|Year : 2022 | Volume
| Issue : 3 | Page : 248-250
Vein valves – From discovery to repair to bioprosthesis
MK Ayyappan1, Jithin Jagan Sebastian2
1 Professor, Department of Vascular and Endovascular Surgery, Sri Ramachandra Institute of Higher Education and Research, Junior Consultant, Chennai, Tamil Nadu, India
2 Department of Vascular and Endovascular Surgery, Kauvery Hospital, Chennai, Tamil Nadu, India
|Date of Submission||18-Jul-2022|
|Date of Acceptance||18-Jul-2022|
|Date of Web Publication||21-Aug-2022|
M K Ayyappan
Professor, Department of Vascular and Endovascular Surgery, Sri Ramachandra Institute of Higher Education and Research, Junior Consultant, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ayyappan M K, Sebastian JJ. Vein valves – From discovery to repair to bioprosthesis. Indian J Vasc Endovasc Surg 2022;9:248-50
“The effect of this arrangement plainly is to prevent all movement of the blood from the heart and vena cava, whether it be upwards towards the head, or downwards towards the feet, or to either side towards the arms, not a drop can pass…”
-Excerpt from De Motu Cordis, William Harvey on venous valves
Vein valves have always been central to venous pathophysiology. Dysfunction of these valves in varicose veins and deep venous reflux leads to symptomatology surrounding these conditions. Valves in the veins are as important as valves in the heart in allowing blood one-way, any changeup in this leads to problems very similar to one-way traffic leading to stasis. Valves are very delicate structures made up of cusps of endothelium and loose areolar collagen. Thrombus, increase in the size of the vein, and age can affect these valve cusps and make them redundant and dysfunctional. Throughout history, little importance has been given to these valves, leading to their late discovery toward the end of the 16th century. The discovery of valves and its function in circulation have led to the understanding of pathology behind varicose veins and post-phlebitic sequelae. The story of venous valve discovery is one of the students learning from their teachers, surpassing them to discovering anew and thus furthering the progress of science.
Fabricius ab Acquapendente [Figure 1] is credited with the discovery of venous valves back in 1579. The first complete description of these valves is seen in his book “DE VENARUM OSTIOLIS.” As a leading Italian anatomist, he described the structure, distribution, and position of these valves however was unable to determine its function in the human body. The review by Scultetus et al. on the facts and fiction surrounding the discovery of venous valves calls to question this discovery. The authors speak of several earlier mentions of venous valves before Fabricius work. According to them, it was Charles Estienne who first mentions venous valves in the hepatic veins in his book De Dissectione Partium Corporis Humani Libri Tres which was published in 1545. Although he describes in passing valves, he did not attach much importance to it. Another disputed discoverer of the venous valve is Giovanni Battista Canano, a student of the famed Portuguese physician Amatus Lusitanus. Canano used to demonstrate venous valves at the junction of the azygous vein with the superior vena cava at the auditorium in Ferrara, Italy, in the place of his teacher. This is corroborated in the book Curationem Medicinalium Centuria Prima by Amatus Lusitanus where he gives due credit to his student for having discovered the valves.
|Figure 1: A portrait of Hieronymus Fabricius ab Acquapendente at the Palazzo del Bo, Faculty of Medicine and Surgery, University of Padova (Photograph courtesy of the University of Padova)|
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Both Canano and Estienne, unfortunately, made the mistake of describing these valves in places like the hepatic veins and the azygous veins where their position is variable or sometimes absent. Both these discoveries fell into disrepute as anatomists could not reproduce their results in cadaveric dissections. This was clearly illustrated by Vesalius in Anatomicarium Gabrielis Falloppi Observationum Examen published in 1564 where he states that he could not find the valve at the ostia of the azygous and that Canano's discovery was probably thickening of the vein wall usually seen at these ostia. It was not until Fabricius demonstrated these valves in Padua, Italy, and published it in his book in 1603 that it was accepted by the scientific community of that time. Sitting in his audience listening to his speech was his student William Harvey who was visiting Padua to learn from this famed anatomist. The lecture inspired Harvey to go back to England and begin his research into venous valves trying to discern the true function of these structures.
