Editorials
References 1. Craig S, Tait N, Boers D, McAndrew D. Review of anatomy education in Australian and New Zealand medical schools. ANZ J. Surg. 2010; 80: 212–6. 2. Farey JE, Sandeford JC, Evans-McKendry GD. Medical students call for national standards in anatomical education. ANZ J. Surg. 2014; 84: 813–5. 3. Chapuis P, Fahrer M, Eizenberg N, Fahrer C, Bokey L. Should there be a national core curriculum for anatomy? ANZ J. Surg. 2010; 80: 475–7. 4. Fahrer M. Art macabre: is anatomy necessary? ANZ J. Surg. 2001; 71: 333–4. 5. Ramsey-Stewart G, Burgess AW, Hill DA. Back to the future: teaching anatomy by whole body dissection. Med. J. Aust. 2010; 193: 668–71. 6. Burgess AW, Ramsey-Stewart G, May J, Mellis C. Team-based learning methods in teaching topographical anatomy by dissection. ANZ J. Surg. 2012; 82: 457–60.
801
7. Ramsey-Stewart G. Anatomy and Histology web site. University of Sydney. [Cited 8 Apr 2014.] Available from URL: http://sydney.edu.au/ medicine/anatomy/current-student/whole-body-dissection/index.php 8. Ramsey-Stewart G, May J. Contemporary teaching of anatomy in Australian medical schools: are we doing enough? ANZ J. Surg. 2012; 82: 88–9. 9. Ramsey-Stewart G. Anatomy and Histology web site. University of Sydney. [Cited 8 Apr 2014.] Available from URL: http://sydney.edu.au/ medicine/anatomy/current-student/whole-body-dissection/postgraduate/ index.php
George Ramsey-Stewart, MD, FRACS Discipline of Anatomy and Histology, The University of Sydney, Sydney, New South Wales, Australia doi: 10.1111/ans.12659
Open approaches to the aorta in the endovascular era Endovascular repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysms in anatomically suitable cases. The introduction of advanced techniques such as fenestrated (FEVAR) (fenestrations involving the renal and mesenteric arteries) and iliac branch grafts has extended the proportion of cases which are anatomically suitable for endovascular therapies. Nonetheless, a proportion of patients have aneurysms which are unsuitable for less invasive techniques. Aneurysms with short, highly angulated infrarenal necks, extensive intraluminal thrombus in the juxtarenal and suprarenal aorta and also severe iliac artery tortuosity, calcification and/or small iliac artery calibre/stenoses are frequently unsuitable for endovascular therapies or endovascular treatment may be associated with high levels of perioperative complications and graft failure.1–3 In this issue, Twine et al. found that 28% of aortic aneurysms managed on their unit required open repair because of anatomical contraindications to EVAR or FEVAR.4 This cohort of patients is challenging to treat and the results of this series and a recent systematic review and meta-analysis published by Twine et al.5 support the view that the retroperitoneal approach may provide significant benefits over the traditional transperitoneal approach, in terms of reduced in-hospital complication rates. Generally, the more complex the proximal aortic anatomy, the more likely a retroperitoneal approach will be undertaken. However, complex iliac artery disease on the right side generally requires a separate Rutherford-Morrison incision and thus the standard retroperitoneal approach may not be ideal in such situations. Surgical experience of the retroperitoneal approach (and indeed transperitoneal approach with medial visceral rotation) among surgeons trained in the endovascular era is generally limited. In the
© 2014 Royal Australasian College of Surgeons
future, this may require us to consider undertaking such cases in specialized centres. This further supports the critical importance of formal anatomical training, in particular cadaver-based courses, such as those held at the Clinical Training and Evaluation Centre (http://www.ctec.uwa.edu.au) to ensure that our graduating trainees are comfortable with the various approaches which can be employed to deal with the spectrum of aortic pathology encountered in contemporary practice.
References 1. Stanley BM, Semmens JB, Mai Q et al. Evaluation of patient selection guidelines for endoluminal AAA repair with Zenith stent-graft: the Australasian experience. J. Endovasc. Ther. 2001; 8: 457–64. 2. Dowson N, Boult M, Cowled P, De Loryn T, Fitridge R. Development of an automated measure of iliac artery tortuosity that successfully predicts early graft-related complications associated with endovascular aneurysm repair. Eur. J. Vasc. Endovasc. Surg. 2014; 48: 153–60. 3. Barnes M, Boult M, Maddern G, Fitridge R. A model to predict outcomes for endovascular aneurysm repair using preoperative variables. Eur. J. Vasc. Endovasc. Surg. 2008; 35: 571–9. 4. Twine CP, Von-Oppell U, Williams IM. Left retroperitoneal aortic aneurysm repair in patients unsuitable for endovascular treatment. ANZ J. Surg. 2014; 84: 861–5. 5. Twine CP, Humphries AK, Williams IM. Systematic review and metaanalysis of the retroperitoneal versus the transperitoneal approach to the abdominal aorta. Eur. J. Vasc. Endovasc. Surg. 2013; 46: 36–47.
