January/February 2011 - SASSiT

Volume 1 Issue 1 January – February 2011
The official e-­‐Journal of the South African Society of Surgeons in Training
In this Issue:
Embolectomies,
Fly- Fly fishing and
Viticulture: What
do they have in
common?
… Page 5
Making sense of
EVAR: What
should should
we be
offering our
patients?
patients
… Page 7
7

Editor
Bradley A David
Editorial Committee
Ferhana gool
Abri Bezuidenhout
Shreya Rayamaji
Publishing, Design and
Layout
Bradley A David
‘the Needleholder’ is the
official online e-­‐Journal of
the South African Society of
Surgeons in Training SASSiT
Every effort has been made
to ensure that all material is
the original work of its
authors and that where
applicable outside material
is appropriately referenced.
Please feel free to email us
with your concerns,
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Volume 1 Issue 1 January – February 2011
Contents
Editorial
Planning a career in vascular surgery. What the future holds?
Dr Phillip Matley, President of VASSA …………………………………………….4
Review
A review of endovascular aortic repair (EVAR) in the elective
management of abdominal aortic aneurysms.
Gool F, Malherbe GF…………………………………………………………………………5
Case Reports
Dysphagia Lusoria: A case of an aberrant right subclavian artery and
a bicarotid trunk
Rogers AD, Nel M, Eloff EP, Naidoo NG……………………………………………13
Case Report: Spontaneous Aortocaval Fistula
Forgan T, Du Toit D…………………………………………………………….…………19
Miscellaneous
A biographical guide to the surgical tray:
Michael E DeBakey…………………………………………………………………………11
Thomas J. Forgarty………………………………………………………………………...18
2

A career in vascular surgery
in Southern Africa presents
numerous interesting
challenges for surgeons in
training. Currently there
are less than 40 registered
specialist vascular surgeons
in active practice in a
country with a population of over 40 million,
making fully trained specialist vascular
surgeons a very precious resource. Out of
sheer necessity, a great deal of vascular care
and many vascular procedures are being
performed by general surgeons but this is not
ideal, given the increasing level of
sophistication of vascular and endovascular
surgery and the increasing demands and
expectations of patients.
Vascular disease is on the increase and this is
contributed to by the fact that in developed
counties, people are simply living to an older age.
The scourge of diabetes has already been
recognized as an international epidemic of
worrying proportions. Tobacco use has not been
brought under control and within our country,
hypertension, hyperlipidaemia and aneurysmal
disease are not only very common but tend to
reflect strong genetic factors. Vascular trauma
and unusual vasculopathies such as Takayasu
Disease and HIV vasculopathy are particularly
prevalent in our sub-­‐continent.
Vascular surgery is one of the youngest surgical
specialties. The endovascular revolution,
particularly in the 1990s has almost totally
changed the way that we work. In South Africa,
unlike the United Kingdom and many other parts
of the world, endovascular procedures have
largely remained in the hands of vascular
surgeons rather than radiologists and
cardiologists. This has broadened the scope and
interest level of vascular surgery enormously.
Vascular surgeons provide primary vascular care
and education, diagnosis and assessment as well
as the whole range of medical, surgical and
endovascular treatment. This is in contrast to
several areas of surgical gastro-­‐enterology where
PLANNING A
CAREER IN
VASCULAR
SURGERY IN
SOUTH AFRICA
What does the
future hold?
Dr Phillip Matley
President of VASSA
Guest Editorial
primary care and diagnosis is provided by
gastroenterologists, and cardiac surgery where
this is provided almost exclusively by
cardiologists. The modern vascular surgeon has
an intimate knowledge of vascular medicine and
the medical management of the risk factors and
the disease processes themselves. Furthermore,
vascular surgeons have “hands-­‐on” involvement
in diagnosis and imaging, particularly with the
increasing use of colour-­‐flow duplex ultrasound.
Vascular surgery works well in private practice in
this country. Several private hospitals have
established vascular centres of excellence
including dedicated vascular wards, hybrid
operating theatres (with ceiling-­‐mounted
angiographic facilities) and multi-­‐disciplinary
medical and para-­‐medical teams. Vascular
disease is common in the group of patients who
enjoy private medical cover and there appears to
be an almost limitless number of patients with
varicose veins requesting surgical treatment. The
earning potential of vascular surgeons compares
very well to other specialties in the general
surgery arena.
The endovascular revolution and the increasing
sophistication of vascular care is challenging the
conventional training and career pathways.
3

Increasingly vascular surgeons will be trained in
both radiological and surgical techniques and will
acquire a broad knowledge and experience of
vascular medicine in close association with
cardiology. The historical connections with
general surgery, gastro-­‐enterology and oncology
will become ever more tenuous and it is likely
that vascular trainees will have a very limited
general surgery education before commencing a
4-­‐5 year training programme of pure vascular
surgery.
Modern vascular practice calls for a wide range of
both cognitive and technical skills including
traditional open surgery as well as percutaneous
catheter-­‐based techniques. There is currently
very little role for laparoscopic vascular surgery
but this may change as laparoscopic techniques
develop further,
The speciality is very demanding on the
individual surgeon. The patients tend to be
elderly and high-­‐risk with multiple co-­‐
morbidities that require attention and control.
Vascular emergencies are a daily phenomenon
that will frequently interrupt weekends and
nights and arranging appropriate cover for
weekends and vacations can be a problem, given
the scarcity of registered vascular surgeons.
Group practices largely solve these issues but are
uncommon among vascular surgeons in this
country. With increasing sophistication may
come increasing cost. The high-­‐tech specialties
such as endovascular surgery consume a large
portion of health care expenditure and may be
increasingly unaffordable to patients and funders
in the future.
I practice in a group partnership that includes
three specialist vascular surgeons supported by
three vascular technologists, a full multi-­‐
disciplinary team of para-­‐medical personnel and
a great network of cardiologists, physicians,
radiologists and anaesthetists. We practice in a
private hospital that has a dedicated 22-­‐bed
vascular ward and a hybrid theatre able to handle
everything from a thoraco-­‐abdominal aneurysm
to a carotid stent. We cover vascular
emergencies on a one-­‐in-­‐three rota and allow
ourselves 10 weeks of vacation a year. We do
clinical research and audit and remain very
involved in teaching and in the activities of our
professional societies. It has been a great career
and it keeps getting better.
Surgery
Calender 2011
March UCT Update
22-24
March
12-16
April
15-17
April
Written College exams
European HPB congress/
ASSA-SAGES meeting (Cape
Town)
ASiT congress (Sheffield, UK)
16-18 May Oral College exams (Gauteng)
15 June Closing date for exam entry
21-26
June
28 Aug – 1
Sept
30 Aug-1
Sept
International Surgical Trainees
Congress (Pretoria)
International Surgery Week
(Yokohama, Japan)
Written College exams
October Pretoria Controversies
4

