ةيومدلا ةيعولاا مولعل رصم...

President Atef Allam

Vice PresidentRashad Bishara

Secretary General Ayman Salem TreasurerTarek Radwan

MembersAdel El-Husseiny Ali MoradAshraf HidayetAyman Fakhryr Hesham Sharaf El-DinMagdy HaggagMahsoub MouradMohamed SharkawySaeed El-MallahTarek Abd El-Azim

The Vascular Society of Egypt Executive Board 2013-2015

Nozha International Hospital Heliopolis, Cairo, EgyptTel: 00202 22664248/9Fax: 00202 22660717E-mail: [email protected] site: vsegypt.org

جمعية مصر لعلوم االوعية الدمويةمشهرة برقم 5485

Egyptian Journal of Vascular & Endovascular Surgerywww.egjves.com

Editor-in-ChiefTarek Radwan

Co- EditorsAhmed Taha Atef Allam Ayman Salem Ehab Saad Khaled Abdel Aal Sherif Essam Honorary EditorsAbdel Kader Kotb Amir Nasef Mohamed Abdo Ay Eldin Mohamed Elbatanony Nabil El-Mehairy Reda Gohar International Editors

Editorial BoardAbdel Fattah IsmailAdel Husseini Ahmed EldorryAhmed Saad EldinAhmed SamiAlaa Sharaby Ali MoradAmr GadAli SabbourAshraf HidayetAyman FakhryEmad HusseinEssam Elkady

English Reviewer Austin Leahy (Dublin-Ireland)

Founding Editor Nabil El Marasy

Hanan HamedHasan Abdel AatyHasan BakrHasan SolimanHatem Abdel AzeimHesham Sharaf El-DinHussein Kamal EldinKhalid HindawyMaged EldeebMahsob MoradMahmoud Abo ZidMamdouh KotbYahia Sadek

Mohamed HosniMohamed R. WardaMohamed SharkawyMoneir MabroukNasser HamaadOmar Elfarouk Rafat NagaRashad BisharaSaied Elmallah Sayed ElzayateShereif Shoulkami Tarek Abdel Azeim Waleed Albaz

Saad AlgarniSaudi Arabia

M. HenryNancy-France

Sayed AliDublin-Ireland

Please address all correspondence to:

Hany HafezUK

Wayne YakesUSA

Karim El SakkaUK

Editor-in ChiefTarek Radwan

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From the New VSE PresidentAtef Allam MD

EditorialTarek Radwan FRCS

Arteriovenous Malformations: The Yakes Classification and Its Therapeutic ImplicationsWayne F. Yakes and Alexis M. Yakes

Leadership in Medical Teaching and LearningJavaid BUTT, FRCS (Ed)

Results of Operative Treatment for Leg Ulcers due to Superficial Venous DiseaseSulaiman S Shoab and Philip D Coleridge-Smith

Popliteal Access: A Safe Alternative to Recanalize Superficial Femoral Artery Total Occlusion After Antegrade Approach FailureR. Moia1, J. Clerissi1, et. al.

Management of Juxta and Supra- Renal Aortic Aneurysmwith Difficult AnatomySayed Aly PhD (UCL-London), FRCS

An Update on the Management of Carotid Body TumoursMcHugh SM and Sayed Aly

An Objective Classification for Peripheral Arterial Disease (Study in Progress)Sameh El Imam, A. Allam, et. al.

Abstracts Submitted for Trainees Competition Presented During the 9th

VSE–EVC Meeting May 2013

Vascular ImageMohamed Omar Elfarok M.Sc,

Egyptian Journal of Vascular & Endovascular SurgeryVolume 10 Number 1 March 2014

Contents

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47

63

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77

81

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Egy J Vasc Endovasc Surg Vol 10, No.1, March 2014

From the New VSE President

Dear Colleagues

Being the new president of the Vascular Society of Egypt is a true honor. Along with my colleagues, my goal will be increasing the representation of the society in all aspects of vascular surgery in Egypt.

I would like to heavily thank Prof Dr. Ali Morad, the former president for his outstanding work during a difficult time and I hope that I will be able to improve the society’s services along with the VSE board who I am honored to be a part of and cannot wait to work with on the new goals and objective of the society.

Atef Allam MD VSE President

7

Editorial

Dear Colleagues

A new issue in the 2014 volume is now between your hands as you used to but it is of our utmost pleasure to have this also online on the Eg. JVES website for which you will notice some changes as for the logo. From now on the electronic process for submission of your papers will be active and the next issue will be managed totally through it. We hope this will add to the benefit of the vascular surgeons in Egypt.

Since the Last issue we missed 3 persons the least to be mentioned that they were responsible for initiating the vascular services in their institutes and accordingly in Egypt, Prof dr. SamehHamaam, Major General Dr. Mohamed Sholkamy and Prof. Dr. Abobakr Al-Sedeik.

Tarek Radwan FRCS Editor in Chief

9


Arteriovenous Malformations: The Yakes Classification and Its Therapeutic Implications

Wayne F. Yakes MD, FSIR, FCIRSE * and Alexis M. Yakes

*Director, Vascular Malformation Center, Englewood, Colorado, USA

Introduction

Vascular malformations constitute one of the most challenging entities in the history of medicine to diagnose and treat effectively by whatever endovascular or surgical approaches are employed. These congenital vascular lesions can involve any tissue in the body. The rarity of vascular malformations in the population compounds the problem of treating them. If a physician rarely encounters patients with vascular malformations, it is difficult to gain enough experience to optimally treat them and effectively eradicate them. High-Flow Arteriovenous Malformations (AVMs) are extremely challenging to surgically extirpate or to endovascularly cure. The world’s literature certainly verifies the extreme challenges in the diagnosis and treatment of AVMs. The purpose of this chapter is to advance a new AVM Classification System that has proven therapeutic implications to effectively treat complex AVMs in any anatomical area. By employing the Yakes AVM Classification System, a physician is now able to accurately classify AVMs and determine specific endovascular treatment strategies to consistently treat AVMs, and patients can enjoy the long-term excellent outcomes. Defining the angioarchitecture

of the high-flow AVM determines accurately the endovascular management strategy to best permanently ablate the AVM requiring treatment. Further, employing this new Yakes AVM Classification will lower complication rates in treating these complex congenital vascular pathologies.

Overview

The Houdart Classification of Intracranial Arteriovenous Fistulae and Malformations of high-flow lesions and The Cho-Do Classification of AVMs of the peripheral arterial circulation are strikingly similar despite their anatomic locational differences (CNS vs. peripheral vasculatures).(1,2,3) Both authors also suggest similar therapeutic approaches based on their arteriographic classification. Houdart et al Classification states: Type A (Multiple arterial connections flow into a large aneurysmal vein with single out-flow drainage) and Type B (multiple microfistulae into an aneurysmal vein with single out-flow vein) and Type C (multiple shunts between many arterioles and venules connected to each other). The Cho, Do, et al. Classification based on “nidus morphology” states: Type I (arteriovenous larger fistulae with no more than three separate arteries shunt to the initial single venous outflow

Wayne F. Yakes and Alexis M. Yakes10


component), Type II (“arteriovenous smaller fistulae with multiple arterioles shunt to the initial part of a plexiform appearance” into a single venous component), Type IIIa (“arteriovenous fistulae with non-dilated fistulae with multiple fine shunts are present between arterioles and venules”), and Type IIIb (“arteriovenulous fistulae with dilated fistulae with multiple shunts are present between arterioles and venules”).

Houdart Type A is the same as the Cho-Do Type I, Houdart Type B is the same as the combination of the Cho-Do types IIIa and IIIb. Therapeutic implications are also similar as well. The Houdart Type a and Type b and Cho-Do Types I and II, proffer retrograde approaches to occlude the vein aneurysm outflow as being a potential for curative treatment of these AVM types. I proposed and illustrated the retrograde vein occlusion techniques for high-flow malformations first published and three cases illustrated in my manuscript published in 1990.(4) Later, Jackson et al published the retrograde vein approach in 1996.(5) The Do Group in Seoul, Korea (also the publishers of the Cho-Do AVM Classification) published the retrograde vein approach in 2008 after I demonstrated its efficacy to them in patients at their Seoul, Korea Samsung Medical Center.(6)

The Yakes AVM Classification System has some similarities to both classification systems, and some stark differences. The Yakes classification system is: Type I (is a direct arteriovenous fistula, a direct artery to vein connection (typified by Pulmonary AVF and renal AVF, for example). This angioarchitecture type is not described

in the Houdart or Cho-Do classification systems. Type II (AVM characterized by usually multiple in-flow arteries into a “nidus” pattern with direct artery-arteriolar to vein-venular structures that may, or may not, be aneurysmal). Type IIIa (multiple arteries-arterioles into an enlarged aneurysmal vein with an enlarged single out-flow vein). Type IIIb (multiple arteries-arterioles into an enlarged aneurysmal vein with multiple dilated out-flow veins). Type IV (microfistulous innumerable arteriolar structures to innumerable venular connections that diffusely infiltrate a tissue (typified by, ear AVMs that infiltrate the entire cartilage of the pinna). What is different in this lesion is that there are admixed among the innumerable fistulae capillary beds within the affected tissue. If the affected tissue only had AVFs, the tissue could not survive as capillary beds are required for tissue viability. No other AVM angioarchitecture has this duality.(7) This angioarchitecture is not described in the world’s literature. Comparing Houdart’s CNS Classification and the Cho-Do Peripheral Vascular Classification to the Yakes Classification has some parallels, as has been described, but has several distinct differences.

Houdart Type A and Cho-Do Type I are the same and compare to the Yakes Type IIIa. Houdart Type B and Cho-Do Type II are the same and again are placed in the Yakes Type IIIa. Whether the arteriovenous (Type A/Type I) or arteriolar-venular connections (Type B/Type II) are present are not important as the same arterial physiology is present that the “nidus” being present in the vein wall itself, regardless of the size of AVF on the vein

Arteriovenous Malformations 11


11

wall, as they are both treated endovascularly in the same way. Therefore, the AVF size is irrelevant. Further, even when larger AVF are present, microfistulae are also present as well admixed with the larger connections. It never is purely one microsize only or one macrosize only.

The Houdart Type C is the same as bundling Cho-Do Types IIIa (arteriovenous) and IIIb (arteriolar venular). This is similar to the Yakes Type II. Both authors do not explain in their classifications the Yakes Type IV. The angioarchitecture of arteriovenous and arteriolar-venular innumerable fistulae, totally infiltrating a particular tissue, is another vascular phenomenon that is present that is not explained by the Houdart nor the Cho-Do Classifications.

Being that arteriographically these innumerable microfistulae are proven to infiltrate a tissue, one has to also consider that despite the innumerable micro-fistulae, there is interspersed within these abnormal fistulae vascularity that is normal with capillary beds that is nutrient to the infiltrated tissue as well, or the tissue itself would be devitalized and forced to necrose. Normal capillaries must be present admixed with the innumerable AVF in the infiltrated tissue or it would not be viable and could not survive. Venous hypertension is usually the culprit in the injury that occurs in that infiltrated tissue, and this phenomenon as a vascular etiology for pathologic tissue changes was first eluci-dated by Jean Jacques Merland, M.D. and Marie Claire Riche M.D.(8) Thus, the “normal” vascularity with capillary beds in the infiltrated tissue to allow it to exist

is not discussed in the Houdart or in the Cho-Do Types Classifications nor is the angioarchitecture characteristics described.

The Yakes Type I Classification is a direct AV macro-connection that is characteristic of pulmonary AVF and renal AVF, but can also occur in other tissues. This direct AV connection is not described in the Houdart Classification or in the Shin-Do Classification. The Yakes Type I AV connection can also be present and interspersed in complex AVMs as well (Figure 1).

The Yakes Type II Classification possesses an angioarchitecture synonymous with the classical “nidus” pattern commonly seen in AVMs with multiple in-flow arteries of varying sizes coursing towards a “nidus” (a complex tangle of vascular structures without any intervening capillaries and exiting from this “nidus” into multiple veins from this “nidus”). The Houdart Type C and the Cho-Do Type IIIa/Type IIIb most resemble this angioarchitecture pattern. Thus, the Yakes Type II and Yakes Type IV further define the Houdart Type C and Cho-Do Type IIIa/IIIb patterns (Figure 2), much more specifically.

As an aside, the term “nidus” is rampant in the medical literature (AVM nidus, nidus of infection, etc.). Unfortunately, the initial author was only partially familiar with the Latin language. “Nidus” means “nest” in Latin, and indeed it does. However, “nidus” with the ending “us” denotes male gender. In the Latin language the true term meaning “nest” is, in fact, “nidum”. The ending “um” denotes the neuter gender which a “nest”



truly is. Thus, the original author accurately describing “nest-like” conglomeration of vascular structure was woefully inaccurate penning the words as “nidus” (masculine) instead of the true word “nidum” (neuter). Being rife in the literature for decades, I do not foresee any correction of this term.

In summary, Yakes Type I is the simplest macro direct AV connection. Yakes Type II is the common “nidum” (nest-like) AV connection. Yakes Type IIIa has multiple AV connections (arterial and arteriolar into an aneurysmal vein: “nidum” is in the vein wall) with single outflow vein physiology (Figure 3). Yakes Type IIIb has multiple arterial in-flow connections (arterial and arteriolar) into an aneurysmal vein (“nidum” is in the vein wall) with multiple out-flow veins that is more difficult to treat by retrograde vein approaches (Figure 4). Yakes Type IV angioarchitecture has innumerable micro-AV connections (with lowered vascular resistance) infiltrating an entire tissue but with concurrent normal vascular structures possessing nutrient capillary beds (with normal vascular resistance) to supply and drain the tissue that is diffusely infiltrated to allow this tissue to survive and not be devitalized. The post-capillary veins compete with AVF out-flow veins that are arterialized (hypertensive) (Figure 5), and cause the resultant non-healing pathology. This entity has not been described in the world’s literature.

Therapeutic Implications of the Yakes Classification

Determining a classification system based

on the AVM angioarchitecture is of little use without a practical application. For example, the Spetzler-Martin Brain AVM Classification is of importance to determine the surgical morbidity for treating Brain AVMs.(9) The higher the Spetzler-Martin grade, the higher the morbidity. This allows the neurosurgeon to inform his patient accurately of the risks for treatment. The Schobinger AVM Classification for peripheral AVMs (non-neuro) is useful to quantify the degrees of symptomatology a patient possess regardless of the AVM’s angioarchitecture. The Yakes Classification is utilized to determine endovascular approaches and embolic agents that will be successful to ablate these peripheral AVMs.

Embolic Agents Employed In The Yakes AVM Classification

Yakes Type I direct AV connections, as typically seen in pulmonary AVF and renal AVF, can be permanently ablated by occluding mechanical devices. Coils, Amplatzer plugs, Occluders, detachable balloons, and the like are universally successful to cure Yakes Type I AVMs.

Yakes Type II AVMs with the “nidum” nest-like angioarchitecture can be permanently ablated with absolute ethanol from a superselective transcatheter / transmicrocatheter arterial approach. Also, a direct puncture into the artery(ies) supplying the AVM immediately proximal to the AVM “nidum”, and distal to any parenchymal arterial branches, to then inject ethanol superselectively can be employed to circumvent catheterization obstacles



when a transcatheter / transmicrocatheter positioning to achieve the same position to deliver ethanol into the “nidum” is not possible. These two transarterial approaches allow ethanol to sclerose and permanently ablate the “nidum”. The “nidum” itself can be direct-punctured and ethanol (undiluted) can be injected to sclerose the “nidum” directly to effect cure in its multiple compartments as well.

Yakes Type IIIa AVMs (multiple in-flow arteries into an aneurysmal vein with single enlarged vein outflow) and Yakes Type IIIb AVMs (multiple in-flow arteries into an aneurysmal vein with multiple enlarged out-flow veins) can be curatively treated by several endovascular approaches. The “nidum” in this type of angioarchitecture with an aneurysmal vein is in the vein wall itself. Superselective transarterial ethanol embolization distal to all parenchymal branches via transcatheter/transmicrocatheter and direct puncture endovascular approaches can be curative.

An additional curative endovascular approach for Type IIIa AVMs is to coil embolize the aneurysmal vein itself with, or without, concurrent ethanol injection into the coils within the aneurysmal vein. This is also curative when the aneurysmal vein is totally and densely packed with coils. The aneurysmal vein can be endovascularly approached by direct 18g needle puncture and by retrograde vein catheterization to achieve the same position within the aneurysmal vein to pack it with coils. The retrograde vein approach to curatively treat high-flow vascular lesions was first published

and illustrated in 1990 by Yakes et al. The second article articulating the vein approach to AVM treatment was subsequently published in 1996 by Jackson et al. Cures were documented in these published patient series. Yakes et al described cures of post-traumatic and congenital high-flow lesions and Jackson et al described cures of congenital AVMs by way of the retrograde vein approach in these publications.(4,5)

In the Yakes Type IIIb (aneurysmal vein with enlarged multiple out-flow veins) can be cured by transarterial transcatheter ethanol embolization, and can be cured by direct puncture and retrograde vein coiling techniques. However, the aneurysmal vein portion and the immediate adjacent segments of each out-flow vein must also be packed with coils completely to achieve cure. Yakes Type IIIb AVMs are more challenging to cure than the Yakes Type IIIa AVMs due to the more complex vein out-flow morphology.

Yakes Type IV AVMs presented a unique challenge to determine curative endovascular treatment. AVMs, by definition, are direct AV connections without an intervening capillary bed (Yakes Types I-IV). Thus, superselective catheter and direct puncture needle positioning distal to ALL branches supplying parenchyma and immediately proximal to the AVM itself will obviate tissue necrosis being that the capillary beds are not embolized and only the abnormal AV connections are sclerosed.

However, Yakes Type IV AVMs infiltrate an entire tissue, thus termed by the authors as an “infiltrative” form of AVM. Being that



Figure 1b. Post-embolization selective Left Pulmonary Artery angiogram after placement of 22 fibered coils of .038 & .035 sizes in the AVF totally occluding the massive AVF.

Figure 1c. Main Left Pulmonary Artery angiogram demonstrating closure of the massive AVF post-coil placement. Mechanical closure devices will permanently close and treat this Yakes Type I AVM (AVF).

Figure 1. Yakes Type I AVM (AVF) typified by a single inflow artery connected to a single outflow vein.

Figure 1a.

Ventilator Dependent 30 Year-Old Female with HHT and Massive Left Pulmonary AVM • Causing O2 Sats of 35% on 100% Oxygen Through the Ventilator; Patient Sent By Air Ambulance Emergently For Treatment.Left Pulmonary Artery angiogram demonstrating a massive AVF shunt with single • aneurysmal vein drainage. This single arterio-venous connection is Yakes Type I AVM (AVF).



Figure 2. 24 year old female with painful right facial AVM also causing right facial swelling.

Figure 2a. Example of Yakes Type II AVM with • typical AVM “nidus”. This type AVM can be treated by trans-arterial embolization (easiest approach usually), and direct puncture into the nidus (more difficult). Retrograde vein approaches are usually not successful.Lateral Right Internal Maxillary Artery • arteriogram demonstrating arterial supply from a terminal Internal Maxillary artery branch arising from the Pterygo-Palatine fossa area. Note the typical AVM “nidus” pattern.

Figure 2b. Lateral selective Right Internal Maxillary Artery branch arteriogram pre-embolization. A micro-catheter is required to obtain superselective arterial positioning for ethanol embolization of the AVM. This is required to ONLY embolize the AVM and spare all the normal tissues and capillary beds from ethanol arterial embolization. If not done this way, there will be total tissue devitalization and necrosis that will occur with inadvertant embolization of ethanol of the normal tissues.

Figure 2c. Lateral Right Internal Maxillary Artery arteriogram immediately post-embolization demonstrating total occlusion of the right face AVM with all normal branches remaining intact.

