The History and Future of Vein Surgery

Since humans started to walk upright, the physiology of Homo sapiens has struggled with the difficulties of gravity. The first evidence of upright walking dates back to around 6 million years ago. A foot arch, which is an essential criterion for walking upright, can definitely be found in our ancestors 3–3.5 million years ago. Physiological adaptations of the circulatory system are closely linked to upright walking. The venous blood from the lower extremities has to overcome a pressure column of approximately 100 mm Hg (140–150 cm H ₂ O) on its way back to the heart. This means that sequencing into shorter segments, such as those developed by functioning venous valves in the parts of the body below the pressure reference plane (heart/diaphragm), is necessary and sensible. If such sequencing is missing (e.g., due to agenesis of the valve apparatus or after postthrombotic scarring/destruction of the bicuspid venous valves), then a symptom complex of chronic venous insufficiency can develop. According to the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification, one of the possible manifestations of chronic venous insufficiency is the development of varicosis of the (superficial) leg veins, which can be primary (constitutional-hereditary) or secondary (angiodysplasia with or without arteriovenous fistula, valve agenesis, compression syndromes). Aulus Cornelius Celsus (approx. 25 BCE to CE 50), an educated layman according to today’s assumptions, wrote many important works, including on medicine. His medical work covers eight books on various topic areas. In the seventh volume (surgery), there is information about vascular ligatures. These are the first known “vascular surgery” records. Celsus’s writings did not find fertile ground either in his time or in the following 1500 years and did not reappear until around 1460. In the 31st chapter of the 7th volume (“De re medica libri octo”), Celsus describes the surgical procedure for varicose veins as follows

From here I then move on to the legs. This is where blood vein nodes (varicose veins) arise, which can be removed without difficulty. I have not included the lesson for the operation of varicose veins on the head and abdomen before now because it is the same everywhere. One either makes the diseased veins shrink with a hot iron (ablation) or one cuts them out. If such a varicose vein runs straight, or if it is only simple and of moderate size, even if it does not run in a straight direction, it is best to burn it. If, on the other hand, it is tortuous, it forms many circular turns, or if several are intertwined, it is better to remove it …

This is followed by a description of varicose vein ablation with a hot iron, which he writes has to be done at a distance of finger widths.

…The excision is performed as follows: One cuts the skin evenly above the varicose vein and pulls the edges of the wound apart with hooks. Then one uses the knife to separate the vein from all the parts surrounding it, whereby one has to prevent injury to the vein itself. Then one places a blunt hooklet under it; this is repeated at the distances stated above on the same varicose vein, the course of which can be easily recognized by tightening the hook. Once one has performed the specified operation along the entire course of the varicose vein, one pulls it at one point using a hook and cuts through it. Then one pulls on the next hook, thereby pulling out the previously loosened piece of varicose vein and cutting it off again at this point. Once one has completely freed the leg from the varicose vein in this way, one places the edges of the wound against each other and puts a patch over them to promote healing.

A few decades later, the layman Gaius Plinius Secundus (CE 23–79) wrote down the casuistry of the varicose vein operation by the surgeon Oppius:

The operation was performed on C. Marius, “who was Roman consul seven times.” The consul endured the procedure standing up (“stante sibi extracti passum”) without once expressing the pain. After the operation, however, he said that although he was satisfied with the result, the pain was out of proportion to the illness and he did not want to have the operation a second time .

It is probable that not many affected people were treated surgically in the following 1500 years. This may also have been due to the fact that varicosis symptoms were more widespread in lower social classes. The next similar casuistry is only found in the 17th century, written down by Johannes Scultetus Ulmensis (1595–1645). However, the procedure was reportedly very complicated due to the patient’s improper behavior, and Scultetus therefore decided after this operation to treat patients with varices only with stockings made of dog fur or with external medicines.

Systematic surgery for varicose veins began in the middle of the 19th century with the invention of anesthesia and the introduction of antisepsis. Many names of famous surgical personalities became established in the surgical treatment of varicose veins. Given the frequency of the disease, this is hardly surprising.

EPOCHAL DEVELOPMENTS

First Era: 0–1700

Although varicose veins were mentioned as early as 1550 BCE, the therapy that was first described around CE 0 remained consistent over the centuries and, with minor adjustments, underwent little change until the advent of modern medicine. Accordingly, varicose veins were treated ablatively, whereby the term ablation includes the removal of varices not only by extirpation or extraction but also by cauterization (thermal).

The surgical representation of the diseased vein sections (dissection) and their subsequent ligation/cutting and removal or thermal ablation was first described in detail by Celsus (25 BCE to CE 30) (“de re medica libri octo”) and was probably applied for centuries without any decisive development steps ( Table 13.1 ).

Table 13.1

Representatives of the First Era of the Treatment of Varicose Veins

Papyrus Ebers	1550 BCE	Mentions serpentine veins and venous ulcers
Hippocrates	460–375 BCE	Pricking from time to time
Celsus Aulus Cornelius	25 BCE–CE 50	Blood vein node exposed and coagulated or extirpated with a hot iron. “de re medica libri octo” describes the operation in detail
Scultetus Johannes	1595–1645	Detailed description of a variceal operation in “armamentarium chirurgicum”

Second Era: 1900–1950

Variants of Varicose Vein Removal With the Aim of Radicality (Minimizing Recurrence)

For almost 2000 years, the history of variceal therapy has focused primarily on how the clinical manifestation of varicose veins can be eliminated to minimize the symptoms caused by varicosis. Various variations of techniques and technical aids all pursued the same goal: removing the diseased (dilated, thrombosed, inflamed) vein sections as radically as possible. The lack of diagnostic options did not allow for any in-depth pathophysiological conclusions. Complication rates were high. The anatomical observations at least shed light on the view of the venous system as a whole. Trendelenburg came to the conclusion that the ligation of the great saphenous vein (GSV) had to be part of the therapeutic concept and described the surgical step of “ligation of the great saphenous vein in lower leg varices.” The connection between the insufficiency of the saphenous trunk valves and the development of lower leg varices was the birth of systematic venous surgery. It was Babcock who ultimately postulated that the extirpation of the saphenous vein was the most promising treatment method. For this purpose, he invented the Babcock vein extractor, with which the entire vein trunk could be removed in one step within 3–10 minutes. Stripping the saphenous vein would remain the central pillar of variceal therapy for decades ( Table 13.2 ).

Table 13.2

Representatives of the Second Era of the Treatment of Varicose Veins: Extraction/Exeresis/Extirpation

Trendelenburg Friedrich	1844–1924	On the “ligation of the great saphenous vein in lower leg varices”
Madelung Otto	1846–1926	Radical surgical excision of cirsoid aneurysms (completely via long incisions)
Mayo Charles Horace	1865–1939	Dull ring curette
Perthes Georg Clemens	1869–1927	On the operation of lower leg varices
Babcock William Wayne	1872–1963	Invention of stripping at the beginning of the 20th century
Tournay Raymound	1893–1984	Coined the term phlebology. Founder of the French Society of Phlebology in the mid-20th century
Dodd William Harold Alfred	1899–1987	The pathology and surgery of the veins of the lower limb
Linton Robert Ritchie	1900–79	Communicating veins. Considered varicose veins as a secondary (post-thrombotic) phenomenon. Developed a radical surgical method fraught with complications. Recognized the importance of reflux in the deep system