A review of endovascular aneurysm repair (EVAR)
in the elective management of abdominal aortic
aneurysms.
Gool F, Malherbe GF
University of Cape Town
Aneurysms of the abdominal aorta (AAA) have long been recognized as a
fatal disease process and significant advances have been made over the last
50 years in the surgical management thereof. Treatment of an asymptomatic
aortic aneurysm is indicated when the risk of rupture outweighs the risk of
operation.
AAA’s are now more frequently diagnosed, due
mainly to the increase in life expectancy and also
due to the development of better non-invasive
imaging techniques such as Doppler ultrasound,
Computer Tomography (CT) and Magnetic
Resonance Angiography (MRA).
Conventional open aneurysm surgery is
associated with considerable operative mortality
because the operation is extensive and the
patients often have serious co-morbidities.
In published series, the 30-day or in-hospital
mortality has ranged from 3.8% to 8.2% in
patients undergoing elective open repair of AAA’s.
Intensive care and hospital admissions are
extended with open repair. Severe postoperative
complications are common and more importantly,
the time taken for recovery to the preoperative
state of wellbeing is usually prolonged.
There are also subgroups of patients who are at
increased risk during conventional repair because
of their associated medical co-morbidities or
anatomical variations:
1. Patients with myocardial infarction, renal or
liver insufficiency
2. Inflammatory aortic aneurysms
3. Horseshoe kidney, retro-aortic renal vein
4. Hostile abdomen
It was the combination of these factors that
provided the impetus for the development of
minimally invasive procedures as a treatment
option. The advent of minimally invasive
endovascular stent-graft techniques or the
endovascular aneurysm repair (EVAR) as an
alternative treatment has radically extended the
management options for patients with aortic
aneurysms.
However, the advent of new technology to treat
any surgical condition needs to be evaluated
against conventional treatment
before a surgeon can offer this
choice to patients. The questions
that needed to be answered are:
1. What are the advantages of
the novel approach over conventional
treatment?
2. What are the potential drawbacks of the novel
approach?
3. Does the long-term outcome of the novel
approach match the tested outcomes of
conventional management?
4. What are the cost implications of the novel
approach?
The aim of this review will be to outline the
developmental history and the application of
EVAR technology in the elective management of
AAA’s. Finally, this review will aim to assess how
the evidence collected to date answers the
questions posed above in relation to the use of
EVAR.
The history of EVAR
The first animal studies on
EVAR by stent-graft
combinations date from the
mid-1980s. Unpublished
clinical experience in Russia
dates from 1985 but it was
Parodi and colleagues, from
Buenos Aires, Argentina,
who were the first to
publish experience with a
balloon-expandable stent
attached to a polyester
tubular prosthesis to treat
AAAs in patients who were
REVIEW
5

unfit for open surgery. Their home-made stentgraft
evolved from an endograft with one
proximal stent for infrarenal fixation only to
include a second stent for distal fixation to obtain
effective exclusion of the aneurysm from the
blood flow. These early patients had an aortoaortic
tube graft. Early on the graft endograft was
only used in aneurysms not involving the
bifurcation but later an aorto-uni-iliac stent-graft
was also used, resolving the problem of an
inadequate distal aortic cuff for securing “fixation”
and “seal.”
Over the next decade, a succession of industrymanufactured
endoprostheses was introduced into
the market for treatment of a broad spectrum of
patients with a AAA. A variety of endografts from
different manufacturers are currently available.
The ideal endograft should provide lifelong
protection from rupture of the aneurysm without
any risk of migration or displacement from the
attachment sites. Components should be
sufficiently robust and at the same time small
enough to fit into a delivery system that can be
negotiated easily through the access vessels.
Application of EVAR in the elective
management of AAA’s
Although there are significant variations from
brand to brand, each device consists of three key
components:
• A delivery system to allow placement
• An attachment system that forms a blood tight
seal between the graft and the abdominal aorta
• Graft fabric, which acts as a conduit for blood
flow that has been diverted from the diseased
segment of aorta
INITIAL RADIOGRAPHIC EVALUATION
Although the vast majority of abdominal aortic
aneurysms are infrarenal, less than 50 percent
are amenable to endovascular repair due to
anatomic considerations. Angiography and
computed tomography (CT) are commonly
obtained as initial radiographic studies to
determine both the feasibility of an endograft and
the appropriate size and configuration of the
endograft.
1. Angiography
Since the inner lumen is imaged, but not the
wall of the aorta, angiography cannot evaluate
the true lumen diameter, extent of thrombus,
plaque, and calcification.
2. Computed tomography
Measurements of diameters can be
problematic problematic if the aorta is
angulated and the longitudinal axis is not
perpendicular to the imaging plane.
3. CT angiography
Angiography is more sensitive for measuring
small, axially oriented vessels and vascular
stenoses than CTA, combining angiography
with spiral CT and 3D CTA provides the
maximum amount of information
ANATOMIC CONSIDERATIONS
1. Proximal neck length
The minimum length needed varies from
device to device but may be as long as 15
mm. Newer designs allow suprarenal fixation
and require a shorter proximal neck length.
Ideally, it should be a normal appearing
segment of aorta, without abundant thrombus
or heavy circumferential calcification.
2. Distal neck length
A tube endograft may be placed if a distal
neck is of sufficient length and diameter as
specified by the manufacturer. As an example,
the Ancure device requires a distal neck at
least 12 mm in length and no greater than 26
mm in diameter
3. Aneurysm diameter
Undersizing the diameter of the endograft
may lead to an inadequate seal and failure to
exclude the aneurysm, while oversizing may
lead to kinking of the device, causing a nidus
for thrombus formation or a leak. In a report
from a European registry of patients
undergoing endografting (the EUROSTAR
registry), postoperative complications,
postoperative mortality, late rupture, and
6

aneurysm-related death were all more
frequent in patients with a preoperative
aneurysm diameter ≥6.5 cm.
4. Angulation
An angle of 60º or more leads to difficulties in
implantation, kinking, leakage, and the
possibility of downward migration of the
device.
5. Iliac attachment site
The common iliac artery is the preferred
attachment site, although the external iliac
artery may be used. When the attachment site
is in the external iliac artery, the hypogastric
artery will be covered by the endograft. If the
hypogastric artery is patent, the potential
exists to back fill the aneurysm via back flow
through this vessel into the sac, resulting in
ineffective exclusion of the aneurysm. This
problem can be prevented by preprocedural
embolization of the hypogastric artery.
6. Femoral artery diameter
To accommodate the delivery system of most
devices, a minimal femoral artery diameter of
8 mm is usually required.
7. Accessory renal arteries
Accessory renal arteries are present in up to
30 percent of the population and commonly
originate from the lumbar aorta. Exclusion of
an accessory renal vessel by an endograft can
result in partial renal infarction.
8. Inferior mesenteric artery
However, when the inferior mesenteric artery
is patent and there is significant stenosis of
the superior mesenteric artery, the inferior
mesenteric artery may supply important
collateral blood flow to the bowel. In such
patients, covering a patent inferior mesenteric
artery with an endograft may compromise
blood flow to the bowel. Thus, endograft
placement is contraindicated.
PATIENT FOLLOW-UP
The size of the abdominal aortic aneurysm
following endovascular repair and endograft
placement is followed with plain film of the
abdomen, CT scan or Arterial Duplex sonography.
• Follow-up protocols vary, but a typical
schedule after uncomplicated endograft
placement consists of abdominal plain films
before discharge and at one, six, and 12
months, and then every year thereafter.
Abdominal plain films are an economical and
quick way to evaluate the integrity of the graft
and the stability of graft appearance,
alignment, and position.
• CT scans, which are obtained on a similar
schedule, are used to evaluate the diameter
and volume of the aneurysm and to look for
signs of endoleak or of endograft migration
• A typical follow-up schedule in an
uncomplicated patient post EVAR whose BMI is
within normal limits, at our institution would
be:
• CT Abdomen at 4-6 weeks
• Plain AXR at 4-6 weeks, 6 months and 12
months; then annually
• Arterial Duplex Sonography at 6 months, 12
months then annually
COMPLICATIONS
Illustration of
Endoleaks
Type 1 – 4
Complications that have been reported with
endograft use include:
• Vascular injury during deployment (sometimes
leading to aneurysm rupture)
• inadequate fixation or sealing of the graft to
the vessel wall
• stent frame fractures and separations
• breakdown of the graft material
7

