Handbook of Venous and Lymphatic Disorders

Guidelines of the American Venous Forum, Fourth Edition

Peter Gloviczki, Peter Gloviczki, American Venous Forum

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781498783309
• Edition: 4
• Topic: Medizin
• Subtopic: Chirurgie & chirurgische Medizin

The Handbook of Venous Disorders, first published in 1996, is a handbook for all clinicians and surgeons who are involved with the investigation, evaluation, or management of venous and lymphatic diseases or malformations. These disorders include varicose veins, venous ulcers, DVT, lymphedema, and pulmonary embolism, as well as damage to the veins through trauma or tumor growth. The new edition has been completely updated to bring the book in line with current teaching practices.

PART 1

Basic Considerations of Venous Disorders

1 Venous and lymphatic disease: A historical review

Christine M. Dubberke and Ruth L. Bush

2 Development and anatomy of the venous system

Peter Gloviczki

3 The physiology and hemodynamics of the normal venous circulation

Frank T. Padberg Jr.

4 Classification and etiology of chronic venous disease

Robert L. Kistner and Bo Eklöf

5 The pathophysiology and hemodynamics of chronic venous insufficiency of the lower limb

John Blebea

6 Pathogenesis of varicose veins and cellular pathophysiology of chronic venous insufficiency

Deoranie N. Abdel-Naby, Walter N. Duran, Brajesh K. Lal, Frank T. Padberg Jr., and Peter J. Pappas

7 Venous ulcer formation and healing at cellular levels

Joseph D. Raffetto

8 Acute and chronic venous thrombosis: Pathogenesis and new insights

Jose A. Diaz, Thomas W. Wakefield, and Peter K. Henke

9 Epidemiology and risk factors of acute venous thrombosis

Mark H. Meissner

10 Epidemiology of chronic venous disorders

Eberhard Rabe and Felizitas Pannier

1

Venous and lymphatic disease: A historical review

CHRISTINE M. DUBBERKE AND RUTH L. BUSH

1.1 Introduction

1.2 Varicose veins and chronic venous insufficiency

1.3 The lymphatic system and lymphedema

1.4 Conclusions

References

…it shows what a distance we have travelled in surgery during the last quarter of a century (19th) and finally it should make us very careful of our written statements, for in a few years they look very ridiculous.

Jerry Moore

1.1 INTRODUCTION

This chapter is an updated historical overview that describes the progression of discoveries and subsequent advancements in both the diagnosis and treatment of venous and lymphatic diseases. Reflection on the historical evolution of medical knowledge is important in order to appreciate how far we have truly come and to realize how far we have left to go. As with all scientific progress, our current understanding of venous and lymphatic diseases is inextricably connected and built upon the advancements of our predecessors. We have the luxury of thousands of years of observation, scientific trials, errors, and discoveries, which have sequentially culminated in creating our current expertise in the field today. We are in an unprecedented era of medical economic conscientiousness superimposed with exponential advancements in technology and medical therapies. Comprehensive data collection is utilized to instantaneously evaluate the unlimited variables in our concerted efforts to discern the efficacy and efficiency of medical interventions, and design the best overall evidence-based, patient-centered therapies. How to promote and execute the continuous improvement of patient care, management, and prevention practices is the challenge we currently face. We are at the frontier of knowledge, yet medical uncertainties, unknown etiologies, and lack of definitive treatments for and prophylaxis of common venous disease is a true testament to how far we have left to go. Before we can address how to produce significant change in the future, we will take a step back and review the major historical chronology in the medical management of venous diseases.

1.2 VARICOSE VEINS AND CHRONIC VENOUS INSUFFICIENCY

1.2.1 Venous disease throughout antiquity

The first descriptions of varicose veins and manifestations of chronic venous insufficiency date back thousands of years. Since the human race has walked on two legs, gravity opposed the venous return of blood to the heart, leading to the development of acute venous thrombosis, varicose veins, and chronic venous insufficiency. Thus, the basic principles underlying the treatment of varicose veins today are shockingly reminiscent of the methods used to treat varicosities in ancient times.

