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Year: 2009

Choice of treatment for the patient with urgent AAA: practicaltips

Mayer, D; Rancic, Z; Pfammatter, T; Veith, F J; Lachat, M

Mayer, D; Rancic, Z; Pfammatter, T; Veith, F J; Lachat, M (2009). Choice of treatment for the patient with urgentAAA: practical tips. Journal of Cardiovascular Surgery, 50(5):595-598.Postprint available at:http://www.zora.uzh.ch

Posted at the Zurich Open Repository and Archive, University of Zurich.http://www.zora.uzh.ch

Originally published at:Journal of Cardiovascular Surgery 2009, 50(5):595-598.

Mayer, D; Rancic, Z; Pfammatter, T; Veith, F J; Lachat, M (2009). Choice of treatment for the patient with urgentAAA: practical tips. Journal of Cardiovascular Surgery, 50(5):595-598.Postprint available at:http://www.zora.uzh.ch

Posted at the Zurich Open Repository and Archive, University of Zurich.http://www.zora.uzh.ch

Originally published at:Journal of Cardiovascular Surgery 2009, 50(5):595-598.

Choice of treatment for the patient with urgent AAA: practicaltips

Abstract

Since the first successful attempts of emergency endovascular aneurysm repair (eEVAR) for patientswith ruptured AAAs in the mid 1990s, surgeons have had to decide whether to treat patients byconventional open surgery or by minimally invasive but technically more demanding eEVAR. To date,selection of patients for eEVAR is still heavily debated and factors like hemodynamic instability, fear oftreatment delay for patient transfer or imaging procedures and logistic issues often lead to the exclusionof anatomically suitable patients from eEVAR. However, these adverse factors may be overcome byadherence to an appropriate (intention-to-treat) protocol employing the use of a hypotensive hemostaticapproach, transfemoral aortic balloon occlusion technique (when needed), different types of devices andan appropriate plan to resolve logistic issues, leaving anatomic suitability as the single most importantdeterminant of suitability for EVAR.

J CAADKlVASC SUAG 2(X)g",50:OOO-OOO

Choice of treatment for the patient with urgent AM: practical tips

D. MAYER' , Z. RANCIC '. T. PFMlMAlTER 2, F. J_ VEITH 3,~, M , LACHAT 1

Since <he fl",' su~cessful ~ ltemp .. o f emergen cy en do_ vascul.u a n e u J'}·. m ce paic (eEVAR) for p~ 'i en ts ... i,h nJp!uce d AAih in 'he mid 19~, s urg e o n s h ave had 10 decide whether ' 0 t ...,a t pa tien ts b y con ventio n a l open s urgery or by minimally in vasive but techn ica Uy more demanding e EV.-\R. To da te, s electi o n of pa tie nts fo c eEV.-\R is s till h eavily d eba te d and f"",0t'5 like bemo dy _ n~ lllie in. ta bili'y, fea c o f trea tm ent dd"y fo c patient trnn.f<..,. o c im' w _n g p rocedures and logistic iso;u,,,, oftcn lead ' 0 'he exclusion o f a n atom ically suitable p atients fr o m eEVAR. 1I0wevec, , h""e advern ["""OB may be ovccco m e by adberen~e to a n appropriate ( inten'ion_ to _treat) protoco l employing 'he u . e o f a h ypotensive bemost.-uk appr<XJCh , trnns femo ..... l ao n ie balloon """lu­s ia n tec hnique ("' h e n neede d ), diff,.,.ent ' y pe. of dev i_ c"" and a n a ppco pdate plan ' 0 c,,",on -e logistic i""uco, leavin g a ""to m ie s uitabili ty "" ,be s ingle mo.' impo c_ tant determinant of s uilability for- EV.-\R

Kt" ".(>JtI"" Aort ic ., "-'\If}-''"'', . Ixhtli"al, "-'r-,;ef}-' _ Ar<.'\I f}--"m . rupl LL,,-~ 1 _ End",·.",,,I,,, ' UrgICl I proaxlu"".