Even after an aneurysm is successfully treated
with an endograft, it remains a dynamic entity.
The aneurysm will eventually thrombose and, by
12 months, approximately 50 percent of
aneurysm sacs have shrunk in diameter.
1. Endoleaks
2. Postimplantation syndrome
Patients undergoing endovascular stent graft
placement often experience an acute
inflammatory syndrome characterized by
fever, leukocytosis, elevation of serum Creactive
protein (CRP) concentration, and
perigraft air during the first week to 10 days
after implantation
3. Device migration
Device migration is one of the major causes of
secondary intervention after endovascular
aneurysm repair. If untreated, potential
complications include endoleak, aneurysm
expansion, and rupture.
CLINICAL OUTCOMES
Short-term
The short-term technical success rate for
endovascular aneurysm repair ranges from 83 to
over 95 percent. A 2007 systematic review
identified four randomized trials of 1532 patients
who were considered suitable candidates for
either endovascular or open repair of nonruptured
abdominal aortic aneurysms larger than 5.0 cm in
diameter. 1 The 30 day all-cause mortality was
significantly lower with endovascular repair (1.6
versus 4.8 percent, relative risk 0.33, 95% CI
0.17-0.64).
The two principle contributing trials to this
systematic review were:
• The EVAR 1 trial included 1082 patients who
were at least 60 years of age, with aneurysms
at least 5.5 cm in diameter. At 30 days,
mortality was significantly lower with
endovascular than with open repair (1.6 versus
4.6 percent, adjusted odds ratio 0.34, 95% CI
0.15-0.74). Endovascular repair was also
associated with a significantly shorter hospital
stay (7 versus 12 days), although more
secondary interventions (additional surgical
procedures) were required with endovascular
repair (9.8 versus 5.8 percent).
• The DREAM trial evaluated 345 patients with
aneurysms of at least 5 cm in diameter. There
was an almost significant trend toward lower
operative mortality with endografting than with
surgery (1.2 versus 4.6 percent, risk ratio
0.26, 95% CI 0.03-1.10). Moderate and severe
systemic complications (cardiac, pulmonary,
renal) were more frequent with open repair (26
versus 12 percent), while moderate and severe
local vascular or implant-related complications
were more frequent with endovascular repair
(16 versus 9 percent).
The short-term survival advantage of
endovascular repair appears to be much greater
when endovascular repair is limited to patients at
highest risk from open surgery. This was
illustrated in a report of 454 consecutive patients
who underwent elective repair (206 endovascular
and 248 open surgery) of an abdominal aortic
aneurysm. The overall 30-day mortality rates not
significantly different for endografting and surgery
(2.4 and 4.8 percent, respectively). However,
among patients at highest surgical risk (American
Society of Anesthesiologists class IV), the 30-day
mortality rates were much lower with
endovascular repair (4.7 versus 19.2 percent with
open surgery).
Long term
The early survival benefit seen with endovascular
repair compared to open repair described above is
lost between one and four years, after which
survival appears equivalent. This observation was
seen in the 2007 systematic review discussed
above, which included follow-up of 1473 patients
from the DREAM (two years) and EVAR 1
randomized trials (four years)
Long term outcomes of patients who have
undergone endovascular repair of abdominal
aneurysms have been evaluated with and without
comparison to patients who have undergone open
repair.
EVAR-1:
In this large, randomized trial, endovascular
repair of abdominal aortic aneurysm was
associated with a significantly lower operative
mortality than open surgical repair. However, no
differences were seen in total mortality or
aneurysm-related mortality in the long term.
Endovascular repair was associated with
increased rates of graft-related complications and
re-interventions and was more costly.
EVAR-2:
In this randomized trial involving patients who
were physically ineligible for open repair,
endovascular repair of abdominal aortic aneurysm
was associated with a significantly lower rate of
aneurysm-related mortality than no repair.
8

However, endovascular repair was not associated
with a reduction in the rate of death from any
cause. The rates of graft-related complications
and reinterventions were higher with
endovascular repair, and it was more costly.
Conclusion
1. What are the advantages of EVAR over
conventional open repair?
The results from EVAR1 and DREAM
demonstrate that the short-term morbidity and
mortality related to open repair is clearly
improved in patients undergoing EVAR.
However this benefit does not follow through in
the long-term.
In the select sub-group of patients with
anatomical variants and/or a hostile abdomen
EVAR is a very attractive option to avoid the
unusually excessive risks of open surgery.
2. What are the potential drawbacks of the
novel approach?
Higher long-term aneurysm specific morbidity
and mortality is in large part due to the
Endoleak phenomenon, as discussed earlier.
Stent-technology depends on anatomic
suitability and while EVAR maybe desirable in a
patient it may not be applicable, because of
unsuitable anatomy or problems with access.
In view of uncertain long-term durability it
should be used with caution in younger
relatively low risk patients.
The anticipated use of EVAR to treat patients
who were not fit for open surgery has not been
supported by the EVAR2 trial.
3. Does the long-term outcome of the novel
approach match the tested outcomes of
conventional management?
Long-term follow up in both the EVAR1 and
DREAM trial demonstrate that morbidity and
mortality are equivalent in both groups.
However, the aneurysm specific morbidity and
mortality was significantly higher in the EVAR
arms of the studies. Initial speculation that this
was related to the ‘developmental turnaround
time’ of new technology, may not hold true as
the American-based OVER trial has had very
similar results compared to the EVAR1 and
DREAM trials despite using the latest stent
technology.
4. What are the cost implications of the
novel approach?
EVAR is more costly than open repair not only
because of the initial device costs but also
because of the rigorous CT based follow-up
used in most of the trials. However, in the
EVAR and DREAM trials the long-term costs of
all-cause morbidity associated with open repair
such as wound complications, were not
included in the cost analysis. Moreover, followup
surveillance of the stent is moving away
from CT towards a duplex based regime which
is far more cost effective.
In conclusion, the endovascular management of
abdominal aortic aneurysms should not be viewed
as a replacement for conventional open surgery.
EVAR is a weapon in the armamentarium of the
vascular surgeon, which if used with caution in
the appropriate setting will form part of an
effective elective management strategy for the
treatment of AAA’s.
REFERENCES
1. Sajid MS, Desai M, Baker DM, Hamilton G. Endovascular Aortic Aneurysm
Repair (EVAR) Has Significantly Lower Peri-operative Mortality in Comparison
to Open Repair: A Systemic Review. Asian J Surg. 2008 Jul;31(3):119-23
2. Malas MB, Freischlag JA. Interpretation of Results of OVER in the context of
the EVAR Trial, DREAM, and the EUROSTAR Registry. Semin Vasc Surg. 2010
Sep;23(3):165-9
3. Albuquerque FC Jr, Tonnessen BH, Noll RE Jr, Cires G, Kim JK, Sternbergh WC
3 rd . Paradigm shifts in the treatment of Abdominal Aortic Aneurysms: trends
in 721 patients between 1996 and 2008. J Vasc Surg.2010 Jun;51(6):1348-
52; discussion 1352-3.
4. Deaton DH. Future Technologies to address the failed endoprosthesis. Semin
Vasc Surg. 2009 Jun;22(2):111-8.
5. Lederle, FA, Johnson, GR, Wilson, SE, et al. The aneurysm detection and
management study screening program: validation cohort and final results.
Aneurysm Detection and Management Veterans Affairs Cooperative Study
Investigators. Arch Intern Med 2000; 160:1425.
6. Szilagyi, DE, Smith, RF, DeRusso, FJ, et al. Contribution of abdominal aortic
aneurysmectomy to prolongation of life. Ann Surg 1966; 164:678.
7. Peppelenbosch, N, Buth, J, Harris, PL, et al. Diameter of abdominal aortic
aneurysm and outcome of endovascular aneurysm repair: does size matter? A
report from EUROSTAR. J Vasc Surg 2004; 39:288.
8. Greenhalgh, RM, Brown, LC, Kwong, GP, et al. Comparison of endovascular
aneurysm repair with open repair in patients with abdominal aortic aneurysm
(EVAR trial 1), 30-day operative mortality results: randomised controlled trial.
Lancet 2004; 364:843.
9