Figure 2d. Lateral Right External Carotid Artery arteriogram at 2 year follow-up. No residual AVM is identified. Note that the normal arterial vascularity remains intact.



Figure 3. Example of Yakes Type IIIa AVM angioarchitecture with multiple in-flow arteries/arterioles and single out-flow vein physiology. The vein wall is the “nidus” in this AVM type. Multiple Right Internal Iliac Artery branches supply this right pelvic AVM.

Figure 3a. 32 year old male with right pelvic AVM with single outflow vein drainage towards Right Internal Ilaic Vein. Arterial supply is from multiple Right Internal Iliac Artery branches. Because of the diffuse innumerable small arteries suppling the AVM vein aneurysm wall, transarterial ethanol embolization is not possible. Normal structures could potentially be embolized and resultant nerve damage, pelvic organ damage, tissue necrosis, etc., could result.

Figure 3b. AP selective Right Internal Iliac Artery arteriogram demonstrating innumerable small arterial connections to the single out-flow aneurysmal vein. Superselective catheter positioning for transarterial embolization is not possible. A retrograde venous approach must be employed to treat this Yakes Type IIIa AVM.

Figure 3c. AP pelvis spot film demonstrating arterial catheter in Right Internal Iliac artery, and the retrograde vein catheter placed centrally within the AVM vein aneurysm with the resultant deposition of multiple coils in the vein aneurysm to treat this Yakes Type IIIa AVM.



Figure 3e. AP pelvis follow-up arteriogram 7 years post-retrograde vein coil embolization demonstrating long-term cure of the right pelvic AVM. Again, this technique is curative in Type IIIa and Type IIIb AVMs.

Figure 3d. AP pelvis arteriogram immediately post-coil embolization demonstrating total occlusion of the right pelvic AVM. No residual arteriovenous shunting is present. All normal arteries remain intact post-coil embolization without complication.

the “infiltrated” tissue (e.g., auricular AVMs) is viable proves that capillary beds are undoubtedly interspersed along with the innumerable microfistulae throughout the involved tissue as well. Injection of ethanol by transcatheter / transmicrocatheter and direct puncture approaches will sclerose the innumerable micro-fistulae, but also would flood the capillary beds with ethanol devitalizing that infiltrated tissue. Necrosis of that tissue would then ensue with occlusion of the capillary beds. Thus, Yakes Type IV AVMs were a conundrum to treat with endovascular approaches. Polymerizing agents would also occlude AVFs, but also capillary beds as well causing a massive necrosis. Thinking through this conundrum, one could rightly conclude that the only option is total surgical resection of that entire

tissue as the only treatment option. After further reflection, an endovascular option for curative treatment, not palliative treatment, was considered a possibility. Capillary beds have normal peripheral resistance which is a somewhat restrictive vascular flow pattern from artery to capillary to veins. AVMs/AVF have abnormally lowered peripheral vascular resistance with rapid stunting into arterialized veins. The arterialized AVM out-flow veins are hypertensive. The post-capillary out-flow normotensive veins then compete with the higher pressure AVMs outflow veins for out-flow. This then further restricts normal vein out-flow, which in turn increases the systemic vascular resistance (SVR) of the normal arterioles immediately proximal to the capillary beds, further restricting arteriolar in-flow to the capillary



Figure 4. Example of Yakes Type IIIb AVM typified by multiple inflow arteries/arterioles shunting into the aneurysmal vein with multiple out-flow veins. The “nidus” is the vein wall with the innumerable AV connections.

Figure 4a. Left soft tissue and intraosseous left Femur AVM. Multiple arterial inflow branches from the Left Profunda Femoris Artery into the AVM. The arterial/arteriolar inflow has many parenchymal branches and also provides vascular supply to the AVM.

Figure 4c. Left Common Femoral arteriogram at over one year follow-up demonstrating cure of the soft tissue and intraosseous AVM components. Note the multiple coil placements required to treat the multiple out-flow vein compartments that are present in Yakes IIIb AVMs.

Figure 4b. Venous phase of the Left Profunda Femoris arteriogram demonstrating the vein aneurysms and multiple out-flow vein physiology. To treat this Yakes Type IIIb AVM, multiple veins must be occluded to completely treat this AVM. Transarterial embolization is difficult to perform in that tissue necrosis could occur due to the many parenchymal arterial branches also arising from these multiple AVM feeding branches.



Figure 5. Example of Yakes Type IV AVM typified by total infiltration of a tissue with innumerable micro-fistulas and innumerable outflow-veins. Capillaries are admixed with the innumerable fistulas throughout the tissue involved with this “infiltrative” form of AVM.

Figure 5a. 19 year old male with progressively enlarging left ear over the last 5 years. Now has developed intermittent ulcerations, infections, and hemorrhages (Shobinger III stage).

Figure 5b. T-2 weighted axial MR demonstrating an enlarged left ear with flow-voids totally infiltrating the entire ear and cartilages. The enlargement of the abnormal ear tissues is apparent.

Figure 5c. TAP External Carotid arteriogram demonstrating diffuse vascular infiltration of the left ear with innumerable micro-fistulae shunting into abnormal arterialized veins. The arteriogram mirrors the findings noted on the MR with ear enlargement and total micro-fistulous AVM infiltration and AV shunting evidenced by the MR flow-voids.



Figure 5d. AP Left External Carotid arteriogram at 4 year follow-up demonstrating persistent cure of the left ear AVM. Note the normal vascularity that is now present and the total absence of any residual AV shunting post-endovascular ethanol sclerotherapy.

Figure 5e. Axial MR T-2 weighted at 3 year follow-up demonstrating shrinkage of the left ear and normalization of the vascularity with total absence of the innumerable flow-voids previously present on the pre-treatment MR.

Figure 5f. 4 year clinical follow-up of the left ear. A successful plastic surgery procedure was performed on the superior aspect of the left ear after the ear AVM was totally ablated and cured. The ear now has a more normal contour. Note the normalization of the skin color, no residual ruborous venous hypertensive skin changes are present.



beds. The increased SVR into the capillaries coupled with abnormally low resistance shunting into the admixed innumerable AVF allows preferential flow into the AVFs. Mixing non-ionic contrast with absolute ethanol changes the viscosity and specific gravity of ethanol in this mixture.

Being “thickened” and diluted, this allows for preferential flow to the AVFs and further restricts flow into the capillaries. Despite being 50% diluted with contrast, the ethanol can still effectively sclerose the innumerable micro-fistulae, due to the small luminal di-ameters. This combination of preferential flow into the innumerable AVFs, the increased SVR into the capillaries restricting flow, and the increased viscosity and changing the specific gravity of the contrast and ethanol 50% mixture, all works to spare the capillaries and sclerose the innumerable AVFs. Using pure ethanol would not have this capillary sparing effect, and the AVFs and capillaries would both be sclerosed and occluded. This does cure the AVFs, but devitalizes the tissue itself with occlusion of the capillaries. Use of various polymerizing embolic occlusive agents (nBCA; Onyx) would also cause the same devitalization of the tissues with occlusion of the capillaries. Particulate embolic agents (PVA, Contour Embolic, Embospheres, Etc.) cannot permanently occlude the AVFs, and will make the capillaries ischemic with the proximal occlusion in the in-flow arterioles, but will not devitalize the tissues.

Summary

Yakes Type I: Can be permanently occluded,

with mechanical devices such as coils, fibered coils, Amplatzer Plugs, and other occluding devices. Yakes Type II: Can be permanently occluded with undiluted absolute ethanol. At times slowing the arterial in-flow in the “nidum” with occlusion balloons, tourniquets, blood pressure cuffs, does allow for less ethanol to be used to treat the AVM compartments. Direct puncture techniques into the in-flow artery or AVM “nidum” allow ethanol to embolize the AVM as well.Yakes Type IIIa: Can be permanently occluded with transarterial embolizations with ethanol of the “nidum” the same way as in the Yakes Type II AVM. They can also be permanently occluded by dense coil packing of the vein aneurysm with or without ethanol embolization. This can be accomplished via direct puncture of the vein aneurysm, or by retrograde vein catheterization of the vein aneurysm. Yakes Type IIIb: Can be permanently occluded via transarterial approach as in Yakes Type II AVMs. They can be permanently occluded by treating the vein aneurysm and the multiple aneu-rismal out-flow veins by coil embolization.

Yakes Type IV: Can be permanently occluded via transarterial superselective 50% mixture of non-ionic contrast and ethanol that treats the micro-AVFs and spares the higher resistance capillaries. Direct puncture with 23gauge needles into the micro fistulous AV connections with 50% ethanol injections is also curative.

References

1.Houdart E, Gobin YP, Casasco A, Aymard A, Herbreteau, D, Merland JJ. A Proposed



Angiographic Classification of Intracranial Arteriovenous Fistulae and Malformations. Neuroradiology 1993; 35:381-385.2.Cho SK, Do YS, Shin SW, Kim DI, Kim YW, Park KB, et al. Arteriovenous Malforma-tions of the Body and Extremities: Analysis of Therapeutic Outcomes and Approaches According to a Modified Angiographic Classification. J Endovasc Ther 2006; 13:527-538.3.Park KB, Do YS, Kim DI, Kim YK, Shin BS, Park HS, et al. Predictive Factors for Re-sponse of Peripheral Arteriovenous Malformations to Embolization Therapy: Analysis of Clinical Data and Imaging Findings. J Vasc Interv Radiol 2012; 23:1478-1486.4.Yakes WF, Luethke JM, Merland JJ, Rak KM, Slater DD, Hollis HW, Parker SH, Casasco A, Aymard A, Hodes J, Hopper KD, Stavros AT, Carter TE. Ethanol Embolization of Arteriovenous Fistulas: A Primary Mode of Therapy. J Vasc Interv Radiol 1990; 1:89-96.5.Jackson JE, Mansfield AO, Allison DJ. Treatment of High-Flow Vascular Malformations by Venous Embolization Aided by Flow Occlusion Techniques. Cardiovasc Intervent Radiol 1996; 19:323-328.6.Cho SK, Do YS, Kim DI, Kim YK, Shin SW, Park KB, Ko JS, Lee AR, Choo SW, Choo IW. Peripheral Arteriovenous Malformations with a Dominant Outflow Vein: Results of Ethanol Embolization. Korean J Radiol 2008; 9:258-267.7.Yakes WF, Yakes AM. The Yakes Classification of Arteriovenous Malformations. The 40th Annual Veith Symposium Presentation, November 19, 2013.8.Merland JJ, Riche MC, Chiras J.

IntraspinalExtramedullary Arteriovenous Fistula Draining Into Medullary Veins. J Neuroradiol 1980; 7: 271-320.9.Spetzler RF, Martin NA. A Proposed Grading System for Arteriovenous Malformations. J Neurosurg 1986; 65: 476-483. 10.Enjolras O, Wassef M, Chapot R. Introduction ISSVA Classification: Color Atlas of Vascular Tumors and Vascular Malformations. 1st Edition. New York: Cambridge Uni-versity Press; 2007, 1-12. 11.Legiehu GM, Heran MKS. Classification, Diagnosis and Interventional Radiologic Man-agement of Vascular Malformations. Orthop Clin N Am 2006; 37:435-474. 12.Puig S, Aref H, Chigot V, Bonin AB, Bruenelle F. Classifications of Venous Malforma-tions in Children and Implications for Sclerotherapy.13.Lee BB, Laredo J, Lee TS, Huh S, Neville R. Terminology and Classification of Conge-nital Vascular Malformations. Phlebology 2007; 22:249-252.14.Do YS, Yakes WF, Shin SW, Lee BB, Kim DI, Liu WC, Shin BS, Kim DK, Choo SW, Choo IW. Ethanol Embolization of Arteriovenous Malformations: Interim Results. Radi-ology 2005; 235-674-682.15.Yakes WFJ. Endovascular Management of High Flow Arteriovenous Malformations. Chinese J Stomatol 2008;43: 327-332.16.Yakes WF, Pevsner P, Reed M. Serial Embolizations of an Extremity Arteriovenous Malformation with Alcohol via Direct Percutaneous Puncture. Am J Roentgenol 1986: 146:1038-1040. 17.Vinson AM, Rohrer DB, Wilcox CW, et al. Absolute Ethanol Embolization for Peripheral Arteriovenous Malformation: Report of 2 cures. South Med J 1988; 81:1052-1055.



18.Yakes WF, Haas DK, Parker SH, Gibson MD, et al. Symptomatic Vascular Malforma-tions: Ethanol and Embolotherapy. Radiology 1989; 170:1059-1066.19.Yakes WF, Parker SH, Gibson MD, et al. Alcohol Embolotherapy of Vascular Malforma-tions. Semin Intervent Radiol 1989; 6:146-161. 20.Mourao GS, Hodes JE, Gobin YP, Casasco A, Aymard A, Merland JJ. Curative Treatment of Scalp Arteriovenous Fistulas by Direct Puncture and Embolization with Absolute Alcohol. J Neurosurg 1991: 1991; 75:634-637.

21.Vogelzang RL, Yakes WF. Vascular Malformations: Effective Treatment with Absolute Ethanol. In Arterial Surgery: Management of Challenging Problems; Pearce WH, Yao JST, Editors. Appleton and Lange Publishers 1997: pages 553-550.22.Yakes WF, Rossi P, Odink H. Arteriovenous Malformation Management: How I Do It. Cardiovasc Intervent Radool 1996; 19:65-71.23.Doppman JL, Pevsner P. Embolization of Arteriovenous Malformations by Direct Percu-taneous Puncture. Am J Roentgen 1983; 140:773-778.

25


Leadership in Medical Teaching and Learning

Javaid BUTT, FRCS (Ed), FRCS (Glasgow), Dip Urol (london), MET(Milan)

Consultant General Surgeon, Our Lady’s Hospital, Navan.Co.Meath. IrelandPost-Graduate Faculty Member RCSI.Dublin.

key challenges in effective teaching and learning in health professions

education.

Health professions educational style has been traditionally based upon apprenticeship model for a longperiod. That methodology was trainer- focused all the way up to the competency level of its Student. Medical teachers had the responsibility of developing cognitive, affective and psychomotor domains of their students throughout their career progression.In current times, this instructional philosophy is challenged on all fronts as the health services are changing speedily everywhere with emergence of new discoveries and development of new technologies.

Keeping pace with this paradigm shift demands innovative ways of acquiring knowledge, with a premise of transferring activity focus from teacher to learner. The Commission on the Education of Health Professionals for the 21st Century—a global,Independent initiative—consisting of 20 leaders from diverse disciplinary backgrounds, institutional affiliations, and regions of the world, working together articulated a fresh vision and recommended

renewed actions. Building on a rich legacy of educational reforms, their findings and recommendations adopted a global and multi-professional perspective using a systems approach to analyse education and health, with a focus on institutional and instructional reforms.(1)

Learning styles

This is a term which describes an individual’s natural or habitual pattern of acquiring andprocessing information in learning situations. The core concept is that individuals differ in how they learn. The idea of individualized “learning styles” originated in the 1970s, and acquired “enormous popularity”. Proponents for the use of learning styles in education said that teachers should assess the learning styles of their students and adapt their classroom methods to best fit each student’s learning style.(2)

There is a variety of models used for learning.Some of the of popular ones are as follows;David Kolb’s model; This style is based on the Experiential Learning Theory (ELT), as explained: Experience as the source of learning and development (1984),The ELT model outlines two related approaches

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toward grasping experience: Concrete Experience and Abstract Conceptualization, as well as two related approaches toward transforming experience: Reflective Observation and Active experimentation. According to Kolb’s model, the ideal learning process engages all four of these modes in response to situational demands. In order for learning to be effective, all four of these approaches must be incorporated. As individuals attempt to use all four approaches, however, theytend to develop strengths in one experience-grasping approach and one experience-transforming approach. The resulting learning styles are combinations of the individual’s preferred approaches.(3)

These learning styles are as follows:1.Converger;2.Diverger;3.Assimilator;4.Accommodator;

Neil Fleming’s VAK/VARK model(4)

One of the most common and widely-used categorizations of the various types of learning styles is Fleming’s VARK model (sometimes VAK) which characterize individuals as1. visual learners.2. auditory learners.3. kinaesthetic learners.Fleming claimed that visual learners have a preference for seeing (think in pictures; visual aids such as overhead slides, diagrams, hand-outs, etc.). Auditory learners best learn through listening (lectures, discussions, tapes, etc.).Tactile/kinaesthetic learners prefer to learn

via experience— moving, touching, and doing (active exploration of the world; science projects; experiments, etc.).Its use in pedagogy allows teachers to prepare classes that address each of these areas. Students can also use the model to identify their preferred learning style and maximize their educational experience by focusing on what benefits them the most.

Briggs and Myers recognized that each of the cognitive functions can operate in the external world of behaviour, action, people, and things (extraverted attitude) or the internal world of ideas and reflection (introverted attitude). The MBTI assessment sorts for an overall preference for one or the other.(3) Myers-Briggs Type Indicator, is a psychometric instrument used to sort people into one of 16 personality types.(5)

Belbin Team Roles;We all have unique capacity to work as a member of team in different roles. These roles are used to identify people’s behavioural strengths and weaknesses in the workplace. Belbin Team roles(6) can be either one or combinations of following roles.1. Plant2. Resource investigator3. Co-ordinator4. Shaper5. Monitor Evaluator6. Team worker7. Implementer8. Completer Finisher9. Specialist

This information is useful in building multidisciplinary teams to manage complex

Leadership in Medical Teaching and Learning 27


medical scenarios. This helps to build productive working relationships among diverse group of specialities resulting in selection and development of high-performing teams. Every member of this critical team has a high degree of self-awareness and personal effectiveness towards individual contribution for the benefit of its patients.By working in team roles, we build mutual trust and understanding of each other. Outcome of this activity selects out people by their appropriate talents for the specific positions.

Leadership

Leadership is needed to bring and manage the change in education of health professionals.(7) For those charged with the responsibility of developing leaders, the three necessary steps are to select the right candidates(team selection), create learning challenges (Problem based learning, small group tutorials), and provide mentoring (Outcome measurement). Leadership associated with excellent teaching is multi-faceted especially within the context of research- intensive environment (Graham Gibbs et al.2009) .Nine clusters of leadership activity associated with the support of excellence in teaching were identified, with a number of variants of each:•Establishing credibility and trust.•Identifying teaching problems and turning them into opportunities.•Articulating a convincing rationale for change.•Devolving leadership.•Building a community of practice.•Recognising and rewarding excellent teaching and teaching development.

•Marketing the department as a teaching success.•Supporting change and innovation.•Involving students.

Those who seek to develop effective leadership training programs must first establish a metric for assessing leadership effectiveness. They must then design experiments that can establish a causal or statistically significant relationship between training initiatives and leadership competency. Evidence suggests that the most effective leadership programs will focus on building self-knowledge and skills in rhetoric and critical thinking.(2) Medical field’s developments has brought a real challenge to think of new strategies to train our future generation of medical professionals. This challenge can only be met by team-roles style working rather than conventional model of teaching. Many people recognize that each person prefers different learning styles and techniques. Everyonehas a mix of learning styles. The Seven Learning Styles commonly fits to most people;•Visual (spatial): prefer using pictures, images, and spatial understanding.•Aural (auditory-musical): prefer using sound and music.•Verbal (linguistic): prefer using words, both in speech and writing.•Physical (kinesthetic): prefer using gestures of body, hands and sense of touch.•Logical (mathematical): prefer using logic, reasoning and systems.•Social (interpersonal): prefer to learn in groups or with other people.•Solitary (intrapersonal): prefer to work alone and use self-study.

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Blended learning is a thoughtful fusion of face-to-face and online learning experiences. The basic principle is that face-to-face oral communication and written communication are optimally integrated in such a way that the strengths of each are blended into a unique learning experience. This technique is applied in teaching of junior medical students, therefore subjects as anatomy, physiology and pharmacology can be taught to each student with this blending technique.(8) Enabling blends focus on access and convenience, Enhancing blends supplement teaching and Transforming blends transform teaching and challenge learners to “actively construct knowledge through dynamic interactions.

