Back to Founding of AATS
For many years previous to Founding of The American Association for
Thoracic "Surgery, discussions on vascular surgery neglected to encompass
recorded experience. One text dismissed arterial suture as applicable only in
tangential injury or minor injury to smaller vessels.1. Another asserted:
To summarize
the treatment of aneurysm ... Proximal ligation is the safer in the hands of
those of moderate skill ... aneurysmorrhaphy or excision are to be preferred.
Excision with transplantation of a segment of vessel is only to be attempted by
those who have developed a satisfactory technique by much work on the lower
animals.2.
Such statements had little in common with the experience and hope of
several Founders.
Dr. Rudolph Matas has pre-eminent rank in vascular surgery. Impressed
by frequent failures in the treatment of aneurisms, he devoted much of his life
to this field. On March 30, 1888, he sutured the bleeding orifices of a
traumatic aneurism incurred by previous proximal and distal ligation. His paper
on this operation merits careful reading: "TRAUMATIC ANEURISM OF THE LEFT
BRACHIAL ARTERY, - Failure of direct and indirect pressure; ligation of the
artery immediately above tumor; return of pulsation on the tenth day; ligation
immediately below tumor; failure to arrest pulsation; incision and partial
excision of sac; recovery." By Rudolph Matas, M.D. Visiting Surgeon Charity
Hospital, etc., New Orleans, La.3.
This quote mirrored the future:
It is plain that no other method would have succeeded but that which
was adopted, i.e., the free opening of the sac and the closure of the orifices
of supply in the sac itself. It is in accomplishing this last result that we
have an opportunity of observing the advantages gained by the improved technique
of the present day.
From further
study, he detailed the incidence, anatomic and pathological characteristics and
the usually fatal course of aneurisms. From a burning desire to devise some
remedy for patients, he directed his efforts into the clinical rather than
experimental field. In the fourteen years after the first "Matas Operation",
his experience grew and enabled him to systematize his thoughts before the
American Surgical Association. "Original Memoir - An Operation For the Radical
Cure of Aneurism Based Upon Arteriorrhaphy"4. is an abridged edition
of the complete paper in "The Transactions of The American Surgical Association
of 1902."
By 1906, Matas further refined endoaneurismorrhaphy into three groups:
obliterative, restorative and reconstructive.5 His description is
classic:
I therefore submit my definition of endoaneurismorrhaphy and the
operations that are derived from it.
Matas -
endoaneurismorrhaphy.
Matas - arterio-venous
fistula.
Carrel - method of
vessel anastomosis.
Carrel - method of
kidney transplant.
Carrel - (Guthrie) -
transplant of dog's head, 1908. This operation was performed by C. C. Guthrie
as suggested to him by Alexis Carrel, using Carrel's technique.
Some articles illustrative
of the type common in newspapers at the time of the operation on the Lambert
baby in 1908. The article in the center tells of anti-vivisectionist speeches
in Albany, that at the left describes the Lambert operation, that at the right
tells of agreement reached on vivisection.
SYNONYMS
AND DEFINITIONS
Endoaneurismorrhaphy. - The "Matas operation"
(Bullock); "the radical operation for the cure of aneurism by the intrasaccular
suture of the aneurismal orifices," essentially consists of two fundamental
procedures: (1) the obliteration, by suture, of the vascular orifices which
open into the aneurismal sac; (2) the obliteration of the sac by suture which
brings its inner surfaces in apposition, or by methods of obliteration which
leave the sac undisturbed and tend to secure primary healing by plastic union.
In obliterating the vascular orifices that supply the sac, the parent trunk
which nourishes the aneurism may be preserved or obliterated at the point of
attachment according to the type of sac encountered. Hence the subdivision of
endoaneurismorrhaphy into three varieties:
1. Obliterative
endoaneurismorrhaphy (the fundamental procedure), essentially consists in
opening the sac freely without disturbing it from its surroundings and closing
all visible arterial orifices within the sac, by suture, thus securing complete
hemostasis and permanently stopping all further access of blood into the
aneurismal cavity. The sac is obliterated by approximating its walls with
buried sutures, and closing the wound with or without drainage; or, in rigid
cavities, by simply infolding the overlying skin flaps and lining the cavity
with them (capitonnage of the French) or by one of the several procedures or
variations I have suggested.