Michael Ellis DeBakey was born as Michel Dabaghi (later Anglicized to DeBakey) in Louisiana to
Lebanese immigrants. DeBakey graduated from Tulane University School of Medicine in New Orleans in
1932. He completed his surgical fellowships at the University of Strasbourg, France, under
Professor René Leriche, and at the University of Heidelberg, Germany, under Professor Martin
Kirschner.
‘DeBakey had a machine
shop right outside the
operating room. He
regularly consulted with
an engineer during and
after procedures about
the design of
instruments’
Michael Ellis DeBakey
September 7, 1908 – July 11, 2008
World-renowned Lebanese-American cardiac surgeon, innovator,
scientist, medical educator, and international medical statesman.
During a decorated five-decade medical career, it is without
hyperbole that Dr. Michael E. DeBakey earned the right to be
named as one of the greatest surgeons of the 20th century.
While he was in medical school DeBakey conceived of the
roller pump, the central idea of the heart-lung machine. The
very notion that the heart can be temporarily replaced by a
machine set the stage for a host of medical innovations—from
bypass surgeries and heart transplants to artificial hearts—
and a fundamental change in approach to heart treatment,
heart health and the prevention of heart disease.
DeBakey ushered in, and was often at the forefront of, medical innovations that have saved
millions of lives. He performed over 60,000 operations himself. Chief among these techniques
was arterial bypass and arterial reconstruction. He mastered ways of patching and grafting,
bypassing and re-organizing arteries. He finally put down his scalpel in 1998 at age 90.
Kenneth L. Mattox, chief of surgery at Baylor-affiliated Ben Taub Hospital in the Texas Medical
Center, Houston, has no doubts that his mentor and long-time colleague did that many
operations. “We were doing operations in four different rooms and he would move from room to
room,” Mattox recalls. In the evening, “he sent out for food and we ate between cases.” At 11
p.m., the entire team of residents, nurses, anesthesiologists, everyone, was exhausted, Mattox
says. “I remember Dr. DeBakey sticking his head out a door and saying, ‘Doesn’t anybody else
out there want an operation? We’re just getting warmed up.’”
Mattox also remembers that DeBakey had a machine shop right outside the operating room. He
regularly consulted with an engineer during and after procedures about the design of
instruments. “He would look at the way an instrument fit in his hand, the way a clamp would
spring or close,” Mattox says. “He would talk to the engineer, and a week later he would have a
new instrument.”
The Next time you ask your scrub
sister for a DeBakey forceps
remember the innovative spirit of
its creator – Michael E. DeBakey.
The DeBakey
Forceps designed
with atraumatic
tips so as to
minimize trauma
to delicate tissues.
11

Dysphagia Lusoria: A case of an aberrant right
subclavian artery and a bicarotid trunk
Rogers AD, Nel M, Eloff EP, Naidoo NG
Vascular Surgery Unit, Division of General Surgery, Groote Schuur Hospital, Cape Town
Abstract
Dysphagia Lusoria is dysphagia secondary to an aberrant right subclavian artery
that has a retro-oesophageal course. Adachi and Williams categorized aortic
arch anomalies, showing that the right subclavian artery arising in this fashion
(as the last branch of the descending aorta) is one of the more common.
However, this very rarely co-exists with a bi-carotid trunk.
We present such a case as is it manifested in a 36 year-old lady complaining of
marked weight loss and dysphagia. The diagnosis remained elusive until a CT
scan of the chest was performed; angiography further delineated the pathology.
It is believed that the combination of the common carotid origins with the retrooesophageal
course of the aberrant vessel more frequently accounts for
symptoms in the absence of an aneurysm of the origin of the aberrant vessel.
Several techniques to manage the aberrant vessel have been described in the literature, but we
favoured open ligation and transposition to the right carotid artery.
Case Report
A 36-year-old women presented to the Gastro-
Intestinal Unit of Groote Schuur Hospital with a
three year history of dysphagia. The dysphagia
was initially only for solid food and intermittent,
but more recently she describes a constant ‘stuck
in the throat’ foreign body sensation. She also
admitted to significant (almost 30kg) weight loss.
She was very anxious, and eager to determine
the source of the ailment and was concerned
about the possibility of malignancy.
Physical examination revealed only evidence of
recent weight loss and routine laboratory data
were within normal limits.
There were no abnormalities on chest Xray or
ECG.
Barium Swallow demonstrated an indentation at
the level of the third thoracic vertebra. A small
diverticulum was also reported to be present, just
above the aortic arch.
No pathology was demonstrated during
oesophagoscopy, oesophageal manometry,
larygoscopy and pharyngoscopy.
A course of Antacids and H2 receptor blockers
was initiated for two months, with little benefit.
Psychotherapy was considered and
antidepressants prescribed.
At this time a CT scan of the chest and abdomen
demonstrated an aberrant right subclavian artery,
originating from the descending aorta.
The patient was referred to the Vascular Surgery
Unit for further investigation and possible surgical
intervention. Digital Subtraction Angiogram
confirmed the diagnosis. The ARSA originated
distal to the origin of the left subclavian artery
and coursed through the posterior mediastinum
behind the oesophagus. In addition, the
angiogram also demonstrated a common origin of
the common carotid arteries as a second branch
of the arch.
The patient underwent a right supraclavicular
incision and surgical ligation of the ARSA with
right subclavian–carotid transposition using an
end-to-side anastomosis.
The patient had an uneventful postoperative
course and remains symptom free after follow-up
of twelve months.
Literature Review
Figure 1 – Barium Swallow
The characteristic diagonal
impression at the level of
the third and fourth
vertebrae
The first case of a symptomatic aberrant right
subclavian artery (ARSA) was described in the
medical literature by Hanuld in 1735. 1
The term ‘Dysphagia Lusoria’, however, was
coined by Bayford in 1794 to describe dysphagia
secondary to a retro-oesophageal (aberrant) right
subclavian artery (ARSA). He described a lady
who died of oesophageal obstruction and
resultant emaciation. The condition, in his words
‘may be called lusoria, from Lusus Naturae (Latin
for ‘freak of nature’) that gives rise to it’. 2
13