Problem/Project Based Learning (PBL)

“A learning method based on the principle of using problems as a starting point for the acquisition and integration of new knowledge.(H.S. Barrows 1982) In Project Based Learning (PBL), students go through an extended process of inquiry in response to a complex question, problem, or challenge. While allowing for some degree of student “voice and choice,” rigorous projects are carefully planned, managed, and assessed to help students learn key academic content, practice 21st Century Skills (such as collaboration, communication & critical thinking), and create high-quality, authentic products & presentations. Students gain a deeper understanding of the concepts and standards at the heart of a project. Projects also build vital workplace skills and lifelong habits of learning. Projects can allow students to address community issues, explore careers, interact with adult

mentors, use technology, and present their work to audiences beyond the classroom.(9) Problem-based learning has been described as the most innovative form of teaching for the professions (Boud 1997) (10) Enquiry and problem-based learning approaches are total approaches to learning where students are presented with a problem, challenge or trigger at the start of a learning process. Students work in small group tutorials on the problem and are facilitated by a tutor. Students acquire knowledge of their discipline / profession by working on real-life problems in teams. This develops the students’ key skills e.g. critical and creative thinking, teamwork, information literacy and communication skills in addition to specialist knowledge.

Team Based Learning (TBL) is another educational approach analogous to PBL.In TBL, single faculty interacts with several small groups of students in the same classroom or lecture hall for promoting active learning and team work. This is run in three different repetitive phases. During the1st Preparation Phase, Learners read and study material independently outside the class.This is followed by Phase 2 whereby Learners complete an “Individual readiness assurance test” (IRAT) to assess basic concepts included in Phase1. This is followed by group readiness assurance test(GRAT).Consensus answers are scored for immediate feedback. In Phase 3 called Application phase, Teams work simultaneously on a problem or task and share their answers with Instructors, leading towards control discussion, consolidation, summarizing and focused learning. Both



(PBL, TBL) of the established techniques are utilised in current clinical teaching and topic-based lecturing for medical professionals. For instance, Small group tutorials and grand-round presentations are well established in all academic forums across the medical world. Typically students are given an opportunity to read independently on a common topic, and then they are presented with real life medical scenario which comes close to their background knowledge. This empowers them to question both from the patient as well from their teachers. They formulate a plausible diagnosis, investigate this on certain assumptions and then make possible suggestions to intervene. They get their feedback from their tutors, once the process is completed and then they get freetime to reflect on their exercise. Limitations of these methods are time and consumption of different resources which can be finite in current financials situations.

Large group Teaching and learning

Health profession is expanding with its institutional numbers as well class sizes. Each health professional is asked by their regulatory authority to remain updated and continuously develop their skills. As the learning remains a lifelong process, therefore there is no age limit when to stop. Everybody in medical profession has to maintain their continuous professional development (CPD) throughout their career. This puts extra demands upon delivery of this learning and education to very large groups of health professionals. The most common pedagogical concerns in teaching large classes are engagement, assessment

and technology. Engagement of a large class can be improved by stimulating active learning and higher order thinking and varying teaching strategies to maintain their interest. Managing large classes in a Lecture theatre is demanding. Large classes/lecture halls impose physical and logistical constraints on what a lecturer can physically do. Moore and Gilmartin (2010) describe teaching large classes in the traditional lecture format as ‘the intersection of entertainment and crowd control’. But there are tried and trusted techniques to keep students engaged during the course of a 1-hour lecture which include Interactive lectures, Active learning and Peer-assisted mentoring.(11)

Use of Clickers;This tool is used in all short time courses for large group of professional. This commences with posing different optional questionnaire on the big screen by the intended lecturer. Audience answers anonymously by pressing digital numbers. These are analysed by the presenter in front of whole class. Everybody in this large class answers differently and then keeps an intense interest towards listening to the specialist presenter. Virtual laboratories have been introduced in all health related skill acquisition areas. This is a Simulated environment which is risk free for the learner to achieve same degree of psychomotor skills. Generally students get their first-hand experience with simulated tools and then practice same skills in real life scenarios.Evidence has shown that this simulation provides an higher level of confidence to the learner when faced with real time experience. Key Challenges for future in medical teaching and learnings;

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•Acceptance for the need for scholarship in teaching and learning•Integration of new technologies•Bologna Agreement - learning outcomes•Curriculum design and Student feedback•Significant shifts in thought and practice

Microteaching

Dr.Dwight Allen was one of the founders of traditional micro-teaching at Stanford University. He developed a new micro-teaching model cantered around 2+2 feedback, which is making 2 positive comments and 2 suggestions of improvement.(12) The colleague whose teaching is being evaluated, teaches a five-minute lesson to a group of peers usually four colleagues, focusing on one particular skill or technique. A supervisor is present as an expert in the colleague field. The entire session is videotaped, preferably using more than one camera, so that “split screen effects” can be achieved, capturing teacher and student action and reaction by playback viewing.

This new model of micro-teaching differ from traditional model in that it is capable of beingmodified in any teaching and learning environment, providing an opportunity to colleagues who are involved in this process, as to what skills or techniques should be observed and what ,if any, nonverbal signals should be taken into account and what to ignore. Forthe teacher such micro-teaching sessions give opportunities for safe practice and useful feedback. In health professional education, all the trainees get such an opportunity during their career to

present at the grand-round and then get their feedback by both colleagues and their expert supervisors.Microteaching is a new methodology to enhance learner experience with self-exposure of all relevantpotentials in any student. This involves video recording of presentation with split screen views alongwith audio recording on a topic of choice in front of colleagues, teachers and mentors. This is followed by critique by fellow students by a rule of 2+2 which provides 2 positive suggestions and 2 critique points. Whole presentation is re-run and video recorded again to confirm the learning experiences. In microteaching the teacher reviews a videotape of the lesson after each session, in order to conduct a “post-mortem”. Teachers find out what has worked, which aspects have fallen short, and what needs to be done to enhance their teaching technique. Invented in the mid-1960s at Stanford University by Dr. Dwight Allen, micro-teaching has been used with success for many decades now, as a way to help teachers acquire new skills.

Medical students are afforded this opportunity of micro-teaching by their mentors in a very relaxed fashion with actively encouraging throughout its different phases. Everyone gets the freedom of choosing any presentation relevant to a speciality intertest.Anything different than the usual specialist area is challenging in addition to gearing it towards a group of diverse professionals. The real challenge is to keep the audience interested and engaged thought it’s duration. This practical provides a unique review of one’s own strengths and weaknesses in realtime situation. Following



is my personal experience of microteaching during my first semester of masters in medical professional education. Everybody in my class belonged to a different health sector and all of us were asked to pick a different item for microteaching.This ranged from Heimlich manoeuvring to Psychometric analysis of chocolate melt in our mouth. As there were different professionals in this exercise, we all have to make our individual efforts to keep other parties intertested.This provided a perfect forum to show our innate capabilities to make everybody immersed. Obviously every person was not experienced in exposure to a real-time video camerarecording. Therefore there was obvious apprehension towards this type of situation. At the same time everybody valued thisopportunity to show their hidden talents to make use of this new technology.

Being a surgical professional, mydilemma was to choose a medical topic which could garnish its appeal from other members of my group, all of whom were diverse by their specialty. I thought long and hard about the topic and equipped myself with a choice of a topic called “choking and its relief method”. My thought process started strateaway with recollection of all the facts about Heimlich manouver. I searched all the recourses including library, literature and web-based material gathering high level of evidence based upon robust information. These facts were jotted down on a paper in sequential style to keep the flow of presentaion. Mixing of anecdotal stories and every day application of this manoeuvre was icing on the cake. On the day of microteaching session,I was the first presenter to commence this learning

exercise.Istarted by asking a question from the audience as how many of them knew or seen chocking. Thisway, I measured the depth of knowledge of my class providing me the clues where to focus. I described the clinical manifestations of chocking, displaying full body gestures and hand movements. Stark distress of choking prompted an enormous interest by my audience from the very start.Along the way,I added some stories and made some references to the celebrities who had suffered from this condition. This enhanced group’s participation at a much higher level. This first act allowed me to feel good at the end of first video/audio recordings which was a new experience of learning as a tutor.

This act was followed by a systematic review by fellow students acting as peers and the mentorsacting as theexaminer. There was an objective form filled by all peers critically looking at your ratings as excellent, successful or just pass. This measured content and process in depth, style of body language and eye contact with the audience and finally at its closure and summary. I had a feedback by all the group members, commenting upon my body gestures, voicequality, toomuch use of technical terminology and eye contacting with only one group of audience rather than whole class. Both positive and suggested critique was immensely enjoyable and refreshing. This feedback ensued a reflective thought processing and encouraged to bring the suggested changes in my repeat microteaching session. Participation in microteaching has provided a sense of validation for much of what the

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lecturers do and how they do it, which has resulted in ongoing critical reflection and peer discussion. Although initially giving rise to anxiety among some participants, microteaching has led to greater self-awarenessand enhanced confidence in participants. They can judge their own ability and expertise, and a reaffirmation of their teaching style and practice. As a group, we felt that each one of us learnt a great deal of attributes of a good teacher and the spectrum of improvements for our specific professions.

Microteaching session is a chance to adopt new teaching and learning strategies and, through assuming the student role, to get an insight into students’ needs and expectations. It is a good time to learn from others and enrich one’s own repertoire of teaching methods.

References

1.Frenk J, Chen L, Bhutta ZA Health Professionals for a New Century: Transforming Education for Health Systems in an Interdependent World,” The Lancet (vol.376, pp. 1923–58, 4 December2010).2.James, W.; Gardner, D. (1995). “Learning styles: Implications for distance learning”.NewDirections for Adult and Continuing Education 67.3.Kolb, David (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall.ISBN 0-13-295261-0.4.Leite, Walter L.; Svinicki, Marilla; and Shi, Yuying: Attempted Validation of the Scores

of the VARK: Learning Styles Inventory With Multitrait–Multimethod Confirmatory Factor Analysis Models, pg. 2. SAGE Publications, 2009.5.Myers, Isabel Briggs (1980).Gifts Differing: Understanding Personality Type.Davies-Black Publishing; Reprint edition (May 1, 1995).SBN 0-89106-074-X.6.Belbin, M .(1981).Management Teams. London; Heinemann. ISBN 0-470-27172-8 .7.Robert J. Allio, (2005) “Leadership development: teaching versus learning”, Management Decision, Vol. 43 Iss: 7/8, pp.1071 – 1077.8.Graham, C. R. (2006) Blended learning systems: definition, current trends, and future directions.In: (Bonk, C. J. & Graham, C.R eds.) Handbook of Blended Learning. San Francisco,California. pp. 3-21.9.Hmelo-Silver, Cindy E. (2004).”Problem-Based Learning: What and How Do Students Learn?”.Educational Psychology Review 16 (3): 235–266.doi:10.1023/B:EDPR.0000034022.16470.f3. Retrieved 16 November 2012.10.Boud, D. & Feletti, G. (1991). The Challenge of Problem-based Learning. London: Kogan.11.Moore, N. & Gilmartin, M. (2010) ‘Teaching for better learning: A blended learning pilot project with first-year geography undergraduates’, Journal of Geography in Higher Education, vol. 34:3, 327-344.12.Donnelly, R., Fitzmaurice, M.: Towards Productive Reflective Practice in Microteaching. Innovations in Education and Training International, Volume 48, Issue 3, August 2011, pages 335-346.

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33

Results of Operative Treatment for Leg Ulcersdue to Superficial Venous Disease

Sulaiman S Shoab MS FCPS FRCS (Intercoll)* and Philip D Coleridge-SmithDM FRCS!

*Senior Vascular Fellow,! Reader of Surgery, UCL, LondonCorrespondence to [email protected]

Many different treatment modalities could achieve healing in leg ulcers due to CVD. Recurrence of these ulcers is, however, a major problem. Theoretically leg ulcers due to superficial venous disease only may be cured permanently by appropriate surgery. Definitive diagnosis and therapy in venous disease is becoming increasingly possible(1) There are few reports, however, of their long-term results.(2) Reports that do have a longer follow-up are lacking in the accuracy of the data, mainly because venous duplex ultrasound has not been widely used until relatively recently.

Sapheno-femoral junction (SFJ) ligation and stripping of the long saphenous vein (GSV) was the commonest procedure (>70%). Recurrent veins operations were 15%. Perforator incompetence was reported in only 4%. The mean follow-up period was 52 months (range 12-108 months). >40 % had to use stockings permanently for troublesome symptoms.

Introduction

The prevalence of leg ulcers in one study of 92,100 subjects aged > 40 years was 0.38%(3) In another study of 463 legs with active

ulceration venous insufficiency was detected in 332 patients (72%).(4) In these patients venous insufficiency was the dominant causative factor in 54% of cases. Until quite recently all legs with venous pigmentation/ulceration were dubbed ‘post-phlebitic’. Many authors categorically denied the role of superficial venous disease in venous ulceration.(6) In fact a substantial proportion of leg ulcers are associated with superficial disease alone.(5)

Definitive diagnosis and therapy is becoming possible in many more cases than was previously the case.(6) Duplex scanning has revolutionised diagnosis of venous disorders affecting the lower limb. Measurements of the site and duration of venous reflux can be accurately and reliably charted(7) Theoretically once the haemodynamic derangement is recognised it should be possible to cure the limb. In practice this is possible only in a limited number of cases .(8)

The reports of success with deep venous reconstruction show mixed results. Disease confined to the superficial venous system on the other hand may be ideal for surgical correction. It is widely accepted that patients with superficial incompetence and normal deep veins can achieve good outcomes(9)

Sulaiman S Shoab and Philip D Coleridge-Smith34


There are few reports of the long term outcome of superficial venous surgery for leg ulceration.(10) Most of the reports include relatively short follow-up periods. Reports that do have a longer follow-up are lacking in the accuracy of the data, mainly because ultra-sound imaging was not available until relatively recently. Since 1987 all patients with suspected lower limb venous disease have been investigated with Duplex ultra-sound at the Middlesex Hospital Vascular Laboratory. I carried out a retrospective study to assess the outcome of management based on duplex ultra-sound findings.

Material & Methods

The vascular laboratory records were examined to locate patients who were examined for lower limb venous duplex investigation. Patients with venous ulceration attributable to superficial venous disease were selected for inclusion in the study. These included patients whose disease was predominantly superficial but who also had an element of deep disease which was not considered to be the dominant element.

I examined the Middlesex vascular laboratory records to locate patients with venous ulceration attributable to superficial venous insufficiency (SVI). Outcome of surgery was assessed for patients who had surgery performed at least one year previously. Out of 88 such patients, I was able to contact 52. Telephone interviews or questionnaires were used to assess the status of the ulcer, the use of stockings and the subjective symptoms from the affected leg. Outcome of surgery for ulceration due to

superficial venous disease was assessed for patients who had surgery performed at least 12 months previously. All of these patients had superficial venous disease confirmed by means of Duplex ultrasonography and Photoplethysmography (PPG). Patients with any deep venous problems were excluded from the study. Patients with perforator disease (above/ below knee) were included.Non-parametric tests were used because of the non-normal distribution of the data.

Probability statistics are those for differences between surgical and conservative groups. Out of 88 patients scanned before & after surgery for SVI with leg ulcers since 1989 at the vascular Laboratory of the Middlesex Hospital, London, I was able to contact 52. Telephone interviews or questionnaires were used to assess the status of the ulcer, the use of stockings and the subjective symptoms from the affected leg.

SFJ ligation and stripping of the GSV was the most frequently performed operation (>70%). Recurrent veins were the indication for 15% of the operations. Perforator incompetence was reported in only 4%. Female patients accounted for 61% of the operations. The mean follow-up period was 52 months (range 12-108 months). Initial healing rates were >85% with surgical treatment. Only 40% initial healing was achieved with conservative treatment.

Results

These results are shown diagrammatically in Figure 1 & in Table 2. Clinical recurrence rates are relatively high at >30% in the

Results of Operative Treatment for Leg Ulcers 35


operative group. Nearly one third of the patients still had ulcers at varying intervals of 1-8 years following treatment. Both patients who healed on conservative treatment remained ulcer free. Around 50% of all the patients still had symptoms from their veins. These ranged from cosmetic recurrences to re-ulceration.

Most of the patients who had surgery (>80%) used graduated elastic stocking in the pre-operative and short-term post-operative period. >40 % had to use them permanently to avoid troublesome symptoms. Some patients could not use graduated elastic stockings because of the size of the limb or other factors.

Table 1. Distribution of the patients according to sex and anatomical site involvement♠ Perforator reflux was not an isolated involvement in these patients

Anatomical Site

SFJ/GSV GSV Only SSV GSV/SSV Perforators♠

Recurrent GSV

Recurrent SSV

Male (19)

Mean Age (57-85)

13 1 4 1 1 2 -

Female (33)

Mean Age (44-76)

25 4 2 2 1 3 -

Total (52) 38 5 6 3 2 5 -

Healed ulcers Recurrence Stockings Persisting Symptoms

Surgery (41) 37† (90%) 9‡ (22%) 35§ (85%) 19¥ (46%)Conservative (11) 6† (55%) 2‡ (18%) 7§ (64%) 6¥ (55%)

All (52) 43 (83%) 11 (21%) 42(81%) 25(48%)Significance † 0.01 (Fisher's) ‡ 0.32 (Fisher's) § 0.09 (Fisher's) ¥>0.05(chi-square)

Table 2. shows the rate of initial healing and persistence of ulcers at the time of surgery in patients with ulceration due to superficial venous disease only. There was a higher recurrence rate in the group without surgery. Mean follow-up period since initial duplex examination 52 months.



Figure 1. shows the outcome at the time of the study of the 41 surgically treated patients included in the study. This shows that circa 32% of patients had ulceration either from non-healing or from healing/recurrence/ non-healing. About 60% had primary healing without recurrence following surgery preceded by Duplex ultrasonography.

A=Maintained initial HealingB=No HealingC=Recurrence/ No Secondary HeealingD= Recurrence/Secondary Healing

Discussion

The primary haemodynamic derangement in SVI is reflux. The majority of DVI have reflux as the major mechanism as well. On the other hand the mechanism in some in secondary DVI is obstruction. Quoted results for deep venous reconstruction are better with primary DVI(11) than with secondary DVI.

The role of the superficial venous system has been underestimated in the past. In a study of 300 limbs in 153 patients were examined by Duplex ultrasonography with colour-flow imaging for the presence of venous reflux Ninety-eight limbs had skin changes, which included hyper-pigmentation, lipodermatosclerosis, atrophie blanche and ulceration. Of this group, 2 per cent had no evidence of venous reflux on duplex scanning, 39 per cent had deep vein incompetence, 57 per cent had superficial vein incompetence and 2 per cent had

isolated medial perforating vein reflux. Of 25 limbs with ulceration, 13 had superficial and 12 deep vein reflux. A total of 202 legs, which included 20 normal control limbs, had no skin changes; 22.3 per cent of these had no venous reflux, 8.4 per cent had deep vein incompetence, 65.3 per cent had superficial incompetence and 4.0 per cent had isolated medial calf perforating vein incompetence .(12)

Isolated deep venous reflux was present in only 12 limbs (15%). A combination of deep and superficial venous reflux was found in 25 limbs (32%), and in 42 limbs (53%) there was only superficial venous reflux.

