. When the vein is elevated above the skin level, hang it with a blunt rounded hook. Repeat the procedure about three fingers from the previous site and hang the vein with another hook as previously done. Repeat the procedure at as many sites along the varicose vein as necessary. At the ankle, ligate and strip it by pulling it from the incision just above. When it reaches there, repeat at the higher incision until all of it is stripped.

Ligate the vein and then excise it. If difficulty is encountered in pulling it, ligate its terminal part with a string and pass it under the spatula and dissect it further. Pull gently and avoid its tearing because if it does, it becomes difficult to strip all of it and can cause harm to the patient. When you have stripped it all, put alcohol sponges at the sites of the skin incisions and take care of the incisions until they heal. If the varicose vein is tortuous, you have to incise the skin more frequently, at each change of direction. Dissect it and hang it with the hooks and strip it as previously described. Do not tear the vein or injure it. If this happens, it becomes difficult to strip it. The hooks used should be blunt, eyeless, and rounded, otherwise it can injure the vein".

The Master & Barber Surgeons

By the 13th century, there is a lot of progress in the surgical procedures, led by European physicians called the Master Surgeons. Renowned figures such as Lanfrank of Milan, Guy de Chauliac, Henri de Mondeville, and John of Ardene greatly expanded and refined surgical procedures.

However, the progress of science & surgery stalled for about 350 years when barbers start to routinely conduct surgeries. Between 1500 and 1850 AD, in an era later known as the era of "Barber Surgeons", hemorrhoids are commonly called the "Curse of St. Fiacre". The famous barber-surgeon, Ambroise Paré (A.D. 1510-1590) (Paget., 1910) modified the techniques of Aegineta and Albucasis, favouring ligation at the site of the varix, and sometimes, as Celsus advised, cautery, causing an ulcer which ultimately healed by a hard cicatrix. A century later the leading German surgeon, Heister (1768), recommended bleeding, a diet which amounted to near starvation, and the application of bandages to the legs, so that the coats of the vein might be strengthened.!

The Renaissance

During the Renaissance, surgeries returned the realm of the scientists. A celebrated physician, Lorenz Heister, wrote about the crudeness of past procedures to treat varicose veins, and recommended bleeding, a diet which amounted to near starvation, and the application of bandages to the legs, so that the coats of the vein might be strengthened." Heister (1768),

Acknowledging that varicose veins seem to affect only the upright humans, a physician-scientist called Morgnani wrote: "without doubt, it was not very easy for the blood to pass through a liver of that kind. But why, then, you will say, did it not stagnate equally in the other veins which go to the trunk of the vena portarum? And for this very reason it was that I said you would immediately understand it, or at least in part. Add therefore, to omit other things, the very great length, which is peculiar to this one vein among others, so that it is much more difficult for the blood to be carried upwards, from this vein, than from the others, especially as the situation of the human body requires it, which without doubt is one of the reasons why other animals are not subject to piles. And if you ask why, in those bodies in which there is any impediment to the quick motion of the blood upwards, the veins of the legs in particular are dilated into varices, you will find the same thing to be the cause of them chiefly which we assign for the piles."

The Seventeenth / Eighteenth Century

The leading phlebologists of the 17th and early 18th centuries were French. Pierre Dionis (1668-1718), surgeon in ordinary to the Queen of France, performed surgery on varices. He made multiple longitudinal incisions over the veins and then used cautery to destroy them. Louis Petit (1674-1750), first director of the Academy of Surgery in Paris, taught that the cause of varicose veins was 'anything that obstructed the rising blood in the veins'. He performed radical excisions of varices. The centre of phlebology moved from Paris to London in the late 1700s with the work of John Hunter on thrombophlebitis and pulmonary embolism. He was the first to differentiate between septic phlebitis that required drainage and spontaneous or traumatic phlebitis, which did not require surgery'. Christopher Ubren and his associates, in 1656, are reputed to have been the first to introduce drugs intravenously. Using a metal tube they introduced opium into the veins of a dog. Similar injections were given to a human a few years later by J. D. Major and Casper Scotus. However, it was Francis Rynd in 1845, and Parvez in 1851, who introduced the hypodermic syringe, and opened new avenues of approach to the treatment of varicose veins.