Figures 2 and 3 – Angiogram – The aberrant right subclavian
artery and its course demonstrated on AP and Right anterior
oblique views. Note also the common origin of the carotid arteries.
Burckhard Komerell is credited with the first
radiological description, in 1936, as the condition
had only been diagnosed at postmortem prior to
that time. Komerell’s name survives as the
eponym for the diverticulum sometimes present
at the origin of this attenuated vessel. He stated ‘
. . . the pulsating mass behind the oesophagus
does not consist of the right subclavian itself,
because the calibre of this vessel is much smaller.
Much more likely this mass consists of an aortic
diverticulum, from which the right subclavian
artery originates.’ 3
The incidence of ARSA varies between 0.4 to
1.8% of the population, and is probably the
commonest significant aortic arch anomaly. 4
The Adachi Williams Classification
In about 80% of individuals, three branches arise
from the aortic arch: the brachiocephalic trunk,
the left subclavian artery and the left common
carotid artery. This Adachi described as Type A. 5
11% of individuals have an Adachi type B pattern,
which consists of a common trunk for the left
common carotid and the brachiocephalic artery
and therefore has only two aortic arch branches. 5
The next most common type, Adachi C, has a
vertebral artery originating proximal to the left
subclavian artery as a 4 th branch of the arch. 5
The origin of the retroesophageal right subclavian
artery as the last branch occurs in between 0.4
and 2% of individuals. 4,5,6
The Adachi and Williams Classification recognizes
four basic morphologies within this group: Types
G, CG, H and N (see figure 7.) 4
This case report demonstrates features of Adachi
H, where the right subclavian artery is anomalous
(as in type G), but where the right and left
common carotids arise from a common stem or
bicarotid trunk.
Embryology
Figure 4 – 3 D Reconstruction –
Right posterior oblique view.
The right subclavian artery develops during the
6 th to 8 th week of gestation. The proximal part
originates from the right 4 th aortic arch artery,
and the distal part from the right dorsal and right
seventh intersegmental arteries. 3,7
In these cases, the right 4 th aortic arch artery
and/or the right dorsal aorta involute cranial to
the seventh intersegmental artery – the
connection between the aortic sac and the right
subclavian artery disappears. The right
subclavian artery develops from the right 7 th
intersegmental artery and the distal segment of
the right dorsal aorta. Differential growth shifts
Figure 7 – Retro-oesophageal Subclavian Anomalies. Note
the rare Type H, with the bicarotid trunk.
the origin cranially and lies close to the origin of
the left subclavian artery. It originates dorsally
and therefore has a retroesophageal course. 3,7
The aberrant right subclavian artery stems from
the dorsal margin of the aortic arch, between the
top of the arch and where it lies against the
vertebral column. The proximal part of the artery
14

has a wider diameter than the distal part and the
artery passes through the mediastium in a retrooesophageal
position. The artery may arise from
a diverticulum at the proximal descending aorta,
referred to as Kommerell’s diverticulum. 3,7
Presentation
There are several descriptions of childhood
dyspnoea resulting from an ARSA, and cases of
pneumonia have been ascribed to the condition
on the basis of aspiration and dysphagia. Relative
tracheal laxity may account for this presentation
8, 9
in childhood.
Two thirds of individuals are believed (on the
basis of autopsy studies and retrospective
studies) to remain completely asymptomatic
despite the anomaly. There are a few proposed
mechanisms as to why certain individuals become
symptomatic:
1. Increased oesophageal rigidity with ageing
2. Aneurysm formation
3. Aortic elongation with ageing
4. The presence of a bicarotid trunk. 7,8
In a study by Klinkhamer, published in 1966 and
reviewing all articles from 1763, it is stated that
the aberrant right subclavian artery was found to
be associated with a bicarotid truncus (common
origin of the right and left carotid arteries) in 85
of 295 cases (29%) In 60% of cases there was a
normal origin of the two carotids, and in 10%
they were observed to be closer to one another
than normal. 8
It is believed that the combination of the common
carotid origins with the retro-oesophageal course
of the ARSA more frequently accounts for
symptoms in the absence of an aneurysm of the
origin of the aberrant vessel. In fact, several
authors have questioned the relationship between
the aberrant vessel (in isolation) and the
dysphagia. 8
Klinkhamer, for instance, felt that the aberrant
artery itself was not an adequate explanation for
the dysphagia because some patients have had
very large ARSA’s, without dysphagia or
respiratory symptoms. He maintained that
symptoms are usually only present when the left
and right carotids arise together or close to one
another and therefore prevent the trachea and
oesophagus from being bent forward where the
ARSA crosses. 8
In 80% of individuals, the Brachiocephalic (BCA)
and Left Common Carotid Arteries (LCCA)
originate from the arch 4cm apart. Because the
arch lies obliquely and curves from front and the
right backward and to the left, the BCA is more
ventral than the LCCA origin. This allows the
ARSA from being bent forward (note diagram). If
they arise commonly, the two carotids form a ‘V’
that prevents forward or flexion movements of
the trachea and oesophagus. These structures
are therefore compressed by the SCA posteriorly
and by the CC origins antero-laterally. 6-10
Investigation 7-11
Barium swallow may demonstrate the
characteristic diagonal impression at the level of
the third and fourth thoracic vertebrae.
A pulsating mass may be visualized at endoscopy.
Digital Subtraction Angiogram, CT with contrast,
or MRI may confirm the diagnosis and enable one
to visualise the arch anatomy.
Motility studies are frequently performed during
the diagnostic phase of investigation. A high
pressure zone in the region of the vessel has been
described. Manometry cannot be used to
diagnose the condition nor has it been of any
assistance in distinguishing which patients may
benefit from surgery.
Therapy
Several reports have described improvement with
conservative therapy. These patients usually had
inconclusive findings on manometry. In light of
the relative infrequency of symptoms in patients
with isolated ARSA, some authors have therefore
advocated trials of therapies like prokinetics and
antireflux medications.
The majority of symptomatic patients have
benefited from surgical intervention. Janssen
concluded that in the absence of another cause of
the symptoms and after a trial of medical
management, surgery should be considered. 7 In
1994, Kieffer reported on 19 patients who
underwent surgery, of whom 16 had complete
resolution of their symptoms. 12
Gross first reported surgical management of this
condition in 1946. He described dividing and
ligating the ARSA via a left thoracotomy, in a 4
month old infant. 13 Lichter was the first to
describe surgery on an adult with this condition in
1963. It is not until the last thirty years that
surgery has become the standard therapy for this
condition, and several authors have advocated
various approaches. 14 Pome, in a review of the
literature published in 1987, found only twenty
reported surgically treated patients. 15
The optimal exposure of the aberrant artery origin
is undoubtedly achieved via a left thoracotomy.
This is particularly important when the origin of
the ARSA is dilated. 7,14
Simple ligation and division has been noted to be
inadequate therapy in a significant number of
patients due to the development of subclavian
15