I n th e past , there was no <x h ~r ("ho lce than eon­'"~ntlona l ofX'n surge,)" (COS) for thc tr~atm~ n! of

rupturc-d abdomln~l aortl~ a nc ul)'sm (RAAA) , Things .,wrtcd to chan~c In the mid 90 lcs , when y u , u f, Ilopkln so n (1 a/,J "nd Ma rin , \Uth (1 aU rcport L-d thc lr first S LJ cc~".,fu l a t t~mpt s of ~1\l~!'",;cncy ~nd",'"s­

rubr :m~lLfj-"Sm "'p,1f (eEVA R) I"" p, tk.l1iS with RAAA , SlL'3'-'{)n , th~n had to dc'Cidc whether to treat patients

I<=riv<J on F<b.u')" 1] , l<hl. Ac=pO<J foo publi,""" on """""I"" 10, "'it

Cc,,.,,!,,,,,d.,. . u",.,.., o. ", r" , eli, ", Ie< C:"di",,,ocu,,, '" 'l/<'Y. ].".. ..... y ""'I'"oJ «7.uri<!c _'" ]«), i())1 l.uri<!, s..·. Z<rlrnd F"",; L J Oct .... ""'1"""';' .eh

\bI. '" _ .... .j

'Clinic lor Cardiovascular Sutgety, IJniII6rsily Hospital Zlltich, Zlltfch, Switzerfand

21n1etvlN1lional Radiology lJniversity Ihspite! Zll/fch, Zlltfch, Switzerfand

3Th6 Cleveland Clinic and New Y",* lJnive1"Sl/y Medical CenferNew Y",,*, NY, lJ£4

' lJnivorsity HospIIe! Zll/fell, Zlltich, SWllzerfand

b )' COS o r by minimall ), In vasIve but t ~ chnl ("a ll y

d~tmndlng eEVA R, 1\-1"", than a d<.~ddc "fter thc Intro­duction o f eEVA R, the qucst lon rem ain." what l" th e bener cho ice and whi ch pa lle nt to t",at by ~ lther method?

It I., an acceptL-d b ct that d~spltc ad'lInces In op"r­ath'c tcchnlque a lld p"rlop"rath'c ca", over th~ past SO yea" , the r~s u l ts o f COS for R.o\.\/\ rema lll poor, with tllort~llty m tcs III thc 4o-5(l'% range.'·' Rccent mClaJdml)"Sls rompartng cEVA R with COS ha,,, .,hown ~ trend to lowcr mort~lltr r~K'" for cEVA R, '1-7 Further­mor~. rc=ntl r, two 1"lgc .'ln gl ~ renter .,eries w~r~ publlshL-d with vefj-' low mortality for eEV,W,l' furthcr raIsing ncw hope for th"'" patients ,

I Im,,:\·er. a na lysis o f the cu=ntl y publlshc-d Iit cr­olure ;.I,OW.' wldc varbblHt )' In the Inclusion r.l1 c o f )t,\J\, \ patlcnt' for ~J!VA R, Whcrca, thc tllL-db n Inclu­sion ra t ~ for single ccntcr ;.mdles I, around .\jl%. enl)" "bo ut W% or lc ... of RA.\, \ patknL, ar~ "'portcd to ha,-c had cEVA R In ""'~ro l large Unlt c-d Siat'" dow­ba.' c-s,LO-"

Altho ugh still deba tc>d,17 mo", a nd lllO'" cvld~ncc b aC1:utllulat lng to Indl c"tc tha t with a n ·I~AII flm ­appraich mon"llty mte.., mar \", 1",\1_,,-'<1 for t)", whol~

R.\I\, \ patl ~nt eohort undergo ing treattll~nt (I.e, fo r palle nts t"' " tcd b)" COS and e FVA R).9, IJ , L8-'-' SO w \lat ,'" the factors that determlnc ,,"heth~r a )t,\I\.\ p, lI em will be tr~at c-d by eEVA R o r n m?

,

Th~ slngl ~ m ost Important factor "-,,,m s to be art ~­

rtal "natom y, RAAAs th"t ex t~nd ab",.., th e renal art~r­

Ie" d o no t curre ntl y q ua lify fo r ~ndo\'a<c" l ar trea t­m~nt - although th e y may in the !utur~ , 1'0r elect ive abdomInal aortic arte u",'sm rep aIr (EVAR). there Is a gem:ml agfL'<:m ent th at th ~ n ,-"k (proxIma l landIng zo ne ) ., hm Jl d n m cxc,-,<-'<I .III to :\2 nUll III dlam~t ~r