There is some suggestion that superficial venous surgery may improve both the venous haemodynamics as well as the microangiopathy associated with CVI. A recent study confirmed improvement in physiological parameters following varicose vein surgeryError! Bookmark not define. In 11 patients followed up prospectively the Venous filling index, ejection fraction, residual



volume fraction and the venous filling index were shown to improve significantly at mean follow-up of 4 and 6 months post-operatively. In another study the laser doppler flux and tcP02 were shown to improve following sclerotherapy and compression treatment in 15 patients with moderate to severe disease.(13) There were higher healing rates following surgery preceded by Duplex Ultrasonography compared conservative treatment. However the recurrence rates and the number of ulcers at the time of the study were not different. Previous experience with surgery has been similar.(14) In another published paper Error! Bookmark not defined. the results of surgical treatment of eleven limbs showed a complete and maintained response at 16.4 months mean follow up.

High initial rates of ulcer healing are obtainable with surgery for duplex ultrasound confirmed superficial venous disease. However, recurrence rates may be substantial in the long term. This suggests that either the altered venous haemodynamics are not corrected at the initial operation and/ or these patients develop an irreversible microangiopathy of the leg skin.

Results of Conservative Treatment (15)

Most venous ulcers can be expected to heal when patients are enrolled in a nurse-managed/physician-supervised ambulatory ulcer clinic. Strict compliance with the treatment protocol may significantly decreases the time to healing and prolonged the time to recurrence.(16) In another prospective study 105 consecutive patients with leg ulcers were recruited (aetiology:

77% venous, 4% arterial, 9.5% mixed, 9.5% other). 70 (67%) had a history of previous ulceration. 83 patients could be followed up for 1 year. The healing rate for the whole group was 41 (49%) after 3 months and 61 (73%) after 1 year. The corresponding figures for the 67 venous patients are 44 (66%) and 52 (78%) respectively. From 61 healed ulcers 18 (30%) reoccurred during the 1st year. At the primary examination several factors were investigated which might have influenced the healing rate. Age, ulcer-size, the duration of the ulcer, lateral localisation, absence of foot-pulses and lymphoedematous skin changes on the forefoot could be shown to have negative influence on healing.

Results of Surgical Treatment(14)

In one study of surgical treatment of leg ulcers the results of treatment of 159 consecutive limbs presenting with a clinical diagnosis of venous ulcer in 140 patients (70 male, aged 28-90 years, median 66 years) were reviewed. Of the patients, 61% were referred because of severe pain and 53% of the ulcers had been present > 2 years. Patients were evaluated clinically and by duplex ultrasound, with selective use of venography, photoplethysmography, arteriography and latterly duplex scanning. Seventy-one limbs had surgery to the superficial veins, 18 limbs had arterial In one published paper Error! Bookmark not defined. the results of surgical treatment of eleven limbs that had been subjected to Duplex scanning, venography and Air plethysmography (APG) were studied. All of these patients had GSV disease as the



superficial component. All the patients had deep venous disease in addition. The mean follow up was 16.4 months. All the ulcers healed in this study and remained healed for the duration of the follow-up. The mean clinical score decreased from 10.1 to 1.45. However all the subjects in this study had evidence of deep venous insufficiency in addition. No mention was made of any conservative measures employed or if the patients continued to use support stockings post-operatively.(17) In addition the vast majority of patients had reflux only in the proximal deep vein segments. These are now known to be unimportant unless >1.0 minute in duration and are probably of significance only if they are associated with distal reflux. Some deep venous reflux is associated as a secondary phenomenon with advanced superficial disease.(18) Thus evidence of any deep venous reflux should be critically evaluated and not taken as an absolute contra-indication to surgery per se.(19)

Recurrence rates were high in my series. Larger series of conservative management have shown similar results to the operative management. In one series 188 patients with recently healed leg ulceration were followed for at least 18 months. Overall cumulative recurrence rate was 26% after 1 year and 31% at 18 months.(21) Some series had suggested that >80 % of patients do not require any long-term support stockings after surgery.(9) It seems likely that patients who have non-healing or recurrent ulcers have either had an inadequate operation and/or have a microangiopathy locally that persists despite correction of the venous reflux. It would not be amiss to discuss here

the problem of recurrent veins, which is intimately related to failure of ulcers to heal. Recurrent varicose veins are a common problem and can be difficult to deal with. In a recent study involving a survey of > 150 patients, more than 10 % had to visit their GP post-operatively with recurrent veins within six months of their operation.(22) Patients’ satisfaction rates with varicose vein surgery are generally low and vary amongst different series.(23) This may be because different surgeons vary in the importance given to the meticulousness of operative technique of VV surgery.

Concluding Remarks

High initial rates of ulcer healing are obtainable with surgery for superficial venous disease. Although about a third recurred in my study and a similar number still had an ulcer more than a year after their operation. The ESCHAR study also showed significant recurrence rates although the healing rates had an advantage in the surgical groupxix.(19) This suggests that either the altered venous haemodynamics may not have been corrected at the initial operation and/ or these patients had developed a microangiopathy not reversible with operative treatment alone. They may have had a predisposition to ulceration that is not changed by surgery alone. Careful technique is essential. The exact nature of the microangiopathy and the inflammatory mechanisms involved needs to be addressed simultaneously. Further studies to continue follow-up of patient prospectively using the CEAP classification are warranted.(24) Equally important are further studies into the micro-circulatory



aspects of the disease. A study that would observe the effect of operative treatment on markers of leucocyte and endothelial activation may help in elucidating the effect on the microcirculation. The next section deals with this aspect.

References

1.Kistner RL. Definitive diagnosis and definitive treatment in chronic venous disease: A concept whose time has come. J Vasc Surg 1996; 24: 703-710.2.Sethia KK, Darke SG. Long Saphenous incompetence as a cause of venous ulceration. Br J Surg 1984; 71: 754-755.3.Cornwall JV, Dore CJ & Lewis JD. Leg ulcers: Epidemiology and aetiology. Br J Surg 1986; 7: 636-696.4.Nelzen O, Bergqvist D, Lindhagen A. Leg ulcer etiology - A cross sectional population study. Diab Med 1993; 14 (4): 557 564.5.Shami SK, Sarin S, Cheatle TR, Scurr JH, Smith PDC. Venous ulcers and the superficial venous system. J Vasc Surg 1993; 17: 487-490.6.Kistner RL. Definitive diagnosis and definitive treatment in chronic venous disease: A concept whse time has come. J Vasc Surg 1996. 24; 5: 703-710.7.Sarin S, Sommerville K, Farrah J, Scurr JH, Coleridge-Smith PD. Duplex ultrasonography for assessment of venous valvular function of the lower limb. Bri J Surg 1994; 81: 1591-1595.8.Korstanje MJ. Venous stasis ulcers. Diagnostic and surgical considerations. Dermatologic Surgery 1995; 21(7): 635-40. 9.Burnand K, O’Donnell T, Lea MT, Browse NL. Relationship between post-phlebitic

changes in deep veins and results of surgical treatment of venous ulcers. Lancet 1976; 307: 936-938. 10.Sethia KK, Darke SG. Long Saphenous incompetence as a cause of venous ulceration. Br J Surg 1984; 71: 754-755.11.Masuda EM, Kistner RL. Long term results of venous valve reconstruction: a twenty-one year follow-up. J Vasc Surg 1994; 19: 391-403. 12.Nachbur B. Blanchard M. Rothlisberger H. Chirurgische Therapie des Ulcus cruris. Die Bedeutung der Ausdehnung des Schadens an den tiefen Venen fur die Rezidivquote beim Ulcus cruris. [Surgical therapy of ulcus cruris. Significance of extension of the damage to deep veins for incidence of ulcus cruris recurrence] Wien Med Wochenschr. 1994; 144(10-11): 264-8.13.Leu AJ, Yanar A, Geiger M, Franzeck K, Bollinger A. Microangiopathy in chronic venous insuficiency before and after Sclerotherapy and Compression treatment: Results of a one-year follow-up study. Phlebology 1993; 6: 99-10. 14.Dunn JM. Cosford EJ. Kernick VF. Campbell WB. Surgical treatment for venous ulcers: is it worthwhile? Ann Roy Coll. Surg Engl 1995. 77:421-4. 15.Mayer W, Jochmann W, Partsch H. Ulcus cruris: Abheilung unter konservativer Therapie. Eine prospective Studie. Wiener Medizinische Wochenschrift 1994. 144(10-11):250-2.16.Erickson CA, Lanza DJ, Karp DL. Edwards JW, Seabrook GR, Cambria RA, Freischlag JA, Towne JB. Healing of venous ulcers in an ambulatory care program: the roles of chronic venous insufficiency and patient compliance. Journal of Vascular



Surgery 1995. 22(5): 629-36.17.Bradbury AW, Britenden J, Allan PL & Ruckley CV. Comparison of venous reflux in the affected and non-affected leg in patients with unilateral venous ulceration. Bri J Surg; 83: 513-515. 18.Myers KA. Ziegenbein RW. Zeng GH. Matthews PG. Duplex ultrasonography scanning for chronic venous disease: patterns of venous reflux. Journal of Vascular Surgery 1995. 21(4):605-12.19.Barwell JR, Davies CE, Deacon J, Harvey K, Minor J, Sassano A, Taylor M, Usher J, Wakely C, Earnshaw JJ, Heather BP, Mitchell DC, Whyman MR, Poskitt KR. Comparison of surgery and compression with compression alone in 20.Chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet.

2004 Jun 5; 363(9424): 1854-9.21.Franks PJ, Oldroyd MI, Dickson D, Sharp EJ, Moffatt CJ. Risk factors for leg ulcer recurrence: a randomized trial of two types of compression stocking. Age & Ageing 1995; 24(6): 490-4. 22.Mackay DC. Summerton DJ. Walker AJ. The early morbidity of varicose vein surgery. Journal of the Royal Naval Medical Service. 1995; 81: 42-6. 23.Davies AH. Steffen C. Cosgrove C. Wilkins DC. Varicose vein surgery: patient satisfaction. Journal of the Royal College of Surgeons of Edinburgh. 1995; 40: 298.24.Porter JM, Moneta GL. International consensus Committee on Chronic venous Disease. reporting standards in venous disease; an update. J Vasc Surg 1996; 21: 635 - 45.

41


Popliteal Access: A Safe Alternative to Recanalize Superficial Femoral Artery Total Occlusion after Antegrade Approach Failure

R. Moia1, J. Clerissi1, H. Kamis2, V. Epicoco1,R. Nuzzo1, C. Massa Saluzzo1

1U.O. di ChirurgiaVascolareed Endovascolare - Istituto di CuraCittà di Pavia, UniversitàdegliStudi di Pavia,Pavia, Italia

2Wadi el Neel Hospital, Cairo, Egypt

Abstract

Purpose: To demonstrate the validity of popliteal access angioplasty intervention for chronic total occlusion (CTO) of superficial femoral artery (SFA), following failure of antegrade femo-ral access procedure.

Methods: From January 2009 to March 2010, 28 patients (25 men; mean age 68±6.3 years) with intermittent claudication and chronic SFA occlusion (mean length 97.4±3.8 mm, range 35–220) underwent percutaneous recanalization from a retrograde popliteal access in su-pine position and the knee gently flexed and medially rotated, the popliteal artery was punc-tured using an 16 or 18-G needle under fluoroscopic guidance with a roadmap technique.At the end of the procedure, hemostasis at the popliteal access was obtained with manual compression (15–20 minutes).

Results:Technical success (puncture of the popliteal artery in supine position) was achieved in all cases. In the majority of patients (26, 92.8%), endoluminal recanalization was possible from the popliteal access; SFA recanalization in the other 2 cases was obtained through the subintimal space. Two small hematomas were found in the popliteal region, but no pseudoa-neurysm or arteriovenous fistulas were seen on duplex examinations during follow-up. A re-sidual stenosis <30% in 11 (39%), <50% in 12 (43%) patients and <75% in 5 (18%) patients was noted.No stent fracture was observed.

Conclusion: Popliteal access in the supine position has proven to be a safe and successful technique that represents a convenient alternative to antegrade approach for patients with CTO of SFA.

R. Moia1, J. Clerissi1, et. al.42


Introduction

Percutaneous angioplasty of femoro-popliteal arterial disease, with access via the common femoral artery, is now a well-established technique and is widely practiced. The procedure, however,may fail if the guide wire punctures the arterial wall while the diseasedsegment is being crossed. Once this has happened the situation is extremely difficult to retrieve by continued maneuvers from above. The situation can be retrieved readily by establishing retrograde access via the popliteal artery.(1)

The objective of our study was to demonstrate the validity of popliteal access angioplasty intervention, following failure of a previous procedure performed through an antegrade femoral access. In fact the popliteal artery is more suited to this type of procedures as, its location surface in the popliteal fossa, makes the entry site easily accessible.(2)

Materials and Methods

The study was conducted on 28 patients with mean age 68±6.3 years between January 2009 and March 2010 including 25 men and 3 women. All patients included in the study were affected by chronic obstructive arterial disease (PAD), of which 9 with unilateral stage IIB, 6 with stage III and 13 with stage IV. The risk factors to be considered after correct evaluation of the results are constituted by: diabetes: 13 patients (46%); hypertension: 20 patients (71%); dyslipidemia: 21 patients (75%). At the entrance to the ward the patient is subjected to arterial Doppler ultrasound examination to evaluate the

location, severity of the occlusion and the simultaneous absence of pathologies of the wall of the popliteal artery (aneurysm, calcific sclerosis, reduced thickness, obstruction next to the site access), which represent the main criterion for exclusion from the study.(3-5) In the initial evaluation collection is also the objectivity and the symptoms of the lower limbs considering: presence and level of claudication (28 patients, 100%); the recovery time; pain during rest (13 patients, 46%); presence of trophic lesions (13 patients, 46%); edema (12 patients, 43%); hypothermia of the affected limb compared with the contralateral occlusion (11 patients, 39%); presence of femoral pulses, popliteal, tibial front and rear evaluated on a scale from 3/3 (normal) to 0/3 (severe disease) and of tremors and/or related puffs (Table 1).

The patient candidate to the procedure angiography of the lower limbs is evaluated in the previous days on the basis of blood coagulation parameters (PT, PTT, and INR) of normality. The pharmacological preparation of the patient undergoing angioplasty through the popliteal access does not differ from that for angioplasty of the common run. The day before the procedure, the patient received aspirin, ticlopidine or clopidogrel if probable placement of a stent was considered.(6)

At the entrance to the operating room, the patient was fasting from solid foods and liquids for at least 12 hrs, well hydrated and empty bladder. The patient was placed preferably in ventral decubitus we proceed to the disinfection of the skin of the popliteal fossa with betadine solution and subcutaneous infiltration with 10-20cc

Popliteal Access 43


of local anesthetic (lidocaine 1%) that, associated with an intravenous sedative, is usually sufficient. We considered certain conditions (respiratory failure, obesity, inability hyperextension of the knee) that may affect the position of the patient during the procedure; in this case it is recommended to place the patient in the lateral decubitus position on the side contralateral to the site of entry.

The angiographic access was obtained by making a minimal incision on the skin, after having carefully retrieved the arterial pulse, generally little above the joint, and by pricking with a needle cannula 16 or 18G that transitions the artery from side to side, with an inclination of about 60° with respect to its axis. The cannula is extracted slowly until the appearance of a gush button. Then, we inserted into the cannula a metal guide. Taking into compression artery upstream of the injection, the cannula was removed and the guide introduces an angiographic catheter 4 or 6 French with straight ends or “pigtail”.

The technique of catheterization was suggested by Seldinger’s technique(7,8), currently used world wide. Once reached the vessel with the catheter chosen, we proceeded to the injection of iodinated contrast material and taking the sequences of radiograms, further acquired with a digital technique. At the end of the procedure, the catheter was removed, after introduction of the guide wire and through skin-occluded arterial inducing coagulation through a slow down in the flow upstream through manual compression for 15-20 min and subsequent

application of pressure bandage kept in place for 24hrs. For the duration of the procedure, the patient was monitored with ECG, pulse oximetry and periodic survey of blood pressure. After the intraoperative intravenous injection of a bolus of 5000 units of heparin (9), a peripheral venous access was maintained for infusion of saline injections and any emergency. After the procedure, aspirin was administered for a time determined by the evaluation of coagulation parameters and ticlopidine or clopidogrel if the patient was submitted to the positioning of one or more stents.

Results

Technical success (puncture of the popliteal artery in supine position) was achieved in all cases. In the majority of patients (26, 92.8%), endoluminal recanalization was possible from the popliteal access ( Figure 1 and 2); SFA recanalization in the other 2 cases was obtained through the subintimal space. The short-term assessment, performed 12 hrs after the procedure provided a comparison with the preoperative objectivity of the following findings: validity of peripheral pulses, color and temperature of the skin, the presence of tumefaction and hematoma at the site of access. The possible improvement of painful symptoms reported by the patient was also recorded. The mid-term evaluation allowed studying the axis artery under angiographic procedure through arterial Doppler ultrasound performed one month after discharge. A residual stenosis <30% in 11 (39%), <50% in 12 (43%) patients and <75% in 5 (18%) patients was noted (Figure 3).



Table 1. Patients’ demographics & clinical features

Demographic informationAge, yrs 68±6.3Men, % 89.2%

Risk factorsDiabetes 13(46%)

Hypertension 20(71%)Dyslipidaemia 21(75%)

Clinical featuresClaudication 28(100%)

Rest pain 13(46%)Trophic lesions 13(46%)Hypothermia 11(39%)

Edema 12(43%)

Figure 3. Residual stenosis.

Figure 1. Occluded left superficial femoral artery

Figure 2. Left superficial femoral artery post intervention

Popliteal Access 45


Also, apparent improvement of the painful symptoms in all patients was recorded. The lesions of patients with ulcerative trophic-stage IV showed reduction in size and a marked increase in the granulation tissue.

Peri-and post-procedural complications that have been recorded in our study are comparable with the rates reported in the literature. There were 2 (7%) cases with hematoma at access site (probably due to not complete immobility of the patient). However, they were managed by compression in place and did not require surgery, no perforation of the popliteal artery during the retrieval artery (by alterations of the arterial wall), acute ischemia of the leg, amputation, an allergic reaction to the contrast material or intraoperative death was reported.

Discussion

The results from this small series have encouraged us to offer retrograde transpopliteal angioplasty to patients in whom the antegrade approach has failed. This has been reinforced by reported successes from other series.(7) In one series, success of the procedure was found to improve significantly with experience, although it was not indicated whether the failures were due to inability to enter the popliteal artery or, having successfully entered the artery, to cross the lesion. The present series shows a difficulty in cases with popliteal arteries of small caliber. Experience shows that, once the guide wire has gone off course during attempted crossing of an occlusion, the situation becomes very difficult to retrieve. This series,

along with previous series, has shown that such lesions can be crossed readily and dilated from a retrograde approach,and the technique is therefore commended to practitioners of interventional vascular procedures.

Conclusion

Popliteal access has proven to be a suitable alternative to open femoral arterial angiography in the treatment of peripheral arterial occlusive disease in case of obstructive lesions in iliac-femoral level. This technique is valid in all angiographic techniques made through femoral access, including the placement of coated stents that cannot be placed through the contralateral femoral access because of the rigidity of the materials. The procedure has proven to be well tolerated by patients with reduced incidence of complications in the short and medium term. We currently need to perform a long-term follow-up with the purpose of evaluating, through periodic examinations, the effectiveness of the treatment and the possible need for further intervention.

References

1.Sadiq I, Setna K. A technique for retrograde popliteal artery access in a supine patient. Vascular Disease Management; 2010. p. 57-60.2.Tonnesen KH, Sager P, Karle A. Percutaneous transluminal angioplasty of the superficial femoral artery by retrograde canalization via the popliteal artery. CardiovascInterventRadiol 1988; 11: 127-31.