steal syndromes. The onset of this syndrome
may be immediately postoperatively or late
(described up to seven years later). In addition,
cases of gangrene of the right arm have been
described following simple ligation of the aberrant
vessel. 14
Smith and Pifarre have described reimplanting the
right SCA with a graft onto the ascending arch via
a left thoracotomy. This is a technically
challenging exercise and involves passing the
Right SCA and the graft from the posterior
mediastinum to the anterior, as well as deep
anastomoses. 16,17
The anastomosis of the RSCA to the ascending
arch is much easier to perform via a right
posterolateral thoracotomy, as described by
authors such as Bailey. 18
Pifarre identified a problem with the right
thoracotomy approach in one case report. If the
artery is not divided close to its origin, thrombosis
of the stump may lead to the persistence of
dysphagia. 17
Schumacker described performing an end to side
anastomosis of the R SCA with the right carotid
artery via a median sternotomy. This has been
the method described by at least three further
surgeons. However, this anterior approach also
provides suboptimal control during the dissection
and division of the vessel. The possibility of
transient cerebral ischaemia and the
consequences of damage to an atherosclerotic
carotid artery exist with this approach. Mok
therefore recommended that the divided aberrant
right SCA should be anastomosed to the aortic
arch, with or without an interposition graft. 10
Orvald and Kunlin advocated a cervical approach,
but Kunlin described significant haemorrhage in a
patient when attempting to perform the
procedure via a cervical incision and had to resort
to a median sternotomy. We have already
highlighted the potential complication of residual
dysphagia in cases where a long stump is left. 15
Syders reported a combined approach using both
cervical and left carotid approaches to reimplant
the right SCA onto the right carotid. This, while
considerably safer, involves having to reposition
the patient for the second incision. 15
Lemire described a transternal approach for the
division and reimplanting of the Right SCA to the
ascending aorta. The incidence of pain and
pulmonary complications are probably higher, but
this approach has cosmetic advantages. 19
Pome recommended that a right thoractomy may
be employed for patients without significant
ectasia of the origin of the Right SCA; patients
with ectasia should undergo a left thoracotomy
and cervical incision. 15
The importance of dividing the stump proximally
is again highlighted in the paper by Pome. He
advocated using the aorta rather than the carotid
to avoid a possible subclavian steal syndrome. 15
Janssen reports six cases of dysphagia lusoria
diagnosed and managed between 1992 and 1997.
Three patients responded to either medical
management (antacids etc), or dietary
modification. One patient underwent a right
carotid-subclavian end to side bypass via a right
supraclavicular approach. A persistent RSCA
stump may account for his occasional residual
dysphagia for solid food. Two patients underwent
a two incision approach (ie thoracotomy and
cervical incision). 7
Kieffer et al have the largest single-centre series
of patients who have received therapy for
symptomatic or aneurismal aberrant subclavian
arteries. They divided their patients into four
distinct subgroups:
1. dysphagia lusoria without aneurysm
2. symptomatic occlusive disease of the artery
3. aneurysmal disease of the artery itself
4. aneurysmal disease of the thoracic aorta or
origin of the aberrant artery
It would appear sensible to manage all patients
with aneurismal disease with stentgrafting in light
of the high rupture rate (22.6%) and consequent
mortality rate (100%) independent of the
diameter of the aneurysm. The perioperative rate
of patients undergoing surgical repair of these
aneurysms was 26.9%. 12
There are few reports in the literature of
endovascular or hybrid approaches to this
pathology. Although long term results are still
pending, initial results are promising. Shennib et
al have described minimally invasive, hybrid
endovascular approaches . A right supraclavicular
approach was used to perform a right carotidsubclavian
bypass prior to division of the right
SCA. They then deployed an occluder in an
antegrade fashion into the proximal end of the
right SCA in order to maintain good control of the
deployment and to avoid embolization of the
occluder into the aortic arch from a retrograde
approach. A right femoral artery access was used
via a 9F sheath. 20
Endoluminal grafts have also been used with
some success in the presence of aneurysm of the
ARSA origin. In these cases it may be necessary
to consider performing a further anastomosis
between the left carotid and subclavian artery if
overstenting was intended.
Kopp et al have reported a series of six patients
managed by a variety of techniques during a
seventeen year period. One of the patients had
16