Before William Harvey [Figure 2], the Galenic theory of blood circulation predominated. Galen postulated that blood was produced in the liver and circulated from the hepatic veins to the right heart and from there to the left heart through pores in the interventricular septum, and then from the heart chambers it was driven peripherally by the arteries due to the demand in the muscles. This theory was accepted for more than 1500 years before Harvey changed it to our present understanding of circulation. He was inspired by the work of Fabricius on the valves and demonstrated that the valves allowed only a one-way passage of blood. He attempted to pass a probe antegrade and retrograde and saw that it was possible in one direction as described in his famous 1628 publication, Exercitatio Anatomicae de Motu Cordis et Sanguinis in Animalibus (On the Movement of the Heart and Blood in Animals). The understanding of this unidirectional flow of blood in the arteries and veins led Harvey to define the circulation from the veins to the right heart, the lungs, and the left heart for distribution through the arteries. This called to question Galen's view and gradually overturned it making way for progress in the field. This led to the understanding that veins allow blood to flow in one direction and the pathologies associated with a refluxing vein.
|Figure 2: A portrait of Harvey, from Ribatti D. William Harvey and the discovery of the circulation of the blood|
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Since Harvey, the work on valves had turned to its distribution in the venous system and understanding several pathologies related to them. The distribution of these valves is highly variable and valves found by one anatomist may not be seen by another, leaving room for discrepancies and controversies in their distribution. Noted works by Von Haller, Piersol, Houze A, Bartholin, Morgagni, and Riolan,,, prominent anatomists of the 17th and 18th centuries after Harvey have described these valves in various venous circulations in the human body. The findings on the distribution of these valves have been collated in the article by Franklin.
Hieronymus Fabricius was the first to attribute varicose veins to a problem with the valves in 1603. The pathophysiology of valvular insufficiency in saphenous and deep veins was later followed contributed by noted physiologists such as Richard Lower (1670), Pierre Dionis (1707), and Jean Louis Petit (1774). Sir Benjamin Brodie in 1846 described the role of valvular insufficiency in producing saphenous reflux by the classical tests described today. He was the first to correlate between the size of the saphenous vein and venous valve incompetence. It was the seminal works by Tobold in 1889 and Trendelenburg in 1890 that the concept of saphenous reflux or perforator reflux due to valvular insufficiency as a cause of varicose veins was put forth.
Mid-19th century, surgeons took on the responsibility of repairing these valves. Varicose vein surgery of ablating the vein to prevent reflux had already been established, however, the role of primary valvular reflux of deep veins is still alluded many. Eiseman and Malette in 1953 are credited with the first technique of recreating these valves. Since then, several versions of a neo valve have been created by Wilson, Corcos, Plagnol, and Maleti. In 1968, Kistner pioneered the technique of internal valvuloplasty which was modified subsequently by Raju, Tripati, and Sotturai. Due to the problems with internal valvuloplasty, external sutures to tighten valves were proposed by Kistner in 1990. Robert Linton Kistner from the Straub Clinic in Honolulu, Hawaii was the driving force behind pioneering several surgeries of valve repair showcasing the feasibility of these repairs. External banding, autotransplantation, and vein transposition have been carried out in the last century in an attempt to improve the results associated with surgical valve repair.
The first attempt at implantable vein valves was made half a century ago in 1965 by Mclachlin and colleagues using allografts. These synthetic venous valves were followed by cryopreserved valves by Burkhart in 1997 and currently research into bioprosthesis, initiated by Michael C Dalsing in 1996. The review by Jan de Borst G et al analyses these experimental valve designs that have been contemplated in the past. Research into valve recreation is ongoing with several recent endovascular techniques and implantable valve bio-prosthesis being developed recently. In 2018, Garcia et al. highlights the innovative designs behind three such percutaneous venous valves in development. The first of its kind, the BlueLeaf system (InterVene Inc), is a non-implantable, autologous method of endovascular vein valve creation. Newer valve designs are currently being tested like the Sail valve, an implantable self-expanding polytetrafluoroethylene valve, and the Venovalve, a surgically implantable porcine-derived monocusp valve. We have come a long way and more than 400 years since the discovery of these valves, the quest is on to find the ideal vein valve substitute.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]