a nd sho u ld he ot leos t 10 to 15 mm In length, Furthert nore . It Is gcnemllr agrr-<-'<I that ""wrelr an h"J-1ol'-'<I neck., (>(, (1") ShOllld rt m be treat ed h r EVA R a ltho ugh the re m ar he som e exceptio ns ," Since the a '".I llabllltr o f aort o-uni-1l1 ac devIce.,. th e dista l land­Ing zone ha.' b" rom~ less of a co ncern. and m ore exte nded ao rto- Ilia c aneurysm s mar he t",o K'<I sak ­ly hy th'-""" d",i C'-'S. When adhe rirtg to tllL.,., crite ria . the sult ahllitv of eEVA R for R.\AA has h L..,n repo rted to be os I",,· os 1U% ," Rdchon eI a l, . bv I""",nlng these crlt ~rla to a nc"k le ngth of 2:11) Illm a nd a tl a nglLla tlon of S9O°, rcport a fl~.I .' lbHI1\' o f 4tl% in thdf .><-1'IL'S,"" In our re"'-l1tl)" publl sh '-'<I ",ties eX 102 RAA.\S treate>d br ~FVAR . W~ were abl e to t",o t up to ts..,'f)6of RJ\ AAs hy eEVAR b r further exte ndIng the . .., criterIa (especb ll)" an acceptab le n L"k length of 2:5 mm),'

An mhe r major factor leadIng to the e xclusion of patlents for eEVA R is h~modynaml;: lnSl ablli!)" in con­K1llp<r.l"'· compamti'''' Sl:ti es, toc rcporK'<I propon![X1 o f unstable patl e nts Inclllded In the eEVA R gro up vari'-'S ronsldembly . r~ng!ng fro m 14% t07$;" '" '" In sewml of th."., Sl lldlL'S, unstahl e patient, wen:: exdud­,-'<I from eEVA R, " _lO-1I 'n,e d e llnltl o n o f lLn stable pati ent s also varl e.' w!del r and gener" ll )' lak e'S Into acrount o n ly the sr sto l!c hl ood pr~ssur~ altho ugh thi s m ay va",- f:"ea tlv wllh tlm~ and in tb e duratlon of hypotension, !n v"rlous .'llldies . pati ent s q ua llf)' for l:>elng unstable wb~n the lowest systo l!c bloo d prl'S­sur~ Is I,-'Ss than SO mml ig up to k -.;s than 100 mml 19, ,\ddltio n a l v"ia hl es Include suc h .'ta t ~tl\ent s as "'d'-"f'lte re,."S<itatlon!not re.'pondlng to a tluld bolus" o r "no ,'erh al re pl vj unconsclous" Of · sc, ."", arrll)'th­mi";cardiac arrest" wbld , ar~ me ntl on L'<I In cetUin p ubl!catlons, .... $ -"." I iowever. since the Introduction o f th e concept o f hypot ~nsi'-e hem o stasis'" and the lIberal use oftramfL-'mom l ("'pmcell" c) b~ll00:! occlu­sio n technique J9 b )' Velth a nd O h kl , unstable RA,\A patlen L. oli en m a), h e re.' to rr'<l to an lmprov'-'<I hem o­d )'n a mic stalus and th ere lo", be render,-..:! suitab le cand Idates fo r eEVAR, In Ollr sc ri es of l (ll RAAA pa tients tre"t,-'<I br c1!V.\R . nIne teen pa tient s we", suffl rle ntl)' unstalx e ( leM than SO mml 19 d c'Spli e ade­'llJa le fL-.;w;c lt alion ) to n'-"-..:! tmnskmor~l supm cdlac

,

aortic b ~lloon occlusIon . tim .' !ncreas lng ka., lblllt)' br 1 ,!%,!

Even to dar. th~n:: Is con c<:rn th"ttlm~ 1m t by lra ns­fer to "notlwr lnSl lllJtion (cifeting eEVA R) or for Imag­Ing procL'<IlJfL"S n e'<:ocd to eva luate the suit ab ility for d !VA R m al' nega tl" ,)r Influence OlJt come , '!1,esc a rc the ",asons why man r pa tknt , "na tomlcall r suItabl e for c1!VAR 0'" exclllOC'<l from the p roce>dlJre and u-,.,at­L'<I b)" COS, I l o\\"ev~r, mrl ct adh erence to the concept of hypexe nslve b~mostasl s a nd lllx:ra l lise o f aonlc ba ll<Xln oceluslon all",,·s m ost patknt s to be Imag'-'<I ap proptiatdr and . if n ,-"",-'Ssa!')'. transt"err,-'<I to anotl>­~r in stItutIon . a t I~ast !n Europe whe", diSiances a,-,., shon, In ta ct . sc""" ml repons <Ul!lm\ that althou2i' th~ trdnskr of patien ts w llh RAAA re.",lts In a treatme nt del o)". it dOL'S not a dv~r,"'l)" affea the m ort alltr rat~.'

