To the Editor:
We read with interest the story from Dr. Medins1 about his volunteer medical work during the 1970s in Africa. He described his emergent removal of shrapnel from the bifurcation of a patient's pulmonary artery (PA) “via the old-fashioned Trendelenburg procedure…. The aorta was clamped, the pulmonary artery incised at its bifurcation, the shrapnel removed, and the pulmonary artery closed—all in 5 minutes. The patient survived.”1
This accomplishment by Dr. Medins—without benefit of hypothermia or a heart-lung machine—is laudable indeed. However, in the original account by Trendelenburg,2 he did not report clamping the aorta when removing thromboembolic clots from his patients with massive pulmonary embolism. Instead of cross-clamping the main PA, he looped a rubber tube behind the aorta and the main PA through the transverse sinus, compressing the pulmonary conus from behind to reveal the clots and optimize their removal.2 From what we could determine, neither the aorta nor the main PA was clamped during any old-fashioned Trendelenburg procedure (TP) reported from 1908 through 1957.2–6
The description by Dr. Medins might influence some to believe that the original TP was a valuable or practicable operation. In actuality, when the TP was used to treat pulmonary embolism, the outcomes were usually fatal.2–6 Trendelenburg's own patients did not survive the procedure.2,6 Thereafter, 20 more unsuccessful attempts were reported.6 In March 1924, Kirschner (Trendelenburg's pupil) reported the first successful outcome.7 During the next decade, only 3 more successes were documented, all in Europe.6 In 1934, Edward Churchill noted the dampened enthusiasm for the TP at his hospital after 10 consecutive failures.3 Through 1957, approximately 300 total procedures yielded a dozen survivors at most.4–6
Despite Trendelenburg's intent, the procedure was hazardous, technically difficult, and perhaps performed too late—the patients were often in advanced cardiogenic shock or dying states. The challenge was to balance their precarious clinical course with the timing of the operation.3 Churchill endorsed postponing the TP until the patient was nearing death but cautioned that unnecessary delay would decrease the chance of success: “At times … the procedure could perhaps be more properly termed an immediate postmortem examination than a surgical operation.”3 In this regard, the TP cannot compare with modern open surgical pulmonary embolectomy.
Giovanni Saeed, MD
Department of Cardiovascular Surgery
Rainer Gradaus, MD, PhD
Jörg Neuzner, MD, PhD
Department of Internal Medicine II and Cardiology, Klinikum Kassel GmbH, Kassel, Germany
Footnotes
Letters to the Editor should be no longer than 2 double-spaced typewritten pages and should generally contain no more than 6 references. They should be signed, with the expectation that the letters will be published if appropriate. The right to edit all correspondence in accordance with Journal style is reserved by the editors.
References
- 1.Medins G. The Trendelenburg procedure revisited. Tex Heart Inst J 2013;40(3):371. [PMC free article] [PubMed]
- 2.Trendelenburg F. Ueber die operative Behandlung der Embolie der Lungenarterie. Arch Klin Chir 1908;86(3):686–700.
- 3.Churchill ED. The mechanism of death in massive pulmonary embolism with comments on the Trendelenburg operation. Surg Gynecol Obstet 1934;59:513–7.
- 4.McFadden PM, Ochsner JL. Aggressive approach to pulmonary embolectomy for massive acute pulmonary embolism: a historical and contemporary perspective. Mayo Clin Proc 2010;85(9):782–4. [DOI] [PMC free article] [PubMed]
- 5.Sabiston DC Jr. Trendelenburg's classic work on the operative treatment of pulmonary embolism. Ann Thorac Surg 1983;35(5):570–4. [DOI] [PubMed]
- 6.Bottcher W, Kruger A. The history of surgery in pulmonary embolism [in German]. Z Herz- Thorax- Gefaßchir 2006;20(4):162–73.
- 7.Kirschner MB. Ein durch die Trendelenburgsche Operation geheilter Fall von Embolie der Art. pulmonalis [in German]. Arch Klin Chir 1924;133:312–59.