The Ebers Papyrus was written by the ancient Egyptians in around 1550 BCE and is one of the oldest and most important medical papyri. It contains medical descriptions and treatments of varices and describes them as “tortuous, [and] solid with many knots, as if blown up by air.”¹ Later, the first surgical textbook was written by Sushruta, an Indian surgeon who lived between 800 and 600 BCE. Several translations from the original Sanskrit reveal that he discussed siragranthi or “aneurysms of the veins,” and that “straining or exertion by pressure” caused the described varicosities to develop. He also provided one of the first recorded accounts on the difficulty in treating the associated condition of thrombophlebitis. In his attempts to cure varices, he developed phlebotomy, and described using tree bark-derived astringents (sandhana), freeze-induced blood thickening (skandana), ash-induced dehydration (pachana), and vein cauterization-induced singeing (dahana) as ways of achieving hemostasis. Ultimately, he concluded that varices were incurable.^1,2

The first illustration of varicose veins dates back to the fourth century BCE and is displayed on an ancient Greek votive tablet (Figure 1.1). The stone carving discovered in Acropolis (Athens) shows a twisted swelling extending up the medial side of a massive leg and is believed to have been dedicated to Doctor Amynos, one of the first phlebotomists.

The ancient Greek Corpus Hippocraticum is evidence that Hippocrates (460–377 BCE), the renowned “father of medicine,” recognized a correlation between varicose veins and ulceration. Even at a time when the understanding of pathophysiology was extremely limited, he discouraged standing for patients with lower extremity ulcers, explained that varicosities represented “an influx of blood into the veins,” and appreciated the importance of firm leg compression treatment by his prescription of bandages.^1,3–5 The doctrine of the four humors (blood, phlegm, yellow bile, and black bile) was the foundation of Hippocrates’ medicine and an extremely primitive understanding of circulation physiology, as both veins and arteries were believed to carry air.³ He recommended alternative treatments, such as small punctures in varicose veins and the use of cautery. Hippocrates faced the same difficulties in treating varices as his predecessor, Sushruta, and wrote,

Figure 1.1 Votive offering leg with varicose veins. Epidauros, Greece, third century BCE. (Available at http://www.hkma.org.)

What cannot be cured by medications 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.³

One of the earliest attempts at compiling a complete history of medicine was completed in the first century CE by Aurelius Cornelius Celsus (25 BCE–50 CE), a famous Roman encyclopedist. He described the use of compression linen bandages and various types of plaster to treat leg ulcers, and even performed operative phlebectomy via avulsion with a blunt hook or cautery.^1,3 The widely accepted etiology during this era was continuous bidirectional movement of blood and its spirits, which resulted in varices that stored the toxic humors safely outside of the body. The varicosities harboring evil spirits were believed to be benign unless pressed back into the circulation.¹

Lack of anesthesia and a distorted view of blood circulation did not stop Claudius Galen, a first century (130 CE) Greek physician, from attempting surgical interventions on unsightly varicose veins. Galen elaborated on Celsus’s description of varicose vein surgeries, described venesection, and promoted operative avulsion with a blunt hook. He is also credited with advancing the theory of humoral dynamics in a text that would influence Western medicine and surgery for the next 1500 years.^1,5,6 An excerpt of his writing explains:

In varicose veins of the legs we mark out the whole extent of them by scratches on the outside, then put them on their backs, take hold of the skin surface, and divide that first, then lift up the varicosity with a hook and tie it off, and do the same thing at all the incisions. Or we pull them out with a varicocele hook and cut off the ends, or we pass thread through the coil of the veins with a probe and pull them up and take them out.²

If a vein is straight, or though crooked, is yet not twisted, and if of moderate size, it is better cauterized. If a vein is curved and twisted, as it were into intricate coils and involutions, it is better to cut it out.⁷

Byzantine physicians studied the medical treatments and surgical techniques proposed by previous Greek and Roman physicians at the famous Egyptian Alexandrian school of medicine. Finding a surgical cure for varicose veins was of great interest to ancient physicians, despite the relatively limited knowledge concerning the pathophysiology of the disease process. Medical practice and surgery were highly developed from the fourth to sixth centuries CE. As Byzantine medical texts demonstrate, several surgical techniques for varices were widely studied, shared, and practiced by all eminent Byzantine physicians, including Oribasius, Aeti...