a"-, ociat ed with this co nd lUo n, .o. " Wh~n !lrst co n­ta cted b )" ex tern al In stitutio ns o r e me rge ncy roo m staffs (Hrst p hone ~a ll ). eve ry m em ber of our tea m stres"", the Imponance of llmltlng a ll tlulds or tr"m­fus ions and sugg<"St!; aimlng for a W!j.(d sp tollc blood p re.' .' u", be low ~) mml 19, I'urth ermor~ , b r avo idIng rom plex "n,-",",b etic pro ~c..:! lJres ,.,Jch as poslUonlng of c~ntra l ve nOLJ.' catb e te rs a nd h )" adh e ring to a "SCOOP and nm" a pproach (we ll know n in tra uma surge!')' )," time loss m n be m!nlmized,

For oc'C'.IdL'S. toc n "'-'<I to rush to the operatlng room or tocat", v .. lth R.\AA patie nts was a ge nerallr acao pt­L'<I concept . lea ving no time for furthe r lmasln g p ro­CL'<IurC'S, I I",,·ever. thIs might otk n he the wro ng par­adigm a., It ha.' bt...,n .' !lOwn hy Ll oyd el al. In a tlm ~ to death Slud)' that tl~ malm tr (t'I1%) o f f{, \AA potlents rc'lllaln h~modmamlmll y .' table w!thin the HrsI 1 ho,,,.,; of thelr admIssIon to the treating lnstlllJlion, " in b ct. the m,-'<Ila n Um e betwee n ru p ture and d ea th In a lifOuP of 56 pati ent s o fkrL'<I all)" palllation was nea r­ly I I houn; , We SllUlgl r ,.,J&:l'SC m!T\'ing C>.lt an urg~nt th o racoa bd ominol contrast CT sco n !n a ll RA,\ '\ palients . !f!t Is a"albb l ~ w!thout d da)' (alier a 'llJick ch eek all)' h y the anes th'-~ist) unless one has b e.., n ohtaln L":! b y the rek1Tlng Imtltut lo:\ , The, all",,·s mpld onlln e dL<;C\lssI:Jn alXJ.Jt ihe best treatment mo dallt)" (at our !nstitutl on strIcti )' o n anatomica l crite rIa o nl )") !"'tW'-"-l1 the , -a""ul:rr suIJ,,'lul and mdlologlSi while th e ones thesiologi st., a rc simuit an'-'<lllsly c"rtng out th e fInal pa tie nt p repar.ltlon ( I. e , p \a eem e nt o f an erl" l lines and centra l ,enOllS catocters),9

Flnoll v. iO',(l, tlcs a\so seem to be an Imponant basIs for p"d lient exclusion from eEVA R, !ll several cont ~m­pora f)" com pa ra tl , -e p"bHcati ons, 10gL, tlc prob lem s

a r~ m~ntloned as ofte n leading to tile exd uslon of a nato mlcallr suitable pa lknts lrom eEVA R, l'· '" jl "',.'" u." Sul l:lble patlent, we", exctud~d liun d,VAR I",at­m ent h c'Causc o f: 1) lad;; of a,'albhlllt y of staff {.,ur­geom tm lnL'd In EVA R. md lologl!'ts, .'pccta ll7.ed scruh nur",,, spccbll7.~d mdlo10',(lcal [eclmlclans) d utin ~ tile we~k or on ",-", k ~nds, and 1) unava ll ah lllt " of cndo f(falt ro mp oncnt', Arti cles dea ling w ltll Ihe Imponance of ila,'ing a prc:xoeol for eEVA R In RA,\A patknt s em plla., lze Ihe Importance o f having Imined .'taff 14 ho urs a dar. 7 days a ", c", k and an ade<! uate ~~!ulpme nt stock .J9,»,'; At o ur In !'t llutlon , ~ ro und­tile-dock service I, provided for '"dSC1l br cm ergen('\' pro<.'~'dlLt'es in cl ud ing d ,VAR for lUlu\A9 AI a ll llm<."s. o ne se nior Intety~ntlon al mulo logl!'t . cardiovascular a ne!'thetist and "ascular "urgeo n at'\: a,-ailable , As a n In!'tltullon with a , 'a!'t act ivity In decU,'e lOVA R p ro­",-'<i u"" (a pprox imately fj()(I "Ixlom lna l "nd 150 Iho­mclc EVAR pt'",-,-'<iu",s to dale ). ~ l:umu Sloe\;; d blfur­cmcd and aooo-unHl lac endogr:lfts Is ",'aliable , d NA R procc'dut'\:s ma,' be can1~'<i o ul In a fully c~!ulpp,-'d L1lle't-"-"L1' o p,:mtlng room or in:ill :mglogrJphv .,ultc, c r sca n.' at'\: ava lbble within 5- 15 mlnUk, as Ihe !,ca nn~r Is pan of th~ shock room, An ~EV'\R ~'duca­