The indications for the application of this obliterative suture, or
fundamental procedure, are: All aneurisms in which the sac is of the fusiform
type, in which there are two or more orifices of supply and in which the parent
artery is entirely lost at the seat of the aneurism by blending with the
aneurismal sac throughout its circumference. In these cases no attempt is made
to restore the continuity of the parent artery; the blood stream is interrupted
in that part of the vessel which directly opens into the sac and the arterial
orifices are simply closed by suture, thus shutting off the sac from all
sources of blood supply.
Up to the present time twenty-two cases illustrating this mode of
procedure (obliterative endoaneurismorrhaphy) are exhibited in the group of
thirty-four aneurisms contributed by American operators. Possibly several of
the foreign cases are of this type, but as the contribution of Dr. Lozano has
not yet appeared, we are not yet in a position to state the type of cases
included in his report.
2. Restorative
endoaneurismorrhaphy. This variation in the procedure is solely applicable to
aneurisms of the sacciform type, in which the parent trunk retains its
continuity and normal outline, and the aneurism is a sac simply grafted on the
vessel. By opening the sac freely and washing out the clot, the opening leading
to the artery is exposed inside of the aneurism and is readily closed by a
continued suture which penetrates through all the coats of the sac at the
margin of the orifice of communication. By this procedure the blood supply of
the sac is permanently arrested, the lumen of the parent artery remains
patulous and the arterial stream supplying the limb, or dependent territory, is
immediately restored through its normal channel. The sac is then obliterated by
bringing its endothelial surfaces together with buried sutures and the surface
wound is closed in the usual manner. Up to the present time seven operations of
this type have been reported by American surgeons, all successful, and two, at
least, of the foreign cases may be appropriately added to this list, making
nine in all.
3. Reconstructive
endoaneurismorrhaphy (arterioplasty) is applicable solely to fusiform aneurisms
in which the coats of the sac are firm, elastic and resistant and the two
openings leading to the main artery lie on the same level, in close proximity,
and are situated at the bottom of a superficial or readily accessible sac.
In aneurisms of this type, especially those of traumatic origin, the
continuity of the parent artery may be restored by making a new channel out of
the sac walls which can be brought together by suture over a guide (catheter or
drainage tube) inserted into the proximal and distal openings of the aneurism.
Before tying the last sutures, the guide is removed and the channel is left behind
corresponding to the outline of the original artery. The sac is then
obliterated by approximating its surfaces with buried catgut suture, as
previously applied in the first and second procedures. Thus far, five cases of
this operation have been reported, all by American surgeons. Two of these
patients have relapsed. The first, Morris' case, was followed in six months by
an amputation of the thigh, though it is recognized that a secondary operation
by the obliterative method would have obviated the necessity for this
sacrifice. In the second case (Danna's) when relapse occurred the sac was
reopened, the obliterative method was applied with permanent and perfect
success. The surgeons in the other cases (Craig Barrow of Savannah, 2; Van
Lennep of Philadelphia, 1) report that their patients continue to do well, and,
thus far, without relapse.
Dr. Matas was completely informed on the basic
advances being made by Carrel and others in experimental laboratories. Although
he often expressed great hope for the future of excision and vessel grafting,
he held this opinion after more than 30 years of work: 6
Thus the methods of extirpation of the sac with a
lateral or circular suture of the artery ... the operation in which the
aneurism is extirpated and a transplanted vein is substituted for the missing
part of the artery ... and the method of grafting the popliteal artery ... from
another subject as a substitute for the diseased artery and aneurism ... are
interesting but too hazardous to be regarded as anything more than surgical
experiments or adventures, which as best are justifiable only in a limited
number of very exceptional cases.
It is perhaps unfortunate that Dr. Matas has been so inseparably
connected with the subject of aneurism. This wide-ranging pioneer concerned
himself with many problems. His ideas were often visionary and prophetic. The
reader is referred to his many articles and particularly Keen's Surgery, which
has been considered by some as a Bible in this field. Nothing can supplant a
reading in the original of an originator such as Rudolph Matas.
Alexis Carrel, an experimental surgeon, made his contribution by way of
the laboratory. The death of Sadi Carnot, President of France, from hemorrhage
due to a vessel laceration inflicted by an assassin had seemed avoidable to
him. The technique of blood vessel surgery needed perfection before he could
pursue many of his other ideas. Most of his projects were considered
ultravisionary by large segments of theprofession,
but his persistence led to ultimate success with great benefits still accruing
today.
