Thoracic aortic aneurysms

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Ebers Papyrus (c. 2000 BC)

• First description of heart, aorta, and vascular disease described in Ebers papyrus, the oldest collection of medical documents written by the ancient Egyptians

• “In the Heart are the vessels to the whole of the body… Everywhere he feels his Heart because its vessels run to all his limbs. Therefore it is called the centre of the vessels to all the limbs.”

– from English translation by Cyril P. Bryan

Ebers Papyrus (c. 2000 BC)

“Only magic can cure tumors of the major arteries.” – in regards to aortic aneurysms

Aristotle (4th century BC)

• Aristotle first used the term “aorta” in the 4th century BC to describe what we call the aorta today

• Prior to this, Hippocrates had coined the term to describe the bronchial tree

• The respiratory and circulatory systems were considered one continuous circuit until Harvey described separate circuits in the 1600s

Galen (2nd century AD)

• Galen was a Greek physician practicing in Rome

• Physician to the gladiators

• First trauma surgeon

• Described aneurysms as “localized pulsatile swellings”

• Described the first ruptured aneurysm: “an aneurysm is wounded, the blood is spouted out with so much violence that it can scarcely be arrested.”

Antyllus (2nd century AD)

• A surgical contemporary to Galen, Antyllus described true and false aneurysms and documented the first attempted aneurysm repair in 200 AD

• “Antyllus method”: proximal and distal ligation, central incision of the aneurysm, and evacuation of thrombus

• This was the standard method of aneurysm repair until the 20th century

• Considered the true father of vascular surgery

• “We decline exceptionally big aneurysms, but we will operate on aneurysms in the extremities, the limbs, and the head.”

• “Those who tie the artery, as I advise, at each extremity, but amputate the intervening dilated part, perform a dangerous operation. The violent tension of the arterial pneuma often displaces the ligatures.”

Few developments over the next 1000 years

Vesalius (16th century)

• Vesalius wrote a seven-volume text (On the Structure of the Human Body) with the first human anatomic illustrations based on cadaver dissection

• These documents included detailed descriptions of the heart, great vessels, and vascular system

• Considered the father of human anatomy

• First to describe thoracic and abdominal aortic aneurysms

• “The aneurysms which happen in the internal parts are incurable.” – Ambroise Pare

• In trying to understand blood flow, he described the septum as “thick, dense, and compact as the rest of the heart. I do not see, therefore, how even the smallest particle can be transferred from the right to the left ventricle through the septum.”

19th century

• 1864: first attempt at percutaneous endovascular aneurysm repair by Moore and Murchison

• Cannulated a thoracic aortic aneurysm and packed with 26 yards of wire coils in an effort to induce thrombosis

• The patient died but the aneurysm had partially thrombosed

• 1879: electrothrombosis with passage of current through wires (Moore-Corradi method)

• This method in the treatment of abdominal aortic aneurysms was presented at the Southern Surgical Association as recently as 1952

• Debakey reported his first few cases of resection and replacement with homograft in the discussion following

Early 20th century

• Other indirect methods of repair were reported, primarily stimulation of periarterial fibrosis with cellophane or plastic film wrapped around the aneurysm

• Sometimes successful but results were unpredictable

• In 1948, Albert Einstein underwent this procedure for an abdominal aortic aneurysm and lived 5 years before dying of rupture

More direct methods of ascending thoracic aortic aneurysm repair would require two inventions:

The pump

A conduit

1953

• John Gibbon spent 20 years of research designing the heart-lung machine

• On May 6, 1953, he performed the first open heart surgery on cardiopulmonary bypass to repair an ASD in an 18 year old female

• She was alive and well on the 50th

anniversary of that operation in 2003

1954

• Preserved cadaveric homografts were the first conduit used but were of limited wide-scale utility

• Used in the treatment of abdominal aortic aneurysms and descending thoracic aortic aneurysms with or without associated coarctation in a “clamp and sew” technique

• The Dacron graft was created in 1954 and officially announced in a paper by DeBakey and Cooley in 1958

Ascending aortic aneurysms

Aortic root aneurysms

Aortic arch aneurysms

1990

• The first successful EVAR was done in September 1990

1992

• The first successful TEVAR was done in July 1992

Aortic arch aneurysms

TEVAR for aortic arch aneurysms

Aortic arch debranching for hybrid repair

Aortic arch grafts

“Only magic can cure tumors of the major arteries.” – Ebers Papyrus

4000 years later…

References

• Bobadilla JL. From Ebers to EVARs: A Historical Perspective on Aortic Surgery. Aorta. 2013;1:89-95.

• Cooley DA. Aortic aneurysm operations: past, present, and future. Ann Thorac Surg. 1999;67:1959-62.

• Thompson JE. Early history of aortic surgery. J Vasc Surg. 1998;28:746-52.