3.Zaitoun R, Iyer SS, Lewin RF, Dorros G. Percutaneous popliteal approach for angioplasty of superficial femoral artery occ lus ions .Cathe tCard iovascDiagn 1990;21:154-8.4.Gozzi M, Amorico MG, Colopi S, Favali M, Gallo E, Torricelli P et al. Peripheral arterial occlusive disease: role of MR angiography. La RadiologiaMedica 2006 p. 225-37.5.Noory E, Rastan A, Schwarzwنlder U, Sixt S, Beschorner U, Bürgelin K et al. Retrograde transpopliteal recanalization of chronic superficial femoral artery occlusion after failed re-entry during antegrade subintimal angioplasty. J EndovascTher 2009; 16: 619-23.6.Narins CR. Access strategies for peripheral

arterial intervention. Cardiol J 2009; 16: 88-97.7.Noory E, Rastan A, Sixt S, Schwarzw .nnen O, Schwarz T et alنlder U, LeppنArterial puncture closure using a clip device after transpopliteal retrograde approach for recanalization of the superficial femoral artery. J EndovascTher 2008;15:310-4.8.Glasby MJ, Bolia A. Subintimal angioplasty of a crural vessel via an antegrade popliteal artery puncture. Eur J VascEndovascSurg 2007; 34:347-9.9.Feiring AJ, Wesolowski AA. Antegrade popliteal artery approach for the treatment of critical limb ischemia in patients with occluded superficial femoral arteries. Catheter CardiovascInterv 2007; 69: 665-70.

47


Management of Juxta and Supra- Renal Aortic Aneurysm with Difficult Anatomy

Sayed Aly PhD (UCL-London), FRCS

Consultant Vascular and Endovascular SurgeonBeaumont / Mater University Hospital, Dublin, Ireland

Introduction

An aneurysm is an increase in the aortic diameter by greater than 50% of its normal diameter. Aortic aneurysm classified into abdominal and thoraco-abdominal aortic aneurysm or generalized arterial ectasia, depending on the amount and extent of the dilatation. About 3000 elective aneurysm repair and 1,500 emergency operations in UK each year while the mortality of elective surgery is less than 5%, the mortality of emergency operation is still greater than 50% and also, accounts for 2% male deaths above the age of 55 years.The incidence of aortic aneurysm increases rapidly with age and is much higher in men than in women. Aortic aneurysms are very rare under the age of 55 and confined mainly, to patients with Marfan’s, Ehlers Danlos, or arteria magna syndromes. The majority of aortic aneurysms are asymptomatic and impalpable; consequently their prevalence in the community can be determined only by systematic screening.

In men aged 65 to 74 the prevalence of abdominal aortic aneurysm of diameter 4.0 cm or more is at least 2.0 per cent and increase by 50% in patients’ risk factors

(PVD, CAD and carotid artery disease). The disease is seen less often in people of African descent than in Caucasians. Most of aneurysms are atheromatous but others are mycotic, inflammatory dissecting orarteriovenous aneurysms. Connective tissue degradation: The presence of proteolytic activity in aneurysmal aorta, and also, authentic collagenase (same for elastase)has been proved. It is uncertain whether collagenolysis is the cause or a consequence of aneurysm rupture and recently a unique metalloproteaseelastase has been found only in aneurysm patients.Ultrasound screening studies have shown a prevalence of abdominal aortic aneurysm of 30 per cent in first-degree male relatives of patients with the disease. Because of the late age of onset, many of those with no evidence of an aneurysm at the time of screening could well develop the disease when they are older, so the lifetime prevalence in brothers and sons of aneurysm patients may be as high as 50 per cent.

Naturally The great majority of abdominal aortic aneurysms are fusiform and are confined to the infrarenal segment (80%) and juxtanad

Sayed Aly

48


suprarenal represent 20%. Small saccular aneurysms are sometimes seen adjacent to atheromatous plaques in patients with predominant occlusive disease, and rapidly growing infective mycotic saccular aneurysms occasionally occur as a consequence of bacteraemia. Mycotic aneurysms are a local manifestation of systemic disease, require urgent medical and surgical treatment irrespective of size, and have a totally different natural history from that of the common idiopathic aortic aneurysms of the elderly.

The development of symptoms, risk of rupture, and clinical management of aortic aneurysms depend largely on their diameter AAA is suitable for screening as elective operation of asymptomatic aneurysms can reduce mortality associated with rupture. Probably males over 65 years - especially hypertensive should be included. Single US at 65 years reduce death from ruptured AAA by 70% in screened population1,2. Patients with small aneurysms should undergo regular surveillance. Repeated ultrasound every 6 months is required.

Clinically

The majority of abdominal aortic aneurysms are asymptomatic and are often incidentally, discovered. Large aneurysms in thin patients are readily detected on routine abdominal examination, but most are now discovered by ultrasonography or abdominal radiography performed to investigate unrelated symptoms. In Britain, ruptured abdominal aortic aneurysm still accounts for around a third of all operations for the

disease, compared to 5-20% in the United States. 60% of patients with ruptured AAA do not reach hospital alive, while some of those who do are not operated upon. Rupture of an AAA is presented by a sudden severe central abdominal and lumbar back pain and rarely; there is psoas spasm (due to compression of lumbar or sciatic nerve roots). Rupture of an internal iliac artery aneurysm commonly associated with a buttock pain. Other early symptoms and signs depend on the volume of acute blood loss, and survival after rupture depends on an intact posterior peritoneum, tissue tamponed, and early emergency surgery.

Acute critical ischaemia (due to aortic occlusion- fig 1) and distal embolization isanother presentation. Ureteric occlusion due to inflammatory AAA has been reported. This associated with a variable degree of perianeurysmal fibrosis and the patient may present with hydronephrosis or anuria and renal failure. Aortocaval fistula; is rare and diagnosed per-operatively, when dramatic venous bleeding is seen on opening the aneurysm sac after aortic cross-clamping. Aortoenteric fistula is seen as late complications of aortic surgery, and spontaneous fistulation is extremely rare.

Investigation of the aneurysm

Particularly; cardiac, respiratory and renal function should be evaluated but, also the presence of carotid arterial or other coexistent disease should also evaluated.All patients should have routine monitoring of their blood pressure and an electrocardiogram (ECG)and history of angina and hypertension

Management of Juxta and Supra- Renal Aortic Aneurysm with Difficult Anatomy 49


are essential further. Echocardiography is useful for detecting abnormalities of valve or heart wall function, and the technique of multigated acquisition nuclear imaging allows a ventricular ejection fraction to be calculated at rest and after exercise. In some patients, coronary angiography will be indicated, and any coronary arterial disease discovered may need treatment by angioplasty or coronary artery bypass grafting before aortic surgery can be contemplated safely. Delaying of elective surgery for patients with a recent myocardial infarction is recommended for all but the largest aneurysms, since further infarction and death are substantially increased by operation within 6 months of the infarct. A low ventricular ejection fraction at rest or one, which falls markedly on exercise, is relative contraindications to surgery.1-Ultrasonography (USS) of the abdominal aorta is the first-line investigation; its advantages are that it is cheap, freely available, accurate, reliable, and reproducible. It remains, however, the most useful investigation for measuring the diameter of an infra-renal aortic aneurysm. 2-Computerizedtomography angiography(fig.1&2): It is useful in assessment of suprarenal aortic involvement and to detect inflammatory aortic aneurysms. It used to measure the diameter, but inaccuracies can occur if the section is not at right angles to the long axis of a tortuous aneurysmal aorta. Discrepancy between USS and CT scan is well reported but one should remember that most of the diameter studies based on USS not CT scan usually. 3- The magnetic resonance imaging (MRI):The quality of the images produced by the newer machines

is excellent and since there is no radiation exposure it could well replace computerized tomography in many of its present uses.4-Routine measures of respiratory function, such as peak expiratory flow and spirometry while, more complex measurements of gas exchange are rarely required. Although poor lung function may be a contraindication to elective surgery, the presence of chronic obstructive airways disease is an important risk factor for aneurysm rupture. In the presence of carotid artery stenosis whether carotid endarterectomy should be performed before, during, or after aortic aneurysm surgery, or it should be performed at all, more evidence required.(3) Malignant disease discovered during investigation for the aneurysm presents a particular problem. In general, if primary treatment of the cancer seems to have been successful, then the aortic aneurysm is replaced as soon as the patient has recovered from cancer surgery. If treatment of the cancer is definitely non-curative and life expectation is limited, aneurysm surgery is seldom advised, since in most patients’ death from aneurysm rupture will be a much better alternative than from carcinoma. Although fenestrated EVAR is possible in the majority of juxtarenal aneurysms, design and manufacturing constraints apply and sometimes it may not be possible simply to fabricate a fenestrated stent-graft that fits the anatomy. Currently, commercially available fenestrated stent-grafts are based on the Zenith (Cook Inc, Bloomington, Indiana) system, and the most frequently used design comprises of a proximal body with the fenestrations in addition to the components of a modular bifurcated design.

Sayed Aly

50


Figure 1. Juxta renal AAA



Figure 2. Ruptured Juxta renal AAA

Planning of the fenestrated graft

The seal / fenestration Zone: Choosing the lowest aortic segment that will provide an adequate seal since; any increase in number of fenestrations will increase the difficulty of both designing and deploying a graft and going higher only if essential to find the straightest segment of aorta (at least 50% of segment should be straight). Also we should

decide how will fenestrate and which vessels (renals, SMA, celiac). The anatomical relationship between the four vessels can described in diameter and depth of each, the Clock Position of Vessel(s): Clock positions are determined by first noting the middle of the aorta, then: 12 o’clock is on the anterior margin, 6 o’clock is on the posterior margin, 3 o’clock is 90 degrees away from 12 o’clock on the anatomical left should be assessed.

Sayed Aly

52


Fenestration can be by using scallop (depth of each vary 6-12 mm), two scallops (should be distance at least of > 2 hours – look at the planning sheet), small fenestration and scallop( distance> 1.30 hours), two small fenestration (at least > 2 hours) or two small and large fenestration( > 2hours).

1-Select Side for Graft Body Introduction which is less tortuous vessel with a diameter> 7mm, stenosis. 2-Choose fenestration Configuration: (see working sheet). 3-A sagittal plane can be used to record the clock positions of the vessels – accurate clock and distance information is needed to determine where the fenestrations should be placed during graft construction. Also;any aortic angulations should also be taken into account. 4-Choose Proximal Body Diameter (D1): Measure aortic diameter over a length of approximately 20-30 mm, or the length of the sealing stent(s). Measure the external diameter of the vessel (including the vessel wall thickness when it can be seen). Add an appropriate amount of over-sizing to ensure that the graft has an ‘interference fit’ within the vessel. When the landing zone has varying diameters throughout its length, the graft should be oversized to ensure good contact with the largest diameter of the landing zone. Over-sizing can vary from 15-25%, depending upon anatomy and physician preference. 5-Choose proximal graft length (L1): In general, choose a proximal graft length that will place the distal end of the graft between 20-35 mm above the aortic bifurcation. Angiography using a measuring catheter to consider suitable graft length. 6-Choose Distal Body Length (L2): The minimum overlap that must be planned

is two stents (36mm).The length chosen should place the contralateral limb position 5-10 mm above the aortic bifurcation. The graft component lengths should be chosen so that adequate overlap will be maintained if the completed graft takes a curved path out into the aneurysm sac. 7-Choose Distal Body Ipsilateral Leg Diameter (D3): The incidence of complications and secondary procedures is increased in iliac vessels that have:length less than 17mm, diameters greater than 20mm, tapering, irregularitiesand tortuosity.

8-Choose Distal Body Ipsilateral Leg Length (L3): plan the integral ipsilateral leg length to land just above the common iliac bifurcation – this increases stability and lowers risk of endoleak, choose a limb length that will span the distance from the contralateral limb (5-10 mm above the aortic bifurcation) to the desired landing zone. If endoluminal treatment might require sacrificing one or both of the internal iliac arteries, possible consequences of this approach should be considered and discussed with the patient.9-Choose Controlateral Leg Diameter (D4). 10-Choose Contralateral Leg Length (L4): Determine the length from the distal edge of the limb (of the distal body) to the chosen landing zone in the iliac artery. It is usually desirable to plan the contralateral leg to land just above the common iliac bifurcation for greater stability and reduced likelihood of endoleakWhen an internal iliac is to be sacrificed, it is suggested that at least two stents (34mm) land in the external iliac artery. Fenestrated EVAR is associated with a number of additional issues that influence outcomes both early and late in the follow-up. Fenestrated EVAR takes longer to perform



and is associated with more intraluminal manipulation than standard EVAR, and on average, associated with exposure to higher doses of radiation and contrast material. These factors influence perioperative mortality and morbidity. The fenestrated configuration, by necessity, increases the modularity of the stent-graft. This potentially increases the risk of complications specific to modular junctions such as modular distraction or junctionalendoleaks (type III). Modular distraction between the proximal (fenestrated) and the distal (bifurcated) body modules have been observed. Patency of target vessels (vessels whose perfusion is preserved via the fenestrations or scallops) remains a source of concern in the short and the long term. In the absence of contraindications, all patients are started on Clopidogrel after fenestrated.

The effects of longitudinal hemodynamic force that act upon the fenestrated body are crucially important. The Zenith system incorporates a proximal bare stent with barbs to enhance fixation. However, experimental evidence suggests that the fixation strength may not be fully functional until the barbs are engaged into aorta, a process that may be associated with distal migration by usually less than 3 mm. This degree of movement is likely to be inconsequential with the majority of standard stentgrafts. However, with a fenestrated stent-graft, migration of even this magnitude can result in distribution of shear forces to the interface between the target vessel stent and the fenestrated body of the stent-graft. Stents that are usually placed into target vessels were not primarily designed to withstand

high levels of asymmetric stress. Their hoop strength may not be sufficient to withstand these forces, resulting in crushing or even fracture of stents and possible occlusion. Selection of stents for implantation into target vessels during fenestrated. In excess of a thousand fenestrated stent-grafts have been implanted worldwide, and reports relating to early and intermediate-term outcomes have started to appear in the literature. Although a number of issues fundamental to stent-graft design are yet to be addressed, there is scope for optimism. It should also be noted that at least in some of the fenestrated. Fenestrated EVAR is technically demanding in all respects, from preoperative planning to operation and late secondary interventions, if and when indicated.

Planning a fenestrated stent-graft requires detailed appraisal of aortic anatomy in relation to the proximal landing zone. The information required includes the diameter of the aorta at the level of the target vessels, the orientation of each target vessel along the circumference of the aortic cross section, orthogonal separation between the different target vessels and the desired size of each fenestration. The configuration of each vessel should also be studied to plan a strategy for the operation.During the operation, it is necessary to orientate the fenestrated body in both longitudinal and rotational orientation accurately. Natural curvature of the arterial segment between femoral access and the visceral aorta tends to cause rotation of the stent-graft delivery system as it is being introduced, and this should be compensated or corrected to have the stent-graft oriented accurately in its final position. Fenestrated

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EVAR also regularly requires access to a wider range of catheters and sheaths. The initial cost advantage of the AneuRx and Excluder endograft systems were offset by the more frequent need for proximal and distal extensions. The minimum device cost of a basic repair should not factor into the decision to select one specific device over another because additional devices may be required depending on the design and construction of the endograft system and the accuracy and reliability of their deployment mechanisms.Although suprarenal associated with 18% had renal complications, only one patient had permanent renal failure. Patients with a combination of physiologic and anatomic risk factors identified on multivariate analysis may benefit from fenestrated endograft repair.

Technique

After femoral artery exposure, patients are heparinized to maintain activated clotting times greater than 300 seconds for the duration of the procedure. A stiff wire is advanced into the aortic arch through the femoral artery on the intended side of delivery. A large sheath is inserted into the contralateral femoral artery. A flush catheter is positioned immediately above the celiac artery through the contralateral femoral artery. Angled catheters are placed by puncturing the valve of the large sheath on the contralateral side and left at the level of the aortic bifurcation. The first component is oriented using radio-opaque markers to accommodate the incorporated renal and visceral ostia and then inserted over the stiff wire. Partial expansion of the device is

then accomplished by sheath withdrawal to reveal 2 covered stents.A further angiogram is performed at this point, and the device is more accurately oriented. The graft is then fully exposed by complete withdrawal of the sheath. Diameter-reducing ties cause posterior tethering and prevent complete expansion of the prosthesis after sheath withdrawal. This allows additional adjustment of fenestration position by rotational and longitudinal movement.

Access to the partially expanded endograft is achieved through the contralateral femoral sheaths with the use of steerable catheter-guidewire systems. A minimum of 2 visceral vessels are then cannulated through the respective fenestrations from within the prosthesis. Guiding catheters (8 Fr Multipurpose B Lumex Guiding Catheter, Cook, Inc.) or sheaths (Ansel, Cook, Inc.) are inserted over Rosen wires into both of the accessed fenestrations (Figure 4). In the setting of significant ostial stenosis, other techniques may be required to gain renal access.

Once at least 2 branch vessels are cannulated, the graft material is then fully expanded by removing the wire tethering the posterior aspect of the prosthesis. The top cap is then deployed. Relatively long balloon-expandable stents or stent-grafts (Jostent or Jomed covered stent graft, Abbott, Abbott Park, Illinois) are then used to stent the branch vessels. This is done so that at least 15–16 mm of the stent is lodged within the visceral vessel and 3–4 mm extends out into the aorta. The visceral and renal stenting technique is



modified to account for early bifurcations, ostialstenoses, and severe angulation. The aortic component of the balloon-expanded visceral stents is flared by further dilatation with a 10 mm balloon and then selectively flared with a compliant latex balloon. This maneuver “rivets” the stent-graft to the aortic wall. The top cap is retrieved while access to both stented vessels is maintained with the guiding catheters. The guiding catheters are removed after further angiography. The second (bifurcate) component of the system is then inserted through the ipsilateral femoral artery, oriented, and deployed such that the contralateral limb expands immediately above the aortic bifurcation. Contralateral access is then obtained in a standard fashion through the contralateral sheath, and the remainder of the deployment sequence is similar to the infrarenal Zenith system. Compliant balloon inflation at all joints and distal sealing zones precede completion angiography.

Results

The most recent CCF fenestrated experience was reported in 2006.This included 119 patients. There were 98 men and 21 women, with a mean age of 75 years. They were a high-risk group with 49% having significant coronary artery disease and a 26% having renal insufficiency. Comorbidities are described in Table 1. Although we have made several attempts to categorize these patients into their relevant high-risk factors, many patients had specific issues that did not lend themselves to grouping. The technical success rate was 100%. Conduits were used for access in 6 patients. In addition

to proximal fenestrations, 8 patients also had hypogastric branch devices inserted to preserve antegrade internal iliac flow in at least one internal iliac artery. 9,10 Mortality. The mean follow-up was 19 months (range 0–48 months). Sixteen patients died during the follow-up period, 1 within 30 days, 7 within the first year, and 8 patients after 12 months of follow-up. Kaplan–Meier estimates of survival at 1, 12, 24, and 36 months are 0.99, 0.92, 0.83, and 0.79, respectively. There were no late aneurysm-related deaths and no conversions to open procedures.

Endovascular outcomes

The mean diameter of the proximal neck was 26 mm (range, 17–34 mm). The mean proximal neck length was 8 mm (range, 3–18 mm). The proximal neck length was < 10 mm in 70 patients, and between 10 and 18 mm in 49 patients, all of which had morphologic factors implying compromised sealing or fixation. A total of 302 visceral vessels were incorporated in the prosthesis design. Endoleaks were depicted on the post-procedural CT scan as detailed in Table 2. Four of six patients with proximal type I endoleaks underwent post-operative secondary procedures prior to hospital discharge. There were no mortalities associated with secondary procedures.

