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Raphael M E Suy
195pp Price £50 ISBN 90-901-8493-7 (h/b)
Belgium: Fonteyn, Science et Médecine.
The story of aneurysms goes back a long way. There are traces of them (albeit rather uncertain) to be found in Egyptian tombs, and the ancient Greeks and Romans certainly recognized the lethal nature of a swelling that pulsated in time with the heart and how important it was to distinguish such bumps from abscesses which could be cured by simple incision. In ancient times aneurysms usually resulted from trauma, and would nowadays be called false aneurysms because they did not involve the entire arterial wall. Some were caused by war wounds but many followed clumsy venesection, when the brachial artery was punctured rather than the adjacent vein. From the fifteenth century onwards the picture changed because of the arrival from the New World of syphilis, which leads to weakening of the arterial wall. It took a long time for the connection between venereal disease and aneurysm to be admitted, largely because of the reluctance of clinicians to connect anatomical lesions, particularly in their more influential patients, with sexual behaviour.
From the very earliest days it was known that these lesions could not safely be left alone. Not only were they often very painful, but enlargement and eventual rupture always followed. Treatments included external compression through many ingenious devices, application of unguents and potions, and various eccentric diets. Surgery was kept as a last resort, because it was hardly ever successful. Ligation of the feeding vessels was the standard procedure, but all too often the aneurysm continued to enlarge through collateral channels, or else the arterial supply to a limb failed and gangrene followed. The different patterns of ligation suggested by, among others, John and William Hunter were well thought out but difficult to execute because a quick operation on a conscious patient made precision impossible. Even in the best hands mistakes were frequent, as when Robert Knox gloatingly described to his Edinburgh students how his rival the eminent surgeon Robert Liston had that very morning 'plunged his knife into what he foolishly imagined to be an abscess, and with blood gushing forth from the aneurismal sac, the patient was dead within a few seconds'. For many surgeons, primary amputation, as advised by Percival Pott, seemed the safest option.
With the arrival of general anaesthesia, surgeons could work in a deliberate and careful manner, observing and following the anatomy. Various attempts at reconstructive surgery culminated in the 1920s in the work of Rudolfo Matas, whose 'endoaneurysmorrhaphy', which involved sewing the aneurysmal sac from within, remained the standard procedure for many years. During the twentieth century, syphilis declined as the main pathology, to be replaced by degenerative arterial disease including atherosclerosis. Dramatic improvements in imaging techniques, from arteriography to CT and MRI, enabled the surgeon to plan the approach, and at the same time, metabolic care of the surgical patient made complex and prolonged interventions safer. The commonest and most lethal form of aneurysm was now that of the abdominal aorta. Reconstruction of this lesion, and of complex aneurysms involving the chest, became a safe routine procedure, and the results of emergency surgery for ruptured aneurysm steadily improved. Nonetheless, open repair remained a formidable operation for these patients who were usually elderly and had extensive comorbidity, and an alternative procedure was needed. Parodi's introduction in the late 1990s of endovascular repair (EVAR), by which a prosthesis is guided into the aorta via the femoral artery, producing a new narrow channel while the retained sac is allowed to collapse and thrombose around it, has transformed the management. Certainly EVAR is not the final answer, and problems and complications remain to be resolved, but Parodi's initiative points the way forward.
Raphael Suy, a distinguished vascular surgeon from the University of Leuven, has had a personal as well as a professional interest in the aneurysm story, and his beautifully produced and illustrated book relates it in elegant form. The scholarship is profound and this must remain the authoritative work of reference for the foreseeable future