Collateral circulation

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A Moment in History

William S. Halsted, MD
(1852 – 1922)

American anatomist, teacher, and surgeon, William Stewart Halsted was born in New York City, USA to a wealthy family of English origin. His father was involved in charitable work and Governor and trustee to a city hospital. Not a brilliant student initially, Halsted took an undergraduate in Liberal Arts in Yale, CT., after which he entered the Medical College of Physicians at the Columbia College, where he excelled.

As a second-year medical student Halsted applied and obtained a position in surgery at a local hospital. In here he learned about Lister’s antiseptic technique and became an adamant proponent of it to reduce infection. In 1877 Halsted obtained his MD. After a short time as House Physician at the New York Hospital, Halsted traveled to Europe to further his education studying for two years at the Universities of Vienna, Leipzig, and W?rzburg.

Besides being at the forefront of surgical and antiseptic techniques (introducing the use of rubber gloves in surgery), Halsted was extremely concerned with the way medical students were taught in the US. He pioneered bedside clinical round discussions with the medical students after two years of basic sciences studies. Halsted developed the idea of a patient chart; he also developed the residency program for medical students in use today.

Halsted is probably the most influential researcher and surgeon at the turn of the century. He dedicated time to the study of intestinal anastomoses and the use of silk as a suture material. His experimental work in 1887 proved that the inclusion of the submucosa layer in an anastomosis was mandatory, as well that a single layered anastomosis was enough to attain closure. Perhaps Halsted’s most important contribution was the application and use of the scientific method to surgical questions. Halsted’s principles, also known as "Halsted's Rules of Surgery", set the standards used today in surgical suturing and surgical stapling.

He also pioneered the development and surgical techniques for radical mastectomy as a treatment for breast cancer.

As a side effect of this studied in anesthesia and the use of cocaine for anesthesia, Halsted became addicted to this substance, a problem that followed him through the years. Without impairing his capacity as a researcher and a surgeon, Halsted eventually recovered. He died in Baltimore in 1922 as a complication to surgery.

Sources:
1. Dubay, A. D., & Franz, G. M. (2003). Acute Wound Healing: The Biology of Acute Wound Failure. Surg Clin NA, 83, 463-481.
2. Halsted, W. S. (1887). Circular Suture of the Intestine - An Experimental Study. Am J Med Sci, 436-461.
3. “William Stewart Halsted: his life and contributions to surgery” Osborne, P. Lancet Oncol 2007; 8: 256–65
4. “William Stewart Halsted: Surgical pioneer” Burress, P Endoc Today (2010), 8: (2) 22
5. “William Stewart Halsted (1852–1922) Neurological stamp” Haas, LF J Neurol Neurosurg Psych 2000;69:641
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Details: Published: June 20, 2013

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The term "collateral circulation" is generally used to denote a situation where small blood channels dilate and provide blood supply when a pathology creates a stricture and diminishes blood flow (ischemia).

Although the above is correct, the term is also applicable to a normal, non-pathological situation most common in the human body. Please refer to the accompanying image for the following explanation. If needed, click on the image for a larger depiction. In the image, the arrows represent direction of flow.

Most organs or organ segments receive blood supply from more than one source of blood supply. In some cases, like the stomach, there are up to four arteries that provide blood supply to the organ: the right and left gastric arteries, and the right and left gastroepiploic arteries.

In other cases, like the small intestine shown in the image, blood arrives to the organ arising from several arteries (A, B, and C) that themselves arise from a parent structure. Because of hydrodynamics, the vascular territories of each artery (represented by dashed lines) tend not to overlap. If for any reason there is stenosis or blockage in any of these arteries (A,B, or C) blood will flow immediately through an alternate route and the organ will not suffer ischemia or necrosis.

This is extremely important, as these collateral channels maintain blood supply to areas that may be affected by bending, such as the elbow and knee, which have a rich collateral network. Most of the organs in the body, with some exceptions (brain, heart), have collateral circulation.

Collateral circulation is extremely important for surgery, as surgeons can safely remove parts of organs without affecting the blood supply to the organ. This is also true for all gastrointestinal anastomoses.

Image property of: CAA, Inc. Artist: Dr. Miranda

Collateral circulation

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