a covered wall stent with an occluded proximal
stent graft lumen inserted via a transbrachial
approach. The right SCA was then anastomosed to
the right common carotid artery. 21
References
1. Williams GD, Aff HM, Schmeckebier M, Edmonds HW, Grand EG. Variations in the
arrangement of the branches arising from the aortic arch in the American whites and
negroes. Anat Rec 1932; 54: 247-251
2. Bayford D. An account of a singular case of obstructed degluitition. Memoirs Med
Soc London 1794; 2: 275-86
3. Kommerell B. Verlagerung des Osophagus durch eine abnorm verlaufende Arteria
subclavia dextra (Arteria lusoria). Fortschr Geb Roentgenstrahlen 1936; 54: 590-595
4. Rahman HA, Sakurai A, Dong K, Setsu T, Umetani T, Yamadori T. The
Retroesophageal Subclavian Artery – A case report and Review. Acta Anat Nippon
1993; 68: 281-287
5. Adachi B. Das Arteriensystem der Japener. Bd 1 1928: 22-42 Kenkyu-sha
Publishing Co, Tokyo
6. Saito T, Tamatsukuri Y et al. Three Cases of Retroeophageal Right Subclavian
Artery. J Nippon Med Sch 2005; 72 (6): 375 – 382
7. Janssen M, Baggen MGA, Veen HF, Smout AJPM, Bekkers JA, Jonkman JGJ,
Ouwendijk RJTh. Dysphagia Lusoria: clinical aspects, manaometric findings, diagnosis,
and therapy. Am J Gastroent 2000; 95: 1411-1416
8. Klinkhamer AC. Aberrant right subclavian artery. Clinical and roentgenologic
aspects. Am J Roentgenol Radium Ther Nucl Med 1966; 97: 438-446.
9. Gross RE, Neuhauser EBD. Compression of trachea by anomalous innominate
artery: operation for its relief. Am J Dis Child 1948; 75: 570-574
10. Mok CK, Cheung KL, Kong SM, Ong GB. Translocating the right subclavian artery
in dysphagia lusoria. Br J Surg 1979; 66: 113-116
11. Harada H, Ito T, Yamamoto N, Abe T. Surgical Treatment of an Aneurysm of the
Aberrant Right Subclavian Artery Involving an Aortic Arch Aneurysm and Coronary
Artery Disease. Am Thorac Cardiovasc Surg 2001; 7 (12): 109-112
12. Kieffer E, Bahnini A, Koskas F. Aberrent subclavian artery: Surgical treatment in
thirty-three adult patients. J Vas Surg 1994; 19: 100-111
13. Gross RE. Surgical treatment of dysphagia lusoria. Ann Surg 1946; 124: 532-534
14. Lichter I. The treatment of dysphagia lusoria in the adult. Br J Surg 1963; 50:
793-796
15. Pome G, Vitali E, Mantovani A, Panzeri E. Surgical treatment of the aberrant
retroesophageal right subclavian artery in adults (dysphagia lusoria). J Cardiovasc
Surg 1987; 28: 403 – 411
16. Smith JM, Reul GJ, Wurash DC, Cooley DA. Retro-oesophageal subclavian arteries:
surgical management of symptomatic children. Card Vasc Disease Texas Heart Inst
1979; 6: 333-334
17. Pifarre R, Dieter, RA, Niedballa RG. Definitive surgical treatment of the aberrant
retro-oesophageal right subclavian artery in the adult. J Thorac Cardiovasc Surg 1971;
61: 154-159.
18. Bailey CP, Hirose T, Alba J. Re-establishment of the continuity of the anomalous
right subclavian artery after operation for dysphagia lusoria. Angiology 1965; 16: 509-
513
19. Lemire GG, Rabbat AG, Trudel J. Dysphagia lusoria: current surgical approach. J
CArdiovasc Surg 1978; 19: 311-313
20. Shennib H, Diethrich EB. Novel approaches for the treatment of the aberrant right
subclavian artery and its aneurysms. J Vasc Surg 2008; 47: 1066-1070.
21. Kopp R, Wizgall I, Kreuzer E, Maimarakis G, Weidenhagen R, Kuhni A, Conrad C,
Jauch KW, Lauterjung L. Surgical and Endovascular Treatment of Symptomatic
Aberrant Right Subclavian Artery (Arteria Lusoria). Vasc 2007;15 (2): 84-91
17

Embolectomies, Fly-fishing &
Viticulture:
What do they have in common?
The answer to the question above is simple when one
explores the biographical history of Thomas J. Fogarty,
who as a physician and professor, inventor and
entrepreneur, has saved tens of millions of lives most
notably, by pioneering the tools and methods of less
invasive vascular surgery.
Fogarty was born and raised in Cincinnati, Ohio. His precocious mechanical ability and business
instincts began as a child, designing and building soapbox derby racers and model airplanes, the latter
of which he sold to children from his neighborhood. Soon, he upgraded to a motor scooter; and when
he became frustrated with its gears, he built (and sold) a centrifugal clutch that is still used today in
some simple motors.
Fogarty's interest in medicine began in early high school when he took a job as an equipment cleaner
and later scrub technician at Cincinnati's Good Samaritan Hospital. In the latter position, Fogarty was
frequently able to observe operations and the problems surgeons encountered. By the time he
graduated from high school, Fogarty knew that his calling was to make surgery simpler, cheaper, faster
and safer through technology.
Before he graduated in 1960 from the University of Cincinnati Medical School, Fogarty had designed his
most significant invention. The Fogarty Balloon Embolectomy Catheter, like many revolutionary
inventions is simple in concept. Fogarty built the prototype in his attic, attaching the fingertip of a latex
surgical glove to a catheter using fly-tying techniques familiar to him from boyhood fishing
expeditions.
In 1969 Fogarty patented his device, which is now being used in over 300,000 procedures every year,
all over the world. The catheter was a great improvement on previous embolectomy methods. First, it
does not cut off blood flow, increasing the risk of the patient's losing a limb; and second, the entire
procedure can be performed in one hour through a single small incision, instead of using many larger
incisions and forceps, with the patient under general anesthesia for hours.
Fogarty's balloon catheter procedure was the first successful example of minimally invasive vascular
surgery. Since its introduction, Fogarty and others have developed numerous spin-off applications: for
example, the first balloon angioplasty, performed with a Fogarty catheter in 1965, has led to over
650,000 such operations per year.
He also provides venture capital to other medical device inventors devoted to solving "real-life clinical
problems." In the 1990s, Fogarty became a Professor of Surgery at Stanford University Medical Center.
As if this were not enough, Fogarty has also founded an award-winning vineyard: Thomas Fogarty
Winery, outside of Palo Alto, California.
To date, Thomas Fogarty has personally earned 63 patents, with many others pending. He has
authored or co-authored over 150 professional articles, and is a member of 29 professional societies.
He has won a series of prestigious awards, including the San Francisco Patent and Trademark
Association's Inventor of the Year (1980).
18

Case Report: Spontaneous
Aortocaval Fistula
Forgan T, Du Toit D
Stellenbosch University; Tygerberg Hospital, Dept
of Vascular Surgery
Abstract
A 58 year old man presented with malena stools
and a pulsatile abdominal mass (which turned out
to be an aortocaval fistula (ACF.) At surgery, a
Introduction
A rare complication of infrarenal abdominal aortic
aneurysms is ACF, which occurs in up to 4% of
ruptured or symptomatic aneurysms. 1,2 Due to
the rarity of ACF and the elusive clinical
presentation, they are easily overlooked.
Presentation ranges from the typical signs of
lower back pain, palpable abdominal aortic
aneurysm, machinery abdominal murmur and
high-output cardiac failure to cardiac and renal
failure with few other obvious signs or symptoms.
16,17 Preoperative diagnosis assists in patient
preparation and the selection of the most
appropriate therapeutic modality.
Case Report
A 58 year old male was referred to our institution
from a district hospital with a history of having
passed malena stools, shortness of breath and
hypotension. He was known to have an abdominal
aortic aneurysm (AAA) of 5 cm. He had been
treated for congestive cardiac failure for the
previous year and was also known to have renal
dysfunction. He was also an ex-smoker.
On arrival he was hypotensive with a mean
arterial pressure of 55mmHg and had a
tachycardia of 120. He had a Glasgow Coma
Score of 15 and was tachypnoeic with a
respiratory rate of 30. He was complaining of
central abdominal pain.
On further examination he was an overweight
man with a mildly tender abdomen and a pulsatile
central abdominal mass. It was difficult to
delineate if the mass extended above the costal
margin. No thrill was palpable and no murmur
was heard on auscultation of his abdomen. On
rectal examination he had malena stool. The
patient had a raised JVP, bibasal crepitations and
bipedal oedema.
A blood gas was done which showed a pH of 7,3,
lactate of 5, base excess of -4 and an hb of 8.
Further blood tests revealed that he had mild
Figure 1, Contrasted CT Abdomen showing early
filling of the IVC with contrast.
Figure 2, Contrasted CT Abdomen revealing an
Aortocaval fistula arising in the distal aorta
renal dysfunction.
At this stage the working diagnosis was that of an
aorta-enteric fistula.
In light of the above information a central venous
catheter was inserted, careful fluid resuscitation
was started and the patient was taken for an
emergency CT scan of his abdomen. On returning
to the resuscitation area after his scan he acutely
dropped his blood pressure, decompensated and
was intubated.
The results of the CT scan revealed a 7.7 cm
infrarenal AAA. The IVC and common iliac veins
were distended and early reflux of contrast was
seen (Fig. 1). A communication between the distal
aorta and the IVC was also demonstrated. (Fig. 2)
After further resuscitation the patient stabilized
and he was taken to theatre, where a midline
laparotomy was done. On opening the abdomen
about a liter of ascitic fluid was noted, in
19