The Nineteenth Century

The advent of anaesthesia and antiseptic surgery advanced the treatment of varicose veins with great pace. Friedrich Trendelenburg (1841-1891), perhaps one of the most well known venous surgeons, popularised mid-thigh ligation of the GSV. He made a 3 cm transverse incision at the junction of the middle and upper third of the thigh and ligated the vein in situ. He believed that groin dissection was unnecessary as blood would flow through perforators alleviating back pressure, perhaps similar to the theories applied by CHIVA today,!2 Patients were hospitalised for 5 weeks and he claimed he could do the operation so fast that no anaesthetic was required. Trendelenburg published recurrence rates of 22% at 4 years. This procedure was later modified by Trendelenburg's student Perthes, who advocated a groin incision and a saphenofemoral ligature. Although called the Trendelenburg procedure, the midthigh ligation procedure was actually performed as early as the seventh century. Through the ages, the vast majority of patients who have been treated for varicose disease have undergone some variant of this procedure. Perthes published recurrence rates of 18% in 41 procedures.

In the early 1850s the treatment of varices by injection began to attract attention. Cassaignac, and also Debout in 1853, used injections of perchloride of iron and reported some success. Desgranges used injections of iodotanin. Soule, noted the development of inflammation and suppuration following perchloride of iron injections, and advised the use of compression to prevent dilatation of the veins after injection. Muller reported four cases successfully treated by injections of firon chloride in the 1860s, but Corbiu reported severe phlebitis and sloughing following injections of persulphate of iron. A solution of iodotannin was used by Panas , who reported suppuration in both of his patients, and gangrene of the skin in one of them.

In 1876 Weinlechner, who reported the healing of a varicose ulcer by the injection, with iron perchloride, of varicose veins in the region of the ulcer. The popularity of the injection treatment was now accelerating, and Burroughs (1880) reported a series of sixty patients, with successful results in those who completed the treatment and reported using carbolic acid in one patient with success, and Stevenson repeated this in eight cases. However, at the surgical congress of Lyon in 1894, the injection treatment of varicose veins was much discussed, and it was finally decided, in view of the complications which all too frequently developed, that this treatment should be abandoned.

Despite many incarnations of surgery for varicose veins it took until the early 1900s for the technique of crossectomy, or high saphenofemoral ligation to be established; 1896 saw the publication of 2 important papers, both of which went largely unnoticed.

The Twentieth Century

Several new approaches to stripping the greater saphenous vein (GSV) were introduced in the first few years of the 20th century. The Mayo stripper is an extraluminal ring that cuts the tributaries as it passes along the vein. The Babcock device is an intraluminal stripper with an acorn-shaped head that pleats up the vein as it pulls the vessel loose from its attachments. The Keller device is an internal wire used to pull the vein through itself, as is done today with perforation-invagination (PIN) strippers.

Many historical surgical approaches were unpalatable to patients. The Rindfleisch-Friedel operation of the early 1900s, for example, involved cutting a deep (ie, to the level of the deep fascia) spiral gutter that wrapped around the leg 6 times, bringing into view a large number of superficial veins, each one of which was ligated. This wound was left open to heal by granulation. The Linton procedure (see Image 3), introduced in the late 1930s, also used an open approach for removal of incompetent vessels and subfascial interruption of perforating veins, and this procedure also led to cosmetically undesirable outcomes.