Robert Fitridge, MS, FRACS Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia doi: 10.1111/ans.12807
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
References 1. Craig S, Tait N, Boers D, McAndrew D. Review of anatomy education in Australian and New Zealand medical schools. ANZ J. Surg. 2010; 80: 212–6. 2. Farey JE, Sandeford JC, Evans-McKendry GD. Medical students call for national standards in anatomical education. ANZ J. Surg. 2014; 84: 813–5. 3. Chapuis P, Fahrer M, Eizenberg N, Fahrer C, Bokey L. Should there be a national core curriculum for anatomy? ANZ J. Surg. 2010; 80: 475–7. 4. Fahrer M. Art macabre: is anatomy necessary? ANZ J. Surg. 2001; 71: 333–4. 5. Ramsey-Stewart G, Burgess AW, Hill DA. Back to the future: teaching anatomy by whole body dissection. Med. J. Aust. 2010; 193: 668–71. 6. Burgess AW, Ramsey-Stewart G, May J, Mellis C. Team-based learning methods in teaching topographical anatomy by dissection. ANZ J. Surg. 2012; 82: 457–60.
801
7. Ramsey-Stewart G. Anatomy and Histology web site. University of Sydney. [Cited 8 Apr 2014.] Available from URL: http://sydney.edu.au/ medicine/anatomy/current-student/whole-body-dissection/index.php 8. Ramsey-Stewart G, May J. Contemporary teaching of anatomy in Australian medical schools: are we doing enough? ANZ J. Surg. 2012; 82: 88–9. 9. Ramsey-Stewart G. Anatomy and Histology web site. University of Sydney. [Cited 8 Apr 2014.] Available from URL: http://sydney.edu.au/ medicine/anatomy/current-student/whole-body-dissection/postgraduate/ index.php
George Ramsey-Stewart, MD, FRACS Discipline of Anatomy and Histology, The University of Sydney, Sydney, New South Wales, Australia doi: 10.1111/ans.12659
Open approaches to the aorta in the endovascular era Endovascular repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysms in anatomically suitable cases. The introduction of advanced techniques such as fenestrated (FEVAR) (fenestrations involving the renal and mesenteric arteries) and iliac branch grafts has extended the proportion of cases which are anatomically suitable for endovascular therapies. Nonetheless, a proportion of patients have aneurysms which are unsuitable for less invasive techniques. Aneurysms with short, highly angulated infrarenal necks, extensive intraluminal thrombus in the juxtarenal and suprarenal aorta and also severe iliac artery tortuosity, calcification and/or small iliac artery calibre/stenoses are frequently unsuitable for endovascular therapies or endovascular treatment may be associated with high levels of perioperative complications and graft failure.1–3 In this issue, Twine et al. found that 28% of aortic aneurysms managed on their unit required open repair because of anatomical contraindications to EVAR or FEVAR.4 This cohort of patients is challenging to treat and the results of this series and a recent systematic review and meta-analysis published by Twine et al.5 support the view that the retroperitoneal approach may provide significant benefits over the traditional transperitoneal approach, in terms of reduced in-hospital complication rates. Generally, the more complex the proximal aortic anatomy, the more likely a retroperitoneal approach will be undertaken. However, complex iliac artery disease on the right side generally requires a separate Rutherford-Morrison incision and thus the standard retroperitoneal approach may not be ideal in such situations. Surgical experience of the retroperitoneal approach (and indeed transperitoneal approach with medial visceral rotation) among surgeons trained in the endovascular era is generally limited. In the
© 2014 Royal Australasian College of Surgeons
future, this may require us to consider undertaking such cases in specialized centres. This further supports the critical importance of formal anatomical training, in particular cadaver-based courses, such as those held at the Clinical Training and Evaluation Centre (http://www.ctec.uwa.edu.au) to ensure that our graduating trainees are comfortable with the various approaches which can be employed to deal with the spectrum of aortic pathology encountered in contemporary practice.
References 1. Stanley BM, Semmens JB, Mai Q et al. Evaluation of patient selection guidelines for endoluminal AAA repair with Zenith stent-graft: the Australasian experience. J. Endovasc. Ther. 2001; 8: 457–64. 2. Dowson N, Boult M, Cowled P, De Loryn T, Fitridge R. Development of an automated measure of iliac artery tortuosity that successfully predicts early graft-related complications associated with endovascular aneurysm repair. Eur. J. Vasc. Endovasc. Surg. 2014; 48: 153–60. 3. Barnes M, Boult M, Maddern G, Fitridge R. A model to predict outcomes for endovascular aneurysm repair using preoperative variables. Eur. J. Vasc. Endovasc. Surg. 2008; 35: 571–9. 4. Twine CP, Von-Oppell U, Williams IM. Left retroperitoneal aortic aneurysm repair in patients unsuitable for endovascular treatment. ANZ J. Surg. 2014; 84: 861–5. 5. Twine CP, Humphries AK, Williams IM. Systematic review and metaanalysis of the retroperitoneal versus the transperitoneal approach to the abdominal aorta. Eur. J. Vasc. Endovasc. Surg. 2013; 46: 36–47.
Robert Fitridge, MS, FRACS Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia doi: 10.1111/ans.12807
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