Discussion

Endovascular repair has been embraced by vascular surgeons since its introduction in 1991. Criticisms of the technique have included the potentially inferior durability of endovascular repair compared to open repair

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and the requirement for more assiduous follow-up. However, despite the increased requirement for secondary intervention, most of these procedures (all in our series) can be performed endoluminally with minimal morbidity.(11,12) Given the relative complexity of the planning and execution of the technique using fenestrated grafts, experience has been limited to centers with extensive experience with endovascular grafting.(6,8,13–16)

Most of the centers performing appreciable numbers of fenestrated grafts are now at the stage of reporting their intermediate-term results. The intermediate-term results of fenestrated grafts seem to support their continued use, especially in patients with anatomic contraindications for standard EVAR. Close surveillance is important for early identification of visceral or branched vessel stenosis and preocclusion. Failure, although uncommon, as a result of death, secondary interventions, branch vessel patency, and complications seem to occur most commonly during the first year and then diminish.15 As the procedure matures, long-term results and randomized clinical trials will ultimately be required to determine the safety, efficacy, and stability of the procedure itself as well as devices. The definition of complications also merits discussion. In the CCF series, there were 30 endoleaks out of 119 patients. 8All of those that underwent a secondary intervention had them carried out endoluminally. Historically, most type 2 endoleaks do not require intervention. When they do, the procedures are done with a miniscule incidence of morbidity and mortality. Thus, it is debatable whether

type 2 endoleaks should be classified as complications of endovascular repair. Secondary interventions have long been considered the bane of EVAR. However, all of the interventions in our series of complex grafts were achieved with endovascular means without recourse to open surgery. The magnitude of the intervention and its associated morbidity is more important than its mere existence. In EVAR 2, there were 32 secondary interventions out of 178 patients, including 3 conversions to open surgery. It seems unlikely that secondary interventions contributed appreciably to the mortality rate in our series or in EVAR 2 as the 30-day mortality rate following secondary intervention was 0 in EVAR 2 and 1 patient in our series.

Complications

As listed in table 1, 2 could be systemic or related to the procedure.Regarding the patient with renal impairment, in his report Chao demonstrated the feasibility and safety of using carbon dioxide digital subtraction angiography for EVAR10 but it is not popular.Regardless the type of endograft used; there is a 10% decrease in creatinine clearance in the first year after endovascular aneurysm repair. Suprarenal fixation does not seem to increase postoperative renal impairment. Decline in renal function over time after endovascular aortic repair is probably due to multiple factors, and measures known to be effective in protecting kidneys should be considered for these patients. Long-term follow-up with measurement of creatinine clearance, along with renal imaging and regular blood pressure measurements



Systemic: Myocardial infarction, congestive heart failure, arrhythmias, respiratory, renal failure.Procedure related: Dissection, malpositioning, renal failure, thromboembolizaton, ischemic colitis, groin hematoma, wound infection.Device related:Migration, detachment, rupture, stenosis, kinkingEndoleak and endotension

Type I - Perigraft leakage at proximal or distal graft attachment sites (near the renal and iliac arteries)Type II - Retrograde flow from collateral branches such as the lumbar, testicular and inferior mesenteric arteries. Type III - Leakage between different parts of the stent (at the anastomosis between components) Type IV - Leakage through the graft wall

should be performed to detect possible late renal dysfunction. Elevated creatinine level should not Metha11 who also reported that perioperative hypotension and increased contrast volume are significant risk factors report a contraindication for EVAR as in prospective control study. Endoleaks and endotension: An endoleak is a leak into the aneurysm sac after endovascular repair. Type II occurs in nearly 15% of patients and the early incidence varies only slightly with graft type. The long-term prevalence and clinical significance are masked by different treatment patterns, spontaneous resolution, newly evident endoleaks, and aneurysm size at initial treatment.(12) Endotenion and sac pressure can be assessed and monitor such pressure by implanting remote sensor. In his report, Hoppe demonstrated that; In all patients (12 patients) , post-EVAR systolic sac pressure decreased by an average of 33% (P </= 0.005) compared to pre-EVAR measurements, and a 47% decrease at one-month (P </= 0.05). On follow-up CT scans, the average maximum aneurysm diameter pre-EVAR was 6.3 +/- 1.6 cm and post-EVAR 6.0 +/- 1.7 cm (P</=0.05). Remote sac pressure measurement may provide important information in addition to

imaging and may help to reduce the number of follow-up CT scans13. The incidence of endoleaks after EVAR is 10%-20%. Significant endoleaks should be treated promptly. Endovascular treatment can be done with different techniques, but success in not constant due to adverse anatomical conditions and technical difficulties. There was no significant difference in the performance of the two endografts but the direction of results was slightly in favour of patients with Zenith (versus Talent) endografts.(14)In a mid term study: Between June 1999 and January 2005, 109 selected patients were suitable and treated (EVAR). Assisted primary technical success was achieved in 99%. No type I endoleaks and 11% type II at 1 month. Complete resolution of type II endoleaks, and the overall prevalence of type II endoleaks was 14%. Shrinkage at 1, 2, 3, and 4 years was observed in 20.7%, 30.5%, 38.9%, and 36.8% of cases. The presence of type II endoleak influenced the trend of aneurysm size throughout the 4 years. Aneurysms without endoleak shrank more than aneurysms with type II endoleak(15) and this also supported by Tonnesseen and his group.(16) Continuous expansion of the aneurysm sac diameter after EVAR

Table 1 & 2. Complications of Endovascular Treatment of AAA

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without obvious endoleak should be treated immediately either by endovascular or conventional surgery to avoid lethal rupture. Stent-graft infection may be a cause of unexplained endotension. Special culture techniques may be required to identify the infecting organism. Prophylactic antibiotics against skin organisms should be considered for all implantations and arterial diagnostic and therapeutic procedures traversing a stent-graft.(17) Close surveillance after endovascular AAA repair is essential to detect late leaks, secondary migration, endotension, structural failure, and infection with or without aortoenteric fistula.(18) The advantages and disadvantages of EVAR have been demonstrated through a large number of publications, including randomized trials.

The UKEVAR trial 1 compared EVAR against open repair in patients fit for conventional repair and anatomically suitable for EVAR. EVAR patients suffered 3% less mortality (65% relative risk reduction) compared to open repair patients. Although, EVAR patients were better in terms of overall survival and health-related quality of life in the first year after the operation, but they required a larger number of secondary interventions during late follow-up compared to the open repair patients. Although originally developed for ‘unfit’ patients, EVAR appear to benefit the ‘fit’ patients more than the ‘unfit’ ones. It is interesting in this context to note that UK-EVAR trial 2, comparing EVAR against best medical treatment in patients anatomically suitable for EVAR(19) and considered unfit for open repair, failed to demonstrate survival advantage with EVAR. However, it should

also be noted that the effect of certain aspects of this study are being debated, and not everyone is convinced that patients unfit for open repair should not be offered an EVAR. There is sufficient evidence now to support the view that EVAR is the treatment of choice for fit patients with anatomically suitable infrarenal aortic aneurysms. Modifications of the technique and adjuvant procedures exist to help in this regard, and patient selection is influenced significantly by experience.

Future prospect

Since the introduction of the technique, EVAR has evolved at a rapid pace level -1 evidence is currently available supporting its routine use for the treatment of infrarenal aortic aneurysms that are suitable for a standard stent-graft. Fenestrated stent-grafts are now available for treatment of juxtarenal aneurysms that are not suitable for a standard stent-graft due to short aneurysm neck. This technology is complex and in its relatively early stages, with encouraging early reports. Longer term results are awaited. Physicians performing EVAR should plan their stent-grafts and not relegate this duty to others.

The main question needed a clear accepted answer with the availability of such technology (available for rupture aneurysm) and the essential required skills; should EVAR be consider a primary treatment for AAA and what will be future impacts on our health finance (as EVAR is not cost effective) and future surgical training( in some centres this procedure fully performed by physicians) since we left the conventional open surgery with more complex AAAs



Type of fenestration Renal vessels SMA Infrarenal neck

Single scallop Not at same levels and distance 3-9mm 20 mm or more

Two scallop Within 3mm 8-15 mm

A scallop & SF Not on same level distance from mid line of lower renal and lower limit of SMA is > 12mm. is< 10 mm

2SFWhen distance from mid line of upper renal and lower limit of SMA is > 12 mm.

Is < 10 mm

2SF & a scallop

When distance from mid line of upper renal and lower limit of SMA is > 5mm (distance of the celiac artery above the SMA should be checked to ensure that it is clear of the upper edge of the graft).

Is < 10 mm

2SF& and LFWhen distance from mid line of upper renal and lower limit of SMA is less than 5 mm

Is < 10 mm

Graft Diameters Minimum vessel Diameter 22-36mm Proximal Body (20Fr) 7.5 mm

Distal Body (20Fr) 7.5 mm8-16mm TFLE Leg extension (14Fr) 5 mm

18-24mm TFLE Leg extension (16Fr) 6 mm

Working sheet 1- for planning a fenestrated graft

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Working sheet 2



(anatomically or stented AAA) which are more surgical demanded and subsequently left us with higher mortality and morbidity with such open surgery. Also we should look seriously, at that group of patients whom they have endotesion and no obvious endoleak can detected and their aneurysm showing no reduction in the diameter or quite slow expansion and assess the risk of stent rupture.

References

1.Scott RA, Wilson NM, Ashton HA, Kay DN. Influence of screening on the incidence of ruptured abdominal aortic aneurysm: 5-year results of a randomized controlled study.Br J Surg. 1995 Aug;82(8):1066-70.2.Wilmink TB, Quick CR, Hubbard CS, Day NE.The influence of screening on the incidence of ruptured abdominal aortic aneurysms.J Vasc Surg.1999 Aug;30(2):203-8.3.Deville C, Kerdi S, Madonna F, de la Renaudière DF, Labrousse L.Infrarenal abdominal aortic aneurysm repair: detection and treatment of associated carotid and coronary lesions.Ann Vasc Surg. 1997 Sep;11(5):467-72.4.Rakita D, Newatia A, Hines JJ, Siegel DN, Friedman B.:Spectrum of CT findings in rupture and impending rupture of abdominal aortic aneurysms.Radiographics. 2007 Mar-Apr;27(2):497-507.5.Siegel CL, Cohan RH, Korobkin M, Alpern MB, CourneyaDL,:Abdominal aortic aneurysm morphology: CT features in patients with ruptured and nonruptured aneurysms.AJR Am J Roentgenol. 1994 Nov;163(5):1123-9.

6.Fillinger MF, Racusin J, Baker RK, Cronenwett JL, Teutelink A, Schermerhorn ML, Zwolak RM, Powell RJ, Walsh DB, Rzucidlo EM. Anatomic characteristics of ruptured abdominal aortic aneurysm on conventional CT scans: Implications for rupture risk.J Vasc Surg. 2004 Jun;39(6):1243-52.7.Komori K, Furuyama T, MaeharaY.Renal artery clamping and left renal vein division during abdominal aortic aneurysm repair.Eur J VascEndovasc Surg. 2004 Jan;27(1):80-38.Nishibe T, Sato M, Kondo Y, Kaneko K, Muto A, Hoshino R, Kobayashi Y, Yamashita M, Ando M.Abdominal aortic aneurysm with left-sided inferior vena cava. Report of a case.IntAngiol. 2004 Dec;23(4):400-2.9.Sampaio SM, Panneton JM, Mozes G, Andrews JC, Noel AA, Kalra M, Bower TC, Cherry KJ, Sullivan TM, GloviczkiP.Aortic neck dilation after endovascular abdominal aortic aneurysm repair: should oversizing be blamed?Ann Vasc Surg. 2006 May;20(3):338-45. Epub 2006 May 19.10.Chao A, Major K, Kumar SR, Patel K, Trujillo I, Hood DB, Rowe VL, Weaver FA.Carbon dioxide digital subtraction angiography-assisted endovascular aortic aneurysm repair in the azotemic patient.J Vasc Surg. 2007 Mar;45(3):451-8.11.Mehta M, Veith FJ, Lipsitz EC, Ohki T, Russwurm G, Cayne NS, Suggs WD, Feustel PJ.Is elevated creatinine level a contraindication to endovascular aneurysm repair?J Vasc Surg. 2004 Jan;39(1):118-23.12.Sheehan MK, Ouriel K, Greenberg R, McCann R, Murphy M, Fillinger M, Wyers M, Carpenter J, Fairman R, MakarounMSAre type II endoleaks after endovascular aneurysm repair endograft dependent?J Vasc Surg. 2006 Apr;43(4):657-61.

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13.Hoppe H, Segall JA, Liem TK, Landry GJ, Kaufman JA.Aortic aneurysm sac pressure measurements after endovascular repair using an implantable remote sensor: initial experience and short-term follow-up.EurRadiol. 2008 May;18(5):957-65.14.PozziMucelli F, Doddi M, Bruni S, Adovasio R, Pancrazio F, Cova M. Endovascular treatment of endoleaks after endovascular abdominal aortic aneurysm repair: personal experience.Radiol Med (Torino). 2007 Apr;112(3):409-19.15.Melissano G, Bertoglio L, Esposito G, Civilini E, Setacci F, Chiesa R.Midterm clinical success and behavior of the aneurysm sac after endovascular AAA repair with the Excluder graft.J Vasc Surg. 2005 Dec;42(6):1052-7.16.Tonnessen BH, Sternbergh WC 3rd,

Money SR.Mid- and long-term device migration after endovascular abdominal aortic aneurysm repair: a comparison of AneuRx and Zenith endografts.J Vasc Surg. 2005 Sep;42(3):392-40017.Ferrar DW, Roberts AK, Lawrence-Brown MM, McLellan D, SemmensJB.Infectedendoluminal stent-graft: implications for endotension, late endoleaks, and prophylactic antibiotics.J EndovascTher. 2005 Dec;12(6):654-9.18.Kar B, Dougherty K, Reul GJ, KrajcerZ.Aortic stent-graft infection due to a presumed aortoenteric fistula.J EndovascTher. 2002 Dec;9(6):901-6.19.Greenhalgh RM, Powell JT. Endovascular Repair of Abdominal Aortic Aneurysm. NEJM 2008;358:494-501.

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An Update on the Management of Carotid Body Tumours

McHugh SM, Sayed Aly

Department of Surgery, Connolly Memorial Hospital, Blanchardstown, Dublin15

Abstract

Introduction: Tumours of the carotid body are rare with an incidence of 0.012%, arising from paraganglionic tissue at the bifurcation of the common carotid artery. We aimed to determine best practice in diagnosis and treatment of CBT through a detailed review of the literature.

Methods: An extensive review of the literature was carried out in both online medical jour-nals and through the Royal College of Surgeons in Ireland library.Both retrospective and prospective studies were included, as well as case reports.

Results: Clinical presentation can be variable and patients with a neck mass or a cranial nerve deficit should be suspected of having a CBT. Novel imaging modalities such as CT or MR angiography are reliable diagnostic techniques allowing for earlier detection. Digital subtraction angiography (DSA) remains the gold standard for diagnosis. The treatment of choice is surgical resection. There have been advances in radiation therapy (RT)which have been recently shown to produce comparable results. In addition small studies have reported lower neurological complications with similar tumour control through stereotactic radiosur-gery.

Conclusion: Recent advances in diagnostic imaging may improve the standard of care in management of CBT. The comparative rarity of CBT poses a distinct challenge as there re-mains a lack of high powered randomised studies comparing treatment modalities.

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Introduction

Carotid body tumours (CBT) are neoplasms that arise from paraganglionic chemoreceptor cells. Tumours of the carotid body are rare with an incidence of 0.012%.(1)

Other terms used to describe these lesions include glomus tumours, paragangliomas, or chemodectomas.(2) Carotid body tumours arise from paraganglionic tissue at the bifurcation of the common carotid artery. With regard to epidemiology CBT is most often seen in patients aged between 50 and 70 years old.There is a higher incidence in females than that in males.(3)In 1953, Linder classified the tumours of the carotid body.(4) Twenty years later Shamblin et al repeated the same classification based on the size and involvement of the carotid artery.(5)

According to Shamblin’s classification of three types type I refers to CBT without encasement of the vessel, size <5 cm and no widened carotid bifurcation. Type II refers to those attached to the blood wall, but without encasement. Type III refers to those located inside the blood vessel with encasement of the blood wall, as well as a tumour size larger than 5 cm and widened carotid bifurcation.(3)

The pathogenesis of CBT remains unknown but hypoxia and genetic factors are thought to be involved. Studies have shown that chronic hypoxia due to sleep apnoea could stimulate hyperplasia of the carotid glands. In CBTsgenetic predisposition accounts for 35% of diagnoses.(6)

Diagnosis

The clinical symptoms vary according to size and locationof the tumour.As regards

presentation patients may present with a mass alone. Patients with a neck mass, a cranial nerve deficit or a pulsatile tinnitus can besuspected of a head and neck paraganglioma.(7) However presentation can also be withheadache, change in voice or vertigo.Compression of surrounding nerve structures leads to corresponding symptoms in the nerve-dominated area.A cranial nerve deficit is seldom present but when present the vagus nerve is most often involved.(8-10)

Cranial nerves eight to twelve may lead to the corresponding signs, but the mandibular ramus of the seventh cranial nerve is rarely involved.

Digital subtraction angiography (DSA) is the gold standard for the final diagnosis of CBTs. Formal angiography also provides for the opportunity for embolisation of blood vessels. This can result in a decrease in intra-operative blood loss.Computed Topography (CT) angiography and magnetic resonance imaging (MRI) can also facilitate demonstrationof the relationship of the tumour with the surrounding tissues. Although CT is the procedure of choice for evaluation of bone involvement, Magnetic resonance imaging provides more information regarding adjacent vascular and skull base structures.(11) Characteristic imaging combined with and location of CBTs coupled with the history and physical examination should enable the correct diagnosis to be made.

Treatment

The treatment of choice is surgical resection.12However surgery is relatively contraindicated in extensive skull base

An Update on the Management of Carotid Body Tumours 65


involvement and multiple paraganglioma that may increase post-operative morbidity and mortality. There have been advances in radiation therapy (RT)which have been recently shown to produce comparable results. When considering surgical resection consideration should be given as mentioned previously to preoperative remobilization of the tumour’s main arterial supply. This can reduce bleeding thus facilitating resection.(13) Similarly there have been reports in the literature of the use of carotid stenting as an adjunct pre-operatively to decrease tumour blood supply before resection thus again minimising blood loss.(14,15) Although the risk of metastatic disease is small, all enlarged ipsilateral lymph nodes should be removed.

Complications of surgery include cerebrovascular accident (CVA) or cranial nerve injury. Permanent cranial nerve deficit of up to 40% has been reported.(16,17) Post-operative morbidityfor Shamblin type I and II carotid body tumours islower than for type III tumours. The incidence of cerebrovascularcomplications is less than 5%, and permanentcranial nerve impairment occurs in 20% for type III tumours.(18,19)

In additionsurgical resection of bilateral carotid body tumours may cause baroreflex failure syndrome, characterized by severe hypertension in the first 72 hours followed by labile blood pressure readings and palpitations.(20-22)

Recent publications have highlighted new treatment modalities which may improve the standard of care in treatment of CBT. Stereotactic radiosurgery delivers high-dose radiation to a localized field. It aims

to increase the chances of obliterative endarteritis and reduce complications by sparing adjacent normal structures.(23)

One such study assessing stereotactic radiosurgery from Egypt assessed 13 cases treated using gamma knife surgery with a follow-up from 12 to 48 months.(23) Here five patients showed improvement in their neurological symptoms and seven cases had stable clinical disease.

Similar findings have been previously reported in the literature. A 2004 study assessing stereotactic radiosurgery in 19 patients noted a 31% decrease in size, with 67% remaining unchanged. Progression-free survival was 100% at 3 and 7 years, and 75% at 10 years.(24) A similar studyof 14 patients noted that the size eight lesions became smaller while 6 remain unchanged with stereotactic radiosurgery.(25) However this treatment modality is not without complications, with hearing loss, facial numbness, vocal cord paralysis and temporary imbalance all previously reported. (24) Despite these potential complications it has been suggested that quality of life indices would appear to be more significant in those undergoing stereotactic radiosurgery as compared to traditional surgical excision.(23,

26, 27)

Radiation therapy is an effective therapeutic option especially in the management of unresectable paraganglioma.(28,29) There is rarely total resolution of the tumour after radiation therapy hence local control usually means stability of tumour size and non-progression of neurological symptoms. A recent retrospective study assessed 31


66


patients with paraganglioma treated between 1963 to 2005. Local control at 15 years was 90%.(30)However there are no randomized trials that compare RT to surgery. Surgery remains the standard of care.