Thelwall Thomas, a Liverpool surgeon, described ligation of the long saphenous vein at the saphenous opening, however, credit for this procedure went to the San Franciscan John Homans in 1916. The second paper was published in Australia by William Moore from Melbourne . He described crossectomy under local anaesthetic as an outpatient. The slow speed of communication between the northern and southern hemispheres at the turn of the century meant that the credit for this went to Geza de Takats of Chicago . In fact, Homans credits the procedure of crossectomy to Madelung who reported full excision of the GSV, Homans' paper describes the use of a transverse incision several inches long made in the groin about an inch below Poupart's ligament. Through this incision the GSV is divided at the saphenous opening. At the same time any other veins that parallel it, or enter it from above are found and divided, 'in order to do away with any vessel capable of re-establishing a large single collateral trunk'. Homans, like Langenbeck and Perthes before him recognised the importance of preventing new vessel formation (neovascularisation) and stated as his first requisite that the GSV should be eradicated in such a way that there was no possibility of the reformation of its channel or the formation of a similar channel.

Today, crossectomy forms part of the gold standard procedure for the treatment of primary great saphenous varicose veins. A small incision is made in the groin crease medial to the pulse emitted by the femoral artery. The saphenofemoral junction is identified with careful dissection. Once the GSV has been identified it can be divided between dips. All of the tributaries should be identified, and rather than simply tying them adjacent to the saphenofemoral junction, they should be dissected back to their first branch before ligation. The authors use a technique of diathermy avulsion of the tributaries back to, and beyond the first branch, which is both fast and efficient. The ligation of the saphenofemoral junction itself can be performed a number of different ways and as yet there is no good evidence to suggest one technique is better than another. Surgeons may use single/ double ligation, transfixion or a method of oversewing the junction flush to the common femoral vein (Figures 7,8). It has become apparent that failure of varicose vein surgery (and the development of recurrent varicose veins) is most common at the level of the groin. Most recurrent GSVS are due to recurrent saphenofemoral incompetence, particularly when the original surgery is done by a vascular specialist. Previously when the operation was done by a general surgeon or a surgical trainee, inadequate groin dissection was common. There is considerable controversy about whether the groin recurrence is due to growth of new vessels at the ligated junction (angiogenesis, or neovascularisation), or whether it is due to dilatation of existing collateral also.

The idea of using endovenous electrosurgical devices for venous wall collagen denaturation is not new. Over the past few decades, monopolar electrosurgical desiccation has been used sporadically (Politowski & Zelazny 1966; Watts 1972; O"Reilly 1977; O"Reilly 1981; Griffith et al. 1989; Gradman 1994). Endovenous obliteration with radiofrequency resistive heating is more advanced method, including precise heating, feedback controlled by the venous wall temperature and impedance (Manfrini et al. 2000; Chandler et al. 2000a). The idea behind using this was to shrink the vein as to make the valves competent again, but on the contrary an obliteration of the vein was observed. This intention to reduce vein luminal diameter in order to eliminate vein reflux using controlled collagen-denaturation contraction (Manfrini et al. 2000) was not efficient enough, and it has been abandoned.

Instead the endovenous obliteration with RF resistive heating has turned out a feasible method for the treatment of superficial venous reflux. The two sizes of catheters allow for obliteration of veins from 2 to 12 mm in diameter and not too tortous for catheter passage. The technique is minimally invasive, but still able to provide satisfactory immediate and long-term results (Chandler et al. 2000a; Manfrini et al. 2000).

A number of techniques including cryostripping (Etienne et al. 1997; Garde 1994), endovenous laser obliteration (Navarro et al. 2001), saphenous valvuloplasty (EV-SFJ and CHIVA) (Schanzer & Skladany 1994; Zamboni et al. 1998; Ik Kim et al. 1999; Incandela et al. 2000), angioscopic techniques (Hoshino et al. 1997), transposition of a competent tributary vein (Yamaki et al. 2001) and echo-sclerotherapy using a sclerosant foam (Cabrera et al. 2000; Tessari et al. 2001), have been proposed to minimize the trauma of CVD treatment or to spare the LSV for possible future artery bypass grafting.

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