Arteriovenous Fistula: The Backstory of the Birth of Cardiovascular Surgery.

The foundation for the celebrated operation on patent ductus arteriosus (PDA) in 1938 was the work on arteriovenous fistula (AVF) during the preceding half century. Galen and Osler wrote about it, and AVF was a major interest of leading surgeons of the late 19th and early 20th centuries, such as William Halsted, Rudolph Matas, Mont Reid, and Emile Holman. Nearly all AVFs of the era developed because of penetrating injury to major vessels. Survivors suffered gradual debilitation and faced death from gangrene or rupture. Development of an operation with a reasonable chance for success came only after the development of the cornerstones of modern surgery: suture, needles, anesthesia, and antiseptic and aseptic surgery. The only durable solution was quadruple ligation, ligation of both the vein and artery above and below the site of the fistula, and a technically demanding operation that risked ischemia and gangrene. Techniques pioneered by Alexis Carrel and Bernard Bertheim allowed strategies of early vascular reconstruction that reestablished normal circulation. Seeing patients with AVF with heart failure, Halsted recognized PDA as a naturally occurring AVF. Other surgeons proposed that ligation of PDA would be lifesaving. The struggles to understand and devise operative strategies to deal with AVF were the first steps toward the spectacular advances in cardiovascular surgery that followed.