Prognosis

Given the comparative rarity of carotid body tumours, there exists a paucity of evidence based publications assessing suitable numbers of patients over a prolonged post treatment period. One study focussing on long term outcome post surgical resection had a median postoperative follow-up of 6.4 years (range 1.5 to 20 years). Seventeen patients in all were assessed. The overall survival rate was 82.4% with a disease-specific survival of 94.1%.(31) A larger retrospective previous review of long term follow up post surgical resection examined 59 carotid body tumours in 55 patients. They

reported a perioperative mortality of only 2%. Survival of patients was reported as equivalent to that for sex- and age-matched control subjects. Only one patient (2%) had development of metastatic disease during long-term follow-up with three patients (6%) having recurrence after complete excision. In all cases of recurrent carotid body tumours they were observed in patients with multiple paragangliomas or a family history of cervical paragangliomas.(32)

A further study from the Netherlands assessed long-term survival of patients with paraganglioma of the head and neck compared with the survival of the general Dutch population. A cohort of 86 patients diagnosed with a paraganglioma of the head and neck between 1945 and 1960 in the Netherlands.The mean survival of the patient group was 26.4 years after diagnosis, whereas the mean expected



survival of the general population was 28.02 years. The average loss of life expectancy was 1.62 years which was explained as secondary to immediately post operative mortalities. However as pointed out by this study even though no decreased residual life span can be attributed to head and neck paragangliomas, the quality of life of these patients is reduced.(18)

Discussion

First described in the literature in 1891,(33)

there have been a large number of sporadic reports in literature concerning carotid body tumours. CBT is bilateral in approximately 5% of cases and 33% of the sporadic and familial forms respectively.(34) It often presents as a gradually enlarging mass that is incidentally identified.(35) The larger the tumour the more neural and vascular injuries occur. It is evident that early diagnosis is of paramount importance. Lack of clinical diagnosis has been reported in up to 30% of casesas a result of CBTs being misdiagnosed ascervical lymphadenopathy or brachial cysts.(35)Novel imaging modalities such as CT or MR angiography are reliable diagnostic techniques allowing for detection at an earlier stage often before the tumour becomes clinically evident.(35)

Treatment options for paragangliomas include surgical resection, radiation therapy, embolisation, stenting or anycombination of these treatment modalities.Pre-operative adrenergic blockade should be considered.(36) In case of a solitary paragangliomathe risks of treatment are mostly related to thelocation of the paraganglioma.(7)The

most importantdeterminant is the size and a progressivecranial nerve deficit.(37-41) Overall prognosis is quite good with complete surgical resection.(36) Novel techniques such as stereotactic radiosurgery have been reported as having success in achieving tumour control with a low risk of new cranial nerve injury.(24) However because of the relative rarity of CBT, there exists a paucity of high volume randomised controlled trials comparing treatment modalities in terms of tumour control, peri-procedural morbidity and long term prognostic implications.

Conclusions

Carotid body tumours represent a unique surgical challenge due to their proximity to surrounding neural and vascular structures. Pre-operative optimisation both of the patient and the tumour size is paramount in decreasing post-procedural complications. Novel treatment modalities such as stereotactic radiosurgery may offer comparative tumour control with fewer cranial nerve injuries. However high power multicentre randomised controlled trials comparing different treatment modalities are lacking as a result of the rarity of carotid body tumours in the population.

References

1.Grotemeyer D, Loghmanieh SM, Pourhassan S, et al. [Dignity of carotid body tumors. Review of the literature and clinical experiences]. Chirurg 2009;80:854-63.2.Prasad SC, Thada N, Pallavi, Prasad KC. Paragangliomas of the Head & Neck: the KMC experience. Indian J Otolaryngol Head


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Neck Surg;63:62-73.3.Ma D, Liu M, Yang H, Ma X, Zhang C. Diagnosis and surgical treatment of carotid body tumor: A report of 18 cases. J Cardiovasc Dis Res;1:122-4.4.Linder F. Tumoren der Karotisdrüse. Langenbecks Arch Chir Suppl Kongressbd 1953;276:156–162.5.Shamblin WR, ReMine WH, Sheps SG, Harrison EG, Jr. Carotid body tumor (chemodectoma). Clinicopathologic analysis of ninety cases. Am J Surg 1971;122:732-9.6.Drovdlic CM, Myers EN, Peters JA, et al. Proportion of heritable paraganglioma cases and associated clinical characteristics. Laryngoscope 2001;111:1822-7.7.Van den Berg R. Imaging and management of head and neck paragangliomas. Eur Radiol 2005;15:1310-8.8.Baysal BE, Ferrell RE, Willett-Brozick JE, et al. Mutations in SDHD, a mitochondrial complex II gene, in hereditary paraganglioma. Science 2000;287:848-51.9.Forsythe JA, Jiang BH, Iyer NV, et al. Activation of vascular endothelial growth factor gene transcription by hypoxia-inducible factor 1. Mol Cell Biol 1996;16:4604-13.10.Gardner P, Dalsing M, Weisberger E, Sawchuk A, Miyamoto R. Carotid body tumors, inheritance, and a high incidence of associated cervical paragangliomas. Am J Surg 1996;172:196-9.11.Hu K, Persky MS. Multidisciplinary management of paragangliomas of the head and neck, Part 1. Oncology (Williston Park) 2003;17:983-93.12.Park SJ, Kim YS, Cho HR, Kwon TW. Huge carotid body paraganglioma. J Korean Surg Soc;81:291-4.13.Wang SJ, Wang MB, Barauskas TM,

Calcaterra TC. Surgical management of carotid body tumors. Otolaryngol Head Neck Surg 2000;123:202-6.14.Nussbaum ES, Levine SC, Hamlar D, Madison MT. Carotid stenting and “extarterectomy” in the management of head and neck cancer involving the internal carotid artery: technical case report. Neurosurgery 2000;47:981-4.15.McDougall CM, Liu R, Chow M. Covered Carotid Stents as an Adjunct in the Surgical Treatment of Carotid Body Tumors: A Report of Two Cases and a Review of the Literature. Neurosurgery.16.Dickinson PH, Griffin SM, Guy AJ, McNeill IF. Carotid body tumour: 30 years experience. Br J Surg 1986;73:14-6.17.Wax MK, Briant TD. Carotid body tumors: a review. J Otolaryngol 1992;21:277-85.18.Netterville JL, Civantos FJ. Rehabilitation of cranial nerve deficits after neurotologic skull base surgery. Laryngoscope 1993;103:45-54.19.Van der Mey AG, Jansen JC, van Baalen JM. Management of carotid body tumors. Otolaryngol Clin North Am 2001;34:907-24, vi.20.Papaspyrou K, Mann WJ, Amedee RG. Management of head and neck paragangliomas: review of 120 patients. Head Neck 2009;31:381-7.21.Sajid MS, Hamilton G, Baker DM. A multicenter review of carotid body tumour management. Eur J Vasc Endovasc Surg 2007;34:127-30.22.Verillaud B, Ducros A, Massiou H, Huy PT, Bousser MG, Herman P. Reversible cerebral vasoconstriction syndrome in two patients with a carotid glomus tumour. Cephalalgia;30:1271-5.



23.Hafez RF, Morgan MS, Fahmy OM. The safety and efficacy of gamma knife surgery in management of glomus jugulare tumor. World J Surg Oncol;8:76.24.Pollock BE. Stereotactic radiosurgery in patients with glomus jugulare tumors. Neurosurg Focus 2004;17:E10.25.Ganz JC, Abdelkarim K. Glomus jugulare tumours: certain clinical and radiological aspects observed following Gamma Knife radiosurgery. Acta Neurochir (Wien) 2009;151:423-6.26.Sharma MS, Gupta A, Kale SS, Agrawal D, Mahapatra AK, Sharma BS. Gamma knife radiosurgery for glomus jugulare tumors: therapeutic advantages of minimalism in the skull base. Neurol India 2008;56:57-61.27.Sheehan J, Kondziolka D, Flickinger J, Lunsford LD. Gamma knife surgery for glomus jugulare tumors: an intermediate report on efficacy and safety. J Neurosurg 2005;102 Suppl:241-6.28.Hatfield PM, James AE, Schulz MD. Chemodectomas of the glomus jugulare. Cancer 1972;30:1164-8.29.Kataria T, Bisht SS, Mitra S, Abhishek A, Potharaju S, Chakarvarty D. Synchronous malignant vagal paraganglioma with contralateral carotid body paraganglioma treated by radiation therapy. Rare Tumors;2:e21.30.Chino JP, Sampson JH, Tucci DL, Brizel DM, Kirkpatrick JP. Paraganglioma of the head and neck: long-term local control with radiotherapy. Am J Clin Oncol 2009;32:304-7.31.Kotelis D, Rizos T, Geisbusch P, et al. Late outcome after surgical management of carotid body tumors from a 20-year single-center experience. Langenbecks Arch Surg

2009;394:339-44.32.Nora JD, Hallett JW, Jr., O’Brien PC, Naessens JM, Cherry KJ, Jr., Pairolero PC. Surgical resection of carotid body tumors: long-term survival, recurrence, and metastasis. Mayo Clin Proc 1988;63:348-52.33.Dias Da Silva A, O’Donnell S, Gillespie D, Goff J, Shriver C, Rich N. Malignant carotid body tumor: a case report. J Vasc Surg 2000;32:821-3.34.Saldana MJ, Salem LE, Travezan R. High altitude hypoxia and chemodectomas. Hum Pathol 1973;4:251-63.35.Martinelli O, Irace L, Massa R, et al. Carotid body tumors: radioguided surgical approach. J Exp Clin Cancer Res 2009;28:148.36.Wieneke JA, Smith A. Paraganglioma: carotid body tumor. Head Neck Pathol 2009;3:303-6.37.Erickson D, Kudva YC, Ebersold MJ, et al. Benign paragangliomas: clinical presentation and treatment outcomes in 236 patients. J Clin Endocrinol Metab 2001;86:5210-6.38.Jackson CG. Neurotologic skull base surgery for glomus tumors. Diagnosis for treatment planning and treatment options. Laryngoscope 1993;103:17-22.39.Saringer W, Kitz K, Czerny C, et al. Paragangliomas of the temporal bone: results of different treatment modalities in 53 patients. Acta Neurochir (Wien) 2002;144:1255-64; discussion 64.40.Thabet MH, Kotob H. Cervical paragangliomas: diagnosis, management and complications. J Laryngol Otol 2001;115:467-74.41.Woods CI, Strasnick B, Jackson CG. Surgery for glomus tumors: the Otology Group experience. Laryngoscope 1993;103:65-70.

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An Objective Classification for Peripheral Arterial Disease (Study in Progress)

Sameh El Imam MSc, A. Allam MD, S. Shoab MD (UCL), FRCSS. Aly PhD (UCL), FRCSI,

Department of Vascular Surgery, Alzahraa University Hospital, Alazhar University (Cairo, Egypt) & RCSI (Beaumont, HMC, Beacon Hospitals); Dublin, Ireland

Atherosclerotic peripheral arterial disease (PAD) involving one or more major vessels ofthe lower limb is common, especially in older patients, due to complex genetic andenvironmental interactions which result in structural and functional vascular abnormalities and reduced blood flow. PAD may be asymptomatic in the early stages, butis always associated with shortened survival due to the invariable association with atherosclerosis in other arterial territories, especially the coronary, carotid and cerebral circulation.

This is highlighted by observational studies showing that reduced ankle– brachial pressure index (ABPI, a marker of disease severity in PAD) is associated with anincreased risk of cardiovascular mortality(1)

However, calcification andsclerosislead to incompressible arteries, with false elevation of ABPI even in thepresenceofmajor distal atherosclerosis. The Strong Heart Study has identified associations between low (<0.90) and high (>1.40) ABPI and increased risk of all-causeandcardiovascular (CV) disease mortality, reporting a Ushaped relationship between anon invasive measureof PAD andreduced life expectancy (Fig.1.1).(2)

For example, adjusted risk estimates for allcause mortality were 1.69 forlow and 1.77 forhighABPIwhile the corresponding estimates for CV disease mortalitywere 2.52 and2.09.(2) Atherosclerotic peripheral arterial disease (PAD) involving one or more major vessels ofthe lower limb is common, especially in older patients, due to complex genetic and environmental interactions which result in structural and functional vascular abnormalities and reduced blood flow.

PAD may be asymptomatic in the early stages, butis always associated with shortened survival due to the invariable association with atherosclerosis in other arterial territories, especially the coronary, carotid and cerebralcirculation. This is highlighted by observational studies showing that reduced ankle– brachial pressure index (ABPI, a marker of disease severity in PAD) is associated with anincreased risk of cardiovascular mortality (Table1.1).(1)

However, calcification and sclerosis lead to incompressible arteries, with false elevation of ABPI even in thepresenceof major distal atherosclerosis. The Strong Heart Study has identified associations between low (<0.90) and high (>1.40) ABPI and increased

Sameh El Imam, A. Allam, et. al.

72


risk of all-causeandcardiovascular(CV) disease mortality, reporting a U shaped relationshipbetween anon invasive measureof PAD and reducedlife expectancy(Fig. 1.1).(2) For example,adjusted risk estimates for all cause mortality were1.69 for low and1.77 for high ABPI,while the corresponding estimates for CV disease mortality were 2.52 and 2.09.(2) The epidemiology of PAD, the observational studies identifyingreversibleandirreversiblerisk factors for disease progression, and the evidence fromrandomisedcontrolled trials which underpins clinical use of disease-modifying therapies as part of multiple risk factor intervention.

The incidence of critical limb ischaemia has been estimated to be around 400 cases permillion population per year, which equates to a prevalence of 1 in 2500 of the population annually.(14) For every 100 patients with intermittent claudication,approximatelyone new patientper year will develop critical ischaemia.(8) Naturally; 70-80% of claudicants will stabilise in he following 1-2 years and 1-9% will deteriorate to critical leg ischaemia in 1-2 years and then 1-2% every following year.Advances in the vascular technology and availability to vascular laboratory did help us to come out with a more practical classification offer us diagnosis and predicate the prognosis. We are here present our phase 1 of the prospective study, which help us to establish its value in the infra-geniculate circulation. In this classification we utilise the accurate evaluation of imaging of Duplex scanning, and image analysis capability of the grey scale to characterise

the atherosclerotic lesion and subsequently advocate the interventional tool and finally predicate the prognosis and out comes. This study was to determine which variables have an implication on management and prognosis of lower limbs arterial disease. Also, to establish an objective classification can be used in practice. In his study by S.Aly (2002, stroke) all the variables of duplex scanning machine, which have influence on the images, were examined and the machine was caliberated for evaluation.

Methods

A total of 2264 arterial segments were examined in 70 patients (50 males. 20 females, median age 68 years) with duplex scan and arteriography. Using duplex ultrasonography the following variables were studied: morphology, surface, degree of the stenosis, and length of lesion. Peak systolic velocity ratio (PSVR) is a well-recognised measure of degree of stenosis.

An image analysis computer (QV200) has been used to determine the mean grey scale, which is able to differentiate between plaque components and determine the surface integrity. A total of 3820 grey-scale calibrated duplex scan images were recorded and analysed using QV200 at Log 40, 0/2/0/ with a gain of -5 to discriminate between the variables in each plaque. The integrity of the surface, length and site of the lesion were determined accurately.

Results

In 3820 images mean of the grey scale

An Objective Classification for Peripheral Arterial Disease 73


was able to discriminate between variable components of the plaque with a sensitivity of 100 per cent and a specificity of 100 per cent. Blood and fat have the lowest pixel value (0-50 mean pixel value), while fibrous tissue and calcium have the highest pixel value (150-256 mean pixel value) compared to the ideal point of if calibrated the scanner when recorded at Log 40, 0/2/0/ with gain of -5.(fig.1)

Seventy per cent of the stenotic lesions were smooth and 30 per cent were ulcerated. A PSVR of 2.0 was able to identify the degree of stenosis with an overall sensitivity of 94 per cent, a specificity of 99 per cent, a positive predictive value of 91 per cent and a negative predictive value of 99 per cent. Duplex scanning was able to determine the length of the diseased segment with a sensitivity of 97 per cent and a specificity of 99 per cent compared with arteriography. Our proposed (MIDL) classification is: Morphology:1) echolucent lesion (i.e. thrombus and fat) (0-50 mean pixel value); 2) Mixed (containing all components) (50-150 mean pixel value);3) Echogenic

(fibrocalcified lesion) (150-256 mean pixel value). (fig. 2)Integrity of surface: Smooth (l), Ulcerated (2)Occlusive.(3)Diameter reduction: Insignificant (I), Significant (2), Occlusive (3). Length: (I) <5cm; (2) 5-10cm; (3) > I0cm.Site (CF, SFA 1,2,3, FP, P1,2, AT 1,2,3,4, PT 1,2,3,4, PA1,2,3,4)

Conclusion

The MIDLS classification provides both morphological and function data that are not only useful in the management of peripheral arterial disease but also allow objective comparison between populationsand predict the prognosis.

Peripheral artery occlusive disease is commonly divided in the Fontaine stages, introduced by René Fontaine in 1954 for ischemia: •Stage I: Asymptomatic, incomplete blood vessel obstruction•Stage II: Mild claudication pain in limb•Stage IIA: Claudication at a distance of


74


M I D L S1= <50 O = occlusive O=occlusive 5cm CF

2 = 50-150 S= smooth Is=insignificant 5/10 SFA 1,2,33 = >150 U=ulcerated Si=significant 10cm PF

P1, 2AT 1,2,3,4PT1,2,3,4PA1,2,3,4

Middlesex Classification (MIdl)

We Propose the Prospective Study to Adopt the Retrograde Approach for the Distal Lesion

Figure 1. Aly S , and Bishop C C Stroke 2000;31:1921-1924

An Objective Classification for Peripheral Arterial Disease 75


An Objective Characterization of Atherosclerotic LesionTable 1. Technical Definition and Scale of Each of the Controls

Parameter Definition and Range ExaminedOverall gain Adjusts gain with respect to the maximum availablePreprocessing Largely controls enhancement of edges of structuresPersistence Frame averaging to reduce coherent specklePostprocessing1 A compression function to permit the display of a

wide echo dynamic range by mapping ranges of echo amplitudes to single shades of gray scale

Log compression A particular function to map the intensity of the returned echo to different shades of gray scale

Transmit power The ultrasound power actually emitted in relation to the maximum available on the machine

Transmit zone Depth of region dynamically focused on transmitDepth gain compensation2 Compensates for attenuation, the loss in the echo

signal strength, as the ultrasound passes through the tissues

•In this study, the transmit power was kept at 0 dB to produce the maximum power output, and the preprocessing was kept at zero to avoid introducing high values from edges. Log compression: at 40 to 50 dB or middle range; persistence: at 2 or 3, to obtain some noise reduction by frame averaging; postprocessing: 0, 2, or 6 to assess the effect of the compression; gain at −5, 0, and +5 dB, at single transmit zone and multiple transmit zones.•1 For convenience, preprocessing, persistence, and postprocessing values are written for example, as 0/2/0, where the numbers represent respective settings.•2 For the in vitro work, attenuation is effectively zero, because the interest was the plaque morphology and a flat depth gain compensation curve is required.

Figure 2. Spearman correlation between MPV of the gray scale ultrasound image and histological structures of the carotid plaques. The figure demonstrates that as the fibrocalcific contents of the plaque reach 90% of the plaque, the MPV reading is >150 (χ2 9.7, P=0.0025), and as the soft content reaches 40% of the plaque, the MPV reading is <50.


