First Femoropopliteal Bypass for a Critical Limb Ischemia: The Saga of Joy and Sorrow : Indian Journal of Vascular and Endovascular Surgery

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First Femoropopliteal Bypass for a Critical Limb Ischemia

The Saga of Joy and Sorrow

Singh, Devender; Praveena, Madavan; Aryala, Shalini

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Indian Journal of Vascular and Endovascular Surgery 9(5):p 391-392, Oct–Dec 2022. | DOI: 10.4103/ijves.ijves_106_22
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First femoropopliteal bypass for a critical limb ischemia: The saga of joy and sorrow.

In spite of revolutionary development in the endovascular techniques for treating peripheral arterial diseases, femoropopliteal bypass using a vein graft still continues to be the dependable procedure for limb salvage. The first femoropopliteal bypass was performed by Jean Kunlin, on June 3, 1948, using saphenous vein in a 54-year-old man who was experiencing ischemic rest pain and gangrene of 3-month duration. The celebration of this successful landmark procedure almost resembles the script of a drama full of emotions with high and low moments.

Jean Kunlin (1904–1991) [Figure 1] was born in Schiltigheim, near Strasbourg. He studied medicine, interned, and worked in the experimental surgery laboratory at Mount Saint Martin's Hospital in Strasbourg under Rene Leriche.[1] Working with Leriche, he grew his interest in vascular surgery as one of the most loyal pupils of his teacher and worked with him till Leriche's death except between 1938 and 1942.[2] He was a very modest person and worshipped Leriche like a father and would not venture into a new technique without his approval. Kunlin had spent considerable time developing a technique to bypass long arterial occlusion with an autologous vein and had almost perfected it in his experimental laboratory. However, he could not convince his mentor, Leriche to use this in a suitable patient and continued to follow that surgical diseases are not an aberration of local anatomy, but a result of the alteration of normal physiology.

Figure 1:
Jean Kunlin

In 1948, a patient was admitted to the American hospital, under the care of Leriche, with ischemic rest pain and gangrene of 3-month duration, had undergone a first toe amputation, which did not heal. The skin further necrosed and then spread to the dorsum of the foot. The patient had undergone a lumbar sympathectomy and arterectomy of the thrombosed superficial femoral artery, which was the treatment of the day, as suggested by Leriche, Kunlin's mentor. The rationale for arterectomy was to stop the vasomotor response caused by the occluded arterial segment resulting in vasoconstriction of the collateral vessels, which further impaired the circulation.

An arteriography demonstrated the patient had a patent popliteal artery feeding a posterior tibial artery. Kunlin proposed a bypass around the occluded segment, but Leriche suggested continued medical treatment. At the end of May, Leriche left on a trip to Holland. During this time, the patient's condition continued to deteriorate, so he agreed to the proposed bypass rather than undergoing an amputation. On June 3rd, the first femoropopliteal bypass was done that involved an end-to-side anastomosis of the reversed saphenous vein to normal segments of arteries above and below the long occlusion [Figure 2]. Within 3 weeks of the bypass procedure, the patient's foot had healed. It was a joyful moment for the patient and the surgeon; however, he could not celebrate as the procedure was done against the wishes of his mentor. Interestingly, this patient underwent a contralateral bypass a few months later. He died a year later of a massive stroke.

Figure 2:
Sketch of the first bypass with a vein graft by Jean Kunlin

The relationship between Kunlin and his mentor Leriche started straining and was quite noticeable to all. There were lots of criticisms on Kunlin being his student and not following the recommended procedure of the day. However, he seemed to protect his mentor, which is evident in a number of supportive statements, almost apologizing for proceeding with the bypass seemingly against the wishes of his revered mentor. In the journal article describing this first case, Kunlin pays homage to Leriche, ascribing to him the first attempt at bypass in a patient with occlusive disease, but the procedure being abandoned due to no clear definition of the distal artery beyond the occlusion. In this same article, his last sentences are “It appears to be imprudent in the realm of our knowledge today to take the risk of undertaking the venous graft procedure because it is available. It is better to perform a sympathectomy.”

In a report of 17 vein bypass graft procedures, Kunlin described a number of the technical aspects of the surgery.[3] The saphenous vein was harvested and reversed. During the harvesting, Kunlin noted a reduction in the diameter of the vein because of spasm and treated this with an infusion of 1% Xylocaine. To allow for smooth passage of the suture material, it was coated with Vaseline, a technique introduced many years earlier by Carrel.

The anastomotic technique that was used to join the vein graft to the artery was revolutionary: rather than perform an end-to-end interposition technique, Kunlin performed an end-to-side anastomosis, reasoning that with this technique, he could preserve collateral branches near the thrombotic zone and the anastomosis could be performed in a healthier region of the artery [Figure 3]. To verify that his anastomosis was adequate, he infused saline through a needle and noted the ease of the infusion. In addition, he used a plastic or rubber probe passed through the anastomosis to verify no technical problems.

Figure 3:
Drawing of end-to-side anastomosis from Jean Kunlin

Leriche, however, seemed to be softening in his opinion about vein bypass surgery. In an abstract presented at a meeting of the Academy of Science in 1948, jointly authored by Leriche and Kunlin, there is a brief discussion of vein bypass grafts in eight patients. The final paragraph points out the encouraging results in these eight patients, suggesting that perhaps bypass grafts represented an improvement in care over sympathectomy.[4]

Kunlin continued to be a very modest person and never sought the honors or recognition, he would have been entitled to. While paying tribute to this great person at the Annual Meeting of the French Vascular Surgery Society in 1994, a former colleague of Kunlin, J. Testart stated:

In making his decision to perform bypass, Kunlin must have been torn between his scientific objectivity and his affection and loyalty to his mentor. Kunlin denies having forsaken his mentor's ideas and even claims to have been in complete agreement with Leriche, since his ultimate goal was to gain an understanding of pain and thus be better able to treat it.

Kunlin though never enjoyed his real success of the procedure, which now is the cornerstone for modern reconstructive vascular surgery; the vascular federation will always remember his contribution and remain grateful.

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Conflicts of interest

There are no conflicts of interest.


1. Testart J. Jean Kunlin (1904-1991) Ann Vasc Surg. 1995;9(Suppl):S1–6
2. Menzoian JO, Koshar AL, Rodrigues N. Alexis Carrel, Rene Leriche, Jean Kunlin, and the history of bypass surgery J Vasc Surg. 2011;54:571–4
3. Kunlin J. Long vein transplantation in treatment of ischemia caused by arteritis Rev Chir. 1951;70:206–35
4. Kunlin J. Possibilite de greffe veineuse de grande dimension dans les thromboses arterielles etendues C J Rend Seances Lalademie. 1948;227:939–40
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