Lower Extremity Bypass for Occlusive Disease: A Brief History.

OBJECTIVES: This is a narrative review that aims to highlight key advancements which led to the current state of lower extremity bypass surgery. It focuses on key contributors during the last century who have driven the standardization of surgical treatment of peripheral arterial occlusive disease.

METHODS: A narrative review was conducted utilizing available resources in the scientific and historical literature to track landmark achievements in the development of modern lower extremity bypass surgery for occlusive disease, focusing primarily on the last century of advancement.

RESULTS: Several critical conceptual, technological, and technical landmarks were identified as critical components of modern lower extremity bypass surgery. This includes fundamental development in the techniques of vascular anastomosis led by Carrel and others, a developing understanding of vascular occlusive disease as a localized and segmental process with broad implementation of the techniques of arteriography, and the development of safe thromboendarterectomy aided by the development and utilization of heparin for anti-coagulation. These factors led to the first femoral to popliteal artery bypass by Jean Kunlin in 1948. From here, advances in vascular prosthetic material pioneered by Voorhees and others, alternative vascular conduits, increasing acceptance of tibial revascularization, and dispelling the myth of diabetic "small vessel" disease broadened revascularization options for patients with complex patterns of occlusive disease and those who have limited conduit availability.

CONCLUSIONS: Modern lower extremity bypass surgery for occlusive disease arose steadily over the course of a century driven by complex problem-solving in the pathophysiological understanding of atherosclerosis, technical developments in vascular anastomosis and arteriography, and evolution in conduit materials and pharmacologic therapy. Future advancements in bypass surgery are targeted on solving the complex problems of anastomotic intimal hyperplasia, expanding technology for alternative vascular conduits, ongoing optimization of risk factors and scrutiny of outcomes to make patient-centered, evidence-based decisions regarding revascularization strategy.