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Figure 3. Bland and Altman statistics used to assess interobserver and intraobserver variation. With this graphical method, the difference between the 2 techniques are plotted against the mean. The horizontal lines are drawn at the mean difference, as well as at the mean difference plus or minus 1.96 times the SD.

greater than 200 metres•Stage IIB: Claudication distance of less than 200 metres•Stage III: Rest pain, mostly in the feet•Stage IV: Necrosis and/or gangrene of the limb

A more recent classification by Rutherford consists of three grades and six categories:(3)

•Category 0: Asymptomatic•Category 1: Mild claudication•Category 2: Moderate claudication•Category 3: Severe claudication•Category 4: Rest pain•Category 5: Minor tissue loss; Ischemic ulceration not exceeding ulcer of the digits of the foot

•Category 6: Major tissue loss; Severe ischemic ulcers or frank gangrene

References

1.Aly s, bishop CC stroke 2000; 31: 1921-19242.Fontaine R, Kim M, Kieny R (1954). “Die chirugischeBehandlung der per ipherenDurchblutungsstörungen. (Surgical treatment of peripheral circulation disorders)”.Helvetica Chirurgica(in German) 21(5/6): 499–533. 3.Vadim Y. Beletsky, MD; Roger E. Kelley, MD; Marjorie Fowler, MD; Travis Phifer, MD;Ultrasound Densitometric Analysis of Carotid Plaque Composition,Stroke. 1996; 27: 2173-2177.

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Abstracts Submitted for Trainees Competition Presented During the 9th VSE–EVC Meeting May 2013

Endovascular Management Of Head And Extremity Vascular Malformations: A Single

Center Experience

Ayman Hasaballah,1Moustafa Othman,2 Ahmed Elbadawy1

1Vascular Surgery Department, 2Radiology Department, Assiut University Hospital, Assiut,

Egypt

Correspondence to: AymanHasaballah, Email: [email protected]

AbstractAim: To report our experience in the man-agement of head and extremity vascular malformations.

Methodology: From November 2010 to November 2012, the study included 20 pa-tients. All AVM cases (11 patients, 55%) underwent trans-catheter embolisation us-ing a mixture of N-butyl cyanoacrylate with lipidol. VM patients were allocated into ei-ther percutaneous injection of 99% ethanol under fluoroscopic guidance (3 cases, 15%) or percutaneous foam sclerotherapy using ethanol-amine oleate 5% under duplex guid-ance (6 cases, 30%).

Results: According to our scale evaluat-ing the outcomes, Satisfying results were observed in 19 patients (95%) after this in-tervention protocol. Non-satisfying outcome

was noticed in a single case (5%).

Conclusion: Detailed diagnostic imaging, arriving successfully to the nidus or the tar-get lesion, delivering therapy in effective concentrations, completion angiography and the need for extra settings, all could ac-complish the mission. Egyptian Journal of Surgery Vol. 32, No. 2, April 2013.

Short and Mid Term Outcome of Intentional Overstenting of Left Subclavian Artery (LSA) without Revascularization after Successful

Thoracic Endovascular Aortic Repair (TEVAR) of Complicated Stanford Type B Aortic Dissection

Ayman Ibrahim MSc Ass,

Lecturer in Vascular Surgery. Cairo University.

AbstractBackground: Thoracic endovascular aor-tic repair (TEVAR) has been increasingly used in the treatment of complicated chron-ic Stanford Type B dissection after its safe-ty and efficacy were reported at the end of the last century. There is growing evidence, that Thoracic Endovascular Aortic Repair (TEVAR) has advantages over open repair as regards the perioperative morbidity and mortality in the treatment of thoracic aortic dissection. However, many of TEVAR pro-cedures necessitate that the proximal end of

Abstracts Submitted for Trainee Competition Presented

78


the stent-graft cover (either partly or totally) the origin of the left subclavian artery (LSA) in order to achieve a safe landing zone.There are reports of delayed onset of verte-bro-basilar insufficiency and left upper limb ischaemia following LSA covering with the stent-graft. Insufficient blood supply to the posterior cerebral circulation may evolve in the presence of hypoplasia of the right ver-tebral artery and/or posterior communicating arteries. Stroke and left upper monoparesis or monoplegia are the feared complications of LSA exclusion.

Considering the consequences, especially the devastating ones in cases of neurologi-cal complications due to LSA coverage, the question of prophylactic LSA revasculariza-tion remains a significant issue. Unfortunate-ly, no reliable technique is available to assess the individual risk of stroke and monoplegia in case of LSA coverage, so that the indica-tion for LSA revascularization continues to be matter of assuming and guessing.

Aim of the study: To present a limited ex-perience in evaluating successful TEVAR cases that needed LSA overstenting without revascularization, as regards the short and mid term (2-4 years) outcome and complica-tions.

Methods: Retrospective analysis of pro-spectively collected data of 7 patients that underwent TEVAR procedure to treat com-plicated Stanford Type B dissection dur-ing the period from Jan 2007 till June 2011 All cases needed LSA coverage to ensure safe landing zone. There was no prior LSA revascularization in all cases. The proximal

landing zone was zone 2 in all 7 cases. All cases were followed up for immediate post-procedure or delayed possible complica-tions namely posterior cerebral stroke and left upper limb ischemia.

Results: There was technical success in excluding the dissection in all patients. Out of 7 cases, 6 cases (85.7%) were free of such LSA exclusion complications, while a single case (14.3%) showed left upper limb neurological defcit that was managed con-servatively and improved later on.

Conclusion: Coverage of the LSA can be used to extend the proximal landing zone for TEVAR without increasing the risk of stroke as in most of cases the right vertebral artery will be sufficient to take over vertebro-basi-lar circulation. The left upper limb vascu-larity may be affected which can managed conservatively or by secondry LCC-LSA by-pass.

Staging of BrachiobasilicArteriovenous Fistula, does it Worth Effort?

Mohamed E. El Sherbeni M.D., Abdelrahman M. Gameel M.D., Medhat El-Leboudy M.D. and

Waleed A. Sorour M.D.

Vascular Surgery unit, Faculty of Medicine Zagazig University

E mail:[email protected]

Objective: The purpose of this study is to assess various techniques of brachio-basilicarteriovenous fistulae (BBAVF) as regard the differences in long term patencies, functional maturation and postoperative complications.

Patient and methods: 106 BBAVF were

Abstracts Submitted for Trainee Competition Presented 79


performed in 104 patients in Zagazig university hospitals, Patients were scheduled to have basilic vein transposition (BVT), as a one-stage (n=28), a two-stage procedure (n=38) or two staged superficialization (n=40).Then patients were followed up in the surgery clinic until the access was fully functional for dialysis.

Results: The study was conducted on 49 male and 55 female with mean age 46.8± 10.1 years, number of complicated fistulae were 14(50%), 16 (42.1%), 21(52.5%) in the 3 groups respectively with the incidence of venous hypertension and steal were significantly higher than that present in the two another staged groups (p value <0.05).

As regard 1ry patency rates, one stage transposition group showing significantly lower patency (p value< 0.05) than the two stages transposition group, the difference between the 1ry patency of the staged superficialization and two stages transposition or one stage transposition group was not statistically significant. Also as regard 2ry patency rates, there was no statistically significant difference between the 3 groups.

Conclusion: one stage BVT group has less operation time and can be cannulated earlier but with lower patency ratesthan other two groups. Although staged BVT has good

patency rates with early use of the fistula and fewer postoperative complications than superficialization but still with more effort in performing an extra anastomosis.

Biograft Extends Vascular Surgeons Choices in Creation of AVG

Sameh El-Imam, Assist. Lecturer of vasc.Surgery,

Alzahraa University Hospital, Alazhar University

AbstractCreation of adequate vascular access is essential to establish an appropriate dialysis in patients with end-stage renal disease. Autogenousarterio venous fistula is the first choice for those patients as the results in terms of patency rate and infection are superior on synthetic grafts.This study constitutes the preliminary results of using biological graft as ( AVG ) in five patients with ESRD in whom veins were exhausted and not suitable for access. Early results of using biological graft especially the loop form for AVG had shown easy technical use , minimal suture hole bleeding , excellent suture retention , and good sealing after needle puncture. One year Patency was 100% . There was no infection or mortality.Preliminary results are shown that using of Biological graft as ( AVG) are safe , effective ,durable and resistant to infection in those immune compromised patients.

Vascular Image 81


81

Vascular Image

Unusual Case of Aortic Occlusion

Mohamed Omar Elfarok M.Sc , FRCSENG, FRCSED,

Consultant Vascular Surgeon, El-Sahel Teaching Hospital

Vascular Case history Female Patient aged 49 Y smoker and not dys-lipaedemic presented with bilateral claudication of 50 Yards and severe hypertension of 210/120 with three medications, presentation is gradually worsens over the last 5 years.

Vascular ExaminationGeneral examination was unremarkable and local vascular examination showed absecent bilateral femoral pulses , and bruit over the abdominal wall , with no evidence of foot ulceration or gangrene.

Vascular Duplex scan Confirmed the presence of monophasic waveform in abdominal aorta and both

common femoral arteries denoting more proximal lesion

Vascular Imaging CT angiogram showed aortic occlusion with large chest collateral crossing the abdominal wall to reach pelvic arteries . It showed also a picture suggestive of hypoplastic aorta and hypoplastic iliac arteries.

Technique of InterventionAngioplasty and Stenting

Under local anesthesia , which is important for cases of aortic occlusion as feeling of pain can indicate subintimal dissection or over sizing by balloon angioplasty and is a warning before rupture happens. We have used double approach with two 6 French

Mohamed Omar Elfarok 82


Sheaths from transbrachial and transfemoral access We preferred to do the recanalization from transfemoral compared to transbrachial because we felt that any dissection from the transbrachial route could extend severely beyond the occluded segment and is difficult to get re-entry. Recanalization using Terumo 0.035 curved tip wire support by a support catheter and we insisted to be intraluminal and then gradual dilatation by 3 , 5 and 8 mm balloon and then stenting the lesion with self expandable 18 mm aortic stent.

Discussion

In patients with ischemic peripheral atherosclerotic disease, the infrarenal abdominal aorta and the iliac arteries are the most commonly involved sites affected by the atherosclerosis.(1) Lesions are generally diffuse and involve the aorta and iliac segments.(1) Localized stenosis or occlusion of the infrarenal aorta above the aortic bifurcation, however, occurs relatively infrequently. In contrast to the male predominance in chronic multilevel atherosclerotic disease (male-female ratio, ~6:1), most patients with localized aortic lesions are women aged 30 to 50 years.(2)The most important risk factors are heavy smoking, abnormal blood lipid concentrations (3,4), and so-called hypoplastic aorta syndrome.(5)

Traditionally, endarterectomy was the treatment of choice for localized aortic stenosis and aortobifemoral or extra-anatomic bypass for more extensive disease. However although surgery delivers durable results, it is associated

with significant peri-operative mortality and morbidity.(6,7) The potential for graft infection is a particular drawback of extra-anatomic bypass. Endovascular treatment delivers hemodynamically acceptable results that are likely to be better than those of extraanatomic bypass. It is likely that recovery and mobilization canoccur much sooner after endovascular procedures, with a potential for lower morbidity, mortality, and costs.

After Dotter and Judkins(8) introduced percutaneous transluminal angioplasty (PTA) in 1964,balloon angioplasty became a feasible alternative treatment for small and medium occludedor stenotic arteries. With the introduction of larger balloons it was possible to treat stenosis inmajor vessels such as the aorta, with the first reported cases in 1980.(9,10) Initially, however, this still required the use of a ‘‘kissing balloon’’ technique, with simultaneousinflation of two or more balloons in the aorta to give an adequate diameter, and this2technique is also advocated for treating lesions involving the distal aorta and common iliacarteries.(11–14)

References

1.DeBakey ME, Lawrie GM, Glaeser DH (1985) Patterns of atherosclerosis and their surgical significance. Ann Surg 201:115.2. Staple TW (1968) The solitary aortoiliac lesion. Surgery 64:569.3.Brewster DC (1991) Clinical and anatomical considerations for surgery in aortoiliac disease and results of surgical treatment. Circulation 83(Suppl I):142–152.4.Cronenwett JL, Davis JT Jr, Gooch JB,

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Garrett HE (1980) Aortoiliac occlusive disease in women. Surgery 88:775–784.5.Greenhalgh RM (1979) Small aorta syndrome. In: Bergan JJ, Yao JST (eds)Surgery of the aorta and its body branches. Grune& Stratton, New York, pp 183–190.6.Brewster DC (1995) Direct reconstruction for aortoiliac occlusive disease. In: Rutherford RB (ed) Vascular surgery. W. B. Saunders, Philadelphia, pp 766–794.7.de Vries SO, Hunink MG (1997) Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta-analysis. J Vasc. Surg 26:558–569.8.Dotter CT, Judkins MP (1964) Transluminal treatment of arteriosclerotic obstruction: description of a new technique and a preliminary report of its application. Circulation 30:654–670.9.Grollmann JR Jr, Del Vicario M, Mittal AK (1980) Percutaneous transluminal abdominal aortic angioplasty. AJR 134:1053–1054.

10.Tegtmeyer C, Wellons HA, Thompson RN (1980) Balloon dilatation of the abdominal aorta. JAMA 244:2626–2637.11.Belli AM, Hemingway AP, Cumberland DC, Welsh CL (1989) Percutaenous transluminal angioplasty fo the distal abdominal aorta. Eur J VascSurg 3:449– 453.12.Ravimandalam K, Rao VRK, Kumar S, Gupta AK, Santosh J (1991) Obstruction of the intfra-renal portion of the abdominal aorta results of treatement with balloon angioplasty. AJR 156:1257–1260.13.Palmer FJ, Warren BA (1988) Multiple cholesterol emboli syndrome complicating angiographic techniques. Clin Rad 39:519–522.14.Dragan S, Sreten G, Miodrag P, Zoran P, Bozina R, Miovan B (1995) ‘‘Kissing balloon’’ technique for abdominal aorta angioplasty Initial results and long term outcome. IntAngiol 14:364–367.

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Instruction to Authors

Editorial policyThe Egyptian Journal of Vascular & Endovascular Surgery publishes reviews, original articles, leading articles, and short reports (technical and case reports). All manuscripts are peer-reviewed.Conditions of PublicationA Manuscript Front Sheet, signed by all authors and a Publisher’s Agreement, signed by the corresponding author must accompany all submissions. The corresponding author is responsible for ensuring that all authors have seen and approved the manuscript. Material relating to human investigation and animal experiments is published on the understanding that the work has been approved by an ethical committee. An article is reviewed on the understanding it has not been submitted for publication elsewhere.Copyright / OffprintAuthors submitting a manuscript do so on the understanding that the contribution is to this Journal only. If it is accepted for publication, exclusive copyright in the paper and illustrations shall be assigned to the publisher. In consideration for the assignment of copyright, the publisher will supply 5 offprint of each paper. Further offprint may be ordered at extra cost. Preparation of manuscripts Papers must be typewritten on A4 paper, on one side of the paper only, double-spaced with 3 cm margins. Manuscripts that do not conform to these requirements will be returned for retyping. Four copies of the manuscript and four hard copies of any illustrations should be submitted to the Editor-in Chief.Manuscript submission Please also submit your manuscript on a CD prepared on a PC-compatible computer (Microsoft Word).InstructionsUse automatic page numbering but avoid other kinds of automatic formatting such as footnotes, endnotes, headers and footers. Put the text and references in one file, with all tables , figures and legends in separate file. Ensure that the typed copies and the file on CD are the same. If there are differences, the CD version will be used. Label the CD with the title of the paper, the name of the first author, the operating system and the word processing software, as well as all file names. Illustrations should be sent in EPS, TIFF or Bmp format.Original articlesArticles should be as brief as possible and we will shorten lengthy manuscripts. The discussion should be clear, concise, and limited to matters arising directly from the results. Each of the following sections should begin on a new page and all pages numbered serially:Titie page, Abstract and key words, Main text in the format of Introduction, Materials and Methods, Results and Discussion, Acknowledgements, References, Tables and Legends for Illustrations.Title page: The title page should give: The title of the article, the authors’ names and affiliations, the name, address, telephone, fax and e-mail of the corresponding author. The category for which the manuscript is being submitted (original article, leading article, review, case report, or technique).

Abstract: The abstract should not exceed 200 words and should conform to the following format: Objectives, Design, Materials, Methods, Results & ConclusionsKey Words: Three to six key words should be included.Acknowledgements: The acknowledgements page should specify contributions that need acknowledging

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, sources of financial and material support.Short Reports: We give priority to case reports describing novel conditions or complications, and technical reports concerning innovations or modifications of existing techniques. Short Reports should not exceed 500 words with up to five references and three illustrations (which should be supplied in electronic format). Short Reports should be in the format of Keywords, Introduction, Report (case or technique) and Discussion. No Abstract is required.Reviews and Leading Articles: We encourage the submission of reviews and leading articles on topics of interest to the Journal. Priority will be given to leading articles addressing a current problem, and systematic reviews. We advise potential authors seeking advice on the suitability of topics to contact the Senior Editors.Letters, Book Reviews and Forthcoming Events: We welcome letters commenting on articles in the Journal. Send your comments to the Editor-in-Chief, including a reference to the article under discussion. Books for review and notification of forthcom ing events should also be sent to the Editor-in-Chief.

References: References should be cited in the Vancouver style. Unpublished communications should be cited in the text, in parentheses. In the text, references should be numbered consecutively by superscript: 1,2 or 1-3. References should be listed in numerical order at the end of the article. The sequence for a journal article is: author(s), title of paper, journal name, year of publication, volume number, first and last pages.The sequence for a book is: author(s), editor(s) or compiler(s), title and edition number, place of publication and publisher’s name, year of publication , first and last pages.Tables and Illustrations: Tables should be numbered in series and must be cited in the text in sequence. Each table with an appropriate brief legend should be typed on a separate page and four copies submitted. Tables should be kept as simple as possible and wherever possible a graphical presentation used instead. Any illustrations must be cited in sequence. If line drawings are submitted they should be in black indelible ink and drawn to approximately 1.5 to 2 times their required size for publication. Four copies are required. Photographs should be in the form of glossy prints. Four prints are preferable but the original plus three good quality photocopies are acceptable. Each illustration should have a label pasted on the reverse side giving its number, corresponding author’s name and an arrow indicating the top. Colour illustrations will be reproduced electronically if sent on disc. The legends for illustrations should be listed on a separate page in numerical order and should contain brief but comprehensive explanations. Keys to symbols and shading used should appear in the legend, not on the illustration. All authors wishing to use illustrations already published must first obtain the permission of the author and publisher and/or copyright holders and give precise reference to the original work. Measurements of length, height, weight and volume should be reported in metric units (metre, kilogram, liter) or their decimal multiples. Temperatures should be given in degrees Celsius and blood pressure in millimeters of mercury. All other measurements including laboratory measurements should be reported in the metric system in terms of the International System of Units (SI).Statistics: Authors are responsible for the accuracy of all statistical calculations. The Editors and referees will consider the design of the study, the presentation of the data, the analysis of the data and the interpretation of the results when evaluating a manuscript.Design: Authors should set out clearly the objectives of the study and state whether the study was retrospective or prospective.Analysis: There should be a clear description of which methods were used . In general , ‘non-parametric’ analyses should be used, e.g. The Mann-Whitney test for comparing two groups and the Wilcoxon test for comparing the changes to a group. Results of statistical tests should be reported by stating the value of the test statistic and the p value, e.g. t=1.34 , p=0.20. Where possible, the results of the primary analysis should be reported using confidence intervals instead of,or in addition to, p values.Interpretation: Statistical significance should not be confused with clinical relevance. Use confidence intervals to assess clinical relevance , especially when interpreting a ‘negative’ finding.

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