Although
lateral repair and end to end suture of vessels had previously been reported,
the methods had not been widely adopted. Infection was common, subsequent
thrombosis or stenosis or both often vitiated initial success. Carrel's answer
was rigid asepsis and meticulous surgical technique. To reduce time during
which the circulation was interrupted, he aimed at simplicity. With his
methods, a few clinical successes began to appear.
However, for Carrel, the end of one problem generated new ones in the
attempt to make his methods more applicable. He met them with enthusiasm, not
dismay. To safely interrupt the circulation he devised "central and lateral
derivation". In the former, the circulation continued through a paraffinized
tube while in the latter, he used a by-pass shunt through either a tube or
vessel graft. This provided ample time for repair by sustaining the circulation
in critical areas. By anastomosing the left ventricle to the descending aorta and
clamping the ascending aorta above the valve, he demonstrated that aortic flow
could be reversed and that it was compatible with life. When the extent of
injury made lateral or end to end suture impossible, he inserted vein grafts
for arterial segments. He proved that they were satisfactory anatomical,
pathological and functional substitutes. Anticipating the desirability of a
vessel bank, he instituted cold-preservation of vessels which at a later date
were also used as satisfactory grafts. He never ceased to search for expansion
of his ideas. Organ transplant seemed a logcal project. His ingenuity overcame
difficulties and he was soon able to report the successful transplantation of
the kidney, ovary, heart, and an entire extremity, even a dog's head, the last,
however, with only transitory success.
Dr. Carrel, at this time, confined his efforts to the experimental
laboratory. His methods were applied sporadically by a few hardy surgeons. The
ultimate place that such experimental work may play in future clinical surgery
is not always clear during the investigation. Carrel's experimental work,
however, received unusual and dramatic recognition through an operation
performed on the infant daughter of Dr. Adrian Lambert. The child had been born
apparently well following normal labor. A day after birth, she began to run
temperature and there followed numerous symptoms, finally diagnosed as severe
internal bleeding due to melena. She continued to grow worse and was, on the
fourth day, almost thought hopeless. Dr. Lambert, however, was familiar with
Carrel's work and, feeling that a direct transfusion might savehis child, persuaded Carrel to come to his aid. The
following paragraph, from Dr. Samuel Lambert's account of the operation, 7
dramatically describes the event:
It was decided to attempt a direct transfusion of blood from the father
of the infant by end-to-end anastomosis of the two blood vessels after the
manner devised by Dr. Carrel of the Rockefeller Institute. This was done
through the skillful surgical manipulation of Dr. Carrel himself and Dr. Geo.
E. Brewer. The right popliteal vein of the baby was sutured to the left radial
artery of the child's father, without anesthetic to either patient, and enough
blood was allowed to flow into the baby to change her skin from a pale
transparent whiteness to a brilliant red color. No measure of the amount of
blood was possible, but the evidences of a sufficient quantity were manifold.
She began to cry lustily and to struggle against the bandages which held her strapped
to an ironing-board. The wound in the leg up to this time had oozed a slight
amount of pale watery blood, which did not clot well. It began to bleed freely
and the blood promptly clotted. The nosebleed stopped instantly. The pulse
became full and strong and slowed down, and the respirations were deep and
full. As soon as the wound was sutured and dressed the baby was fed an ounce of
milk, which she took ravenously and retained, and immediately went to sleep.
The operation was reported, by memo, to John D.
Rockefeller who quoted the entire account in his book "Random Reminiscences of
Men and Events". Anti-vivisectionists were actively campaigning in Albany at
the time and the Rockefeller Institute, a research institute, was in direct
line of fire. The Lambert operation played a decisive role in stemming the
anti-vivisectionist .tide and bringing into sharp, undeniable focus the
incalculable value of experimental medicine.
Alexis Carrel's contributions were accorded magnificent recognition in
1912 when he was awarded the Nobel Prize in Medicine. This was the first time
it had come to America, and the achievement actively stimulated the research
attitude. Yet, it took almost another fifty years for his thinking to permeate
the attitude and methods of the profession. Actually, in many respects, our
vascular and some other surgery of today is not far removed from what Dr.
Carrel did more than fifty years ago. He was indeed an illustrious founder and
richly deserved the honors which came to him.