conjunction with a congested liver. In light of his
initial complaint of malena a gastrotomy was
performed, revealing no blood in the stomach and
a small pre-pyloric ulcer. The ulcer had a black
spot in its base, which was over sewn.
At this stage the patient had been fully
resuscitated and was stable. It was thus decided
to continue with the surgery and address his
aortocaval fistula.
A standard transabdominal retroperitoneal
exposure was performed, with medial visceral
rotation and mobilization of the duodenum away
from the aorta. Once the aorta was suitably
exposed, proximal and distal control was achieved
(proximally to the infrarenal aorta and to bilateral
common iliac arteries distally), IVC control was
obtained with digital pressure and the aneurysm
sac was opened. After haematoma evacuation
from the aneurysm sac the fistula was identified
and closed with transaortic gore-tex suture. Once
the fistula was closed lumbar arterial bleeders
were suture ligated. A standard Dacron graft was
used to repair the aneurysm.
Post operatively the patient did well. After initial
worsening in renal function (possibly due to
hypotension and contrast nephropathy) there was
normalization within two weeks. His CCF also
recovered dramatically, and on discharge from
hospital all cardiac failure medication had been
stopped.
At three month follow up the patient was doing
well with normal renal functions and no signs of
cardiac dysfunction.
Discussion
The most common cause of aortocaval fistula is a
degenerative aneurysm that has eroded into the
adjacent IVC. It may also result from penetrating
abdominal trauma and iatrogenic trauma at
lumbar disc surgery. Rare causes include mycotic
aneurysm, syphilis and connective tissue
disorders such as Ehlers-Danlos syndrome and
Marfan’s syndrome. The overwhelming majority of
patients affected are males in their seventh and
eighth decades of life.
The original description of an aortocaval fistula
(ACF) is attributed to James Syme in 1831. 3 In
later years, Javid, 4 Eisman and Hughes 5 and
DeBakey et al 6 all reported successful repairs.
Prior to the production of prosthetic grafts for
vascular replacement, only desperate measures
such as quadruple ligation and packing were
available. 7 Matas, who described the technique of
endoaneurysmorraphy for traumatic fistulas,
significantly influenced the treatment of ACF. 8
Because the aortocaval fistula is rare and has an
elusive clinical presentation, it can easily be
overlooked. Clinical presentation is commonly
acute but long-standing complaints such as
cardiac and renal failure are also reported. Half
the patients present with high-output,
hyperdynamic circulation with a widened pulse
pressure and a relatively low diastolic pressure. 13
The triad of low back pain, a palpable abdominal
aortic aneurysm and a machinery abdominal
murmur/ continuous bruit is diagnostic 16 and may
be associated with high output cardiac failure and
regional venous hypertension. 14,15
In ACF, fluctuations in haemodynamic status are
as a result of the arterio-venous (AV) fistula
diverting blood flow from the high resistance
arterial circuit to the low resistance and high
capacitance venous circuit. There is a resultant
decrease in total peripheral resistance and a
subsequent increase in venous pressure,
resistance and volume leading to acute pulmonary
oedema and CCF (decompensated cardiac failure
due to increased venous return occurs in 35% of
patients). 16 There is therefore a resultant increase
in heart rate, stroke volume and cardiac output. If
the fistula persists, the myocardium
hypertrophies, and can dilate and lead to
irreversible, hyperdynamic cardiac failure. It is
important to note that cardiac failure secondary
to ACF is refractory to medical treatment. 13 In our
case the patient had been managed for
progressively worsening cardiac failure for a year
before his surgery. Post fistula repair his failure
resolved, indicating that he had had a small
fistula that had been slowly enlarging during that
time.
The pathophysiology of the renal dysfunction in
ACF is unclear. It may not simply be the result of
decreased renal blood flow caused by the heart
failure, but may also arise from increased central
venous pressure decreasing the renal perfusion
pressure, or redistribution of renal blood flow. 17
Haematuria and acute renal failure may occur as
a result of a renal infarction due to renal arterial
problems, or due to renal congestion from a
perforation of an AAA into the renal vein. 18
A contrast-enhanced CT scan has become the
standard method for making a definitive preoperative
diagnosis in haemodynamically stable
patients. The findings on CTA include early
detection of contrast medium in a dilated IVC,
which is isodense with the adjacent aorta, an
associated AAA; the loss of the normal anatomic
space between the IVC and the aorta; and rarely,
the fistula itself may be visualized. 18 The
diagnosis may also be made with magnetic
resonance imaging (MRI), duplex Doppler
ultrasound or digital subtraction angiography. 10
20

Perioperative mortality is high, ranging from 20 to
40%. This is due to the typical patient having
multiple comorbidities. 9 Successful treatment
depends on management of perioperative
haemodynamics, control of bleeding from the
fistula and prevention of deep vein thrombosis
and pulmonary embolism.
The treatment options available have evolved as
technology has advanced. Therapeutic options
include standard operative tube graft repair,
endovascular repair or a hybrid approach.
Operative repair entails a transabdominal
approach with transaortic suture of the fistula and
tube graft placement. Endovascular repair
involves the correct patient selection (this
includes overall patient condition and anatomical
considerations), followed by the endovascular
placement of a bifurcated endovascular graft. 19
Endovascular repair is complicated by theoretical
concerns about the persistent communication
between the aortic sac and the IVC. The presence
of this communication could facilitate the
development of a high-flow type II endoleak
which, if allowed to mature, may lead to
persistent increased cardiac output and sac
pressurization with a resultant increase in the
diameter of the aneurysm sac. Case reports have
revealed that, even if present, the endoleak is
often not significant and usually self limiting. 19 If
the patient’s anatomy is unsuitable for
endovascular repair, a hybrid approach may be
considered. In hybrid procedures, the IVC is
stented, thereby closing the fistula; followed by
open aneurysm repair. By stenting the fistula
prior to open repair, the patient’s haemodynamics
are stabilized, and pulmonary embolism and the
high risk of massive haemorrhage from the fistula
during aneurysm repair are prevented. 20
Conclusion
Aortocaval fistula is a rare complication of aortic
aneurysm. The presentation varies widely;
ranging from acute decompensation to insidious
worsening of apparently unrelated medical
problems, such as cardiac and renal failure.
Preoperative identification of the fistula and
selection of the most appropriate therapeutic
modality for the patient are vital to a successful
outcome.
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Vasc Surg. 2009 Jun;49(6):1574-6.
"Everyday Challenges in
HPB Surgery"
Surgery"
12 April 2011
Cape Town Convention Centre
9 th EHPBA Congress
Providing a once in a lifetime opportunity
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