tion progr.Jlll is pro\iu~'<i to all potet\lla! >laIr meml",fS, " lllilesc n.,(!lLi"'m~nL' "'p"''''ntlile Id~a l willch may not be po.,.' Il) I ~ In ever)" rommunlty o r e'''f)' instllu­tl on, I,ve n th en , some group., h""~ sho \\'n excell ent rcsull.'; In much I".s .:ledl s<1tlng' wlIh a ",asonablc but IImll ~'d cm ergency stock of cndogm tt" or w ltilout a n Inlcn"ntl ona l radlologl!'t a va llabk '" '-'- "

l.aSl bUI not I ~a.' t . patients unfit for geneml an~s­

thesla . mighl profit freon tile fact Iha! eEV"R tlla )" ufte n 1:><: carrl~'<i oul Lmder loca l anesthesia (LA). 'Ill e ben­e fit s o ! l.A s uppl emenl~'d by a nalg oscdat1o n w!lil "-~nil'~ntan)i In eEVA R fcc RAA,\ \\"L1'~ fin;! ""potK'd by la chat eI {II, In ~)(Jl," Al o ur InSi itution, &#0 of RAAA-' tr~at ed lor eE\\\fI. """" exduu~'<i from Ihc Lircubllon under 1. \ (a nd a nalgo"-'<i~llon lor remlfe ntanyi), '1111 ' expe ri ence ha.' b~~n m nflrtlK'd I", .,c"eml ot h ~r groups, l!." .,

Conclusion s

in summary, If It 1-' bell evL'd th ol "I,V,\R tlr!'t - Is Ihe l",ner tt'\:atm enl ('h oice for RA AA. ana tom y Is the sin­gle mo st Import"nt factor in d eterminln f: suitabilll)' for Ihl' fonl\ of tt'\:atmcnl, O! iler romptu nl;,lng hlctors

\bI. "-' _ .... -I

SLlch a., hemodynamIc Instability. Ihe teor of tim e 1m.' etc , ma y 1:><: o ,",-"rm mc br adile rcnc~ 10 an appropti­ole ( intentlo n-lo-trC"dt) protocol emplorln~ the use o f a ilypoK11sl ,'e hemo!'t"t1c appr<mctl. tmnstCmom! aor­Il c balloon occlusion 1<-'Chnlquc (when n L,,-'de<1 ). d!f­f~n.11t Iype.' 01 uc vlC\..,; a nd an approptiate protocol to rc!.oh" logl!'t lc {ssues,

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I. Yu",rsw, WI' " k",;C, Q""", TA, " 'cnh. m PW, HoT'<"""" Hf'­'~<noo.-...uw "'I''''" of l<oki"" >O<tic ."""""" . '== I ?9-U-H 'M"

l . . 'WI> .\lL, \'dh 'J, Cl""""""J, ,>nd"", lA, Lyon RT, ~.; "" 1IA " aI. In<w ""port= w ith ,,,,,,""umruUy plx. d =dov ... uJ...­..,.r" fa< ,I", , .. ,.'m=I of complex v,"",ul", l=iun>. Ann S" 'l' I ?9'i;''','I-I'l-&i; d",-"".oon 6S-9.

j . U.o ... n ,"'J, "-'tan .\.], 1><1 " II, "'l""" W . A ~Iy>i> of <0 l"""" of rup<"",d . 1><iom in. 1 .0"", ''''' "'T'm "' p. j .. n, J S" '!< >002;";;' - 1-1_ Yt.

• . • \Io.-.•• d, ."'D . f.UR !o< ,h. ,,,,.trn=< of rupt " ",d .'-AA. p~, \'"", So"" ,>-<loon", 11"" lCl!9-,2 1.9- 11.

~ . . \1.>~rncci -",! . G.,rd,-Cl u,-""" I., Cino CS, Ch", 0 1. Y",dovoocul", "1'ill of N pn.«d .lxbruru.l._, ~, • '}"""",-oc ""_.

. 00 """" _.",ly>i'. J ''''"' Smg ;<)<)<A- " I ,1_, l. Ii- ".yt 1!s, ' ult"" AJ, w n da> " J, "'-y'" IUJ, lla,..n "J. A .,-.<=u'­

"' = i ... ·'OO m "' ... .wy". of .."00.,.."", 1,,, .-.p,i, (E\'H) fa< rup<u.-.d . ixiomi.w "",,", '='T"". Eu, J v.>< Fndooov"", So", ~;~~.~.j.1. s .... , u, 'iorio)!', ",..w, S~,'>no T, \~rty~, EI.yeo PD . I>rl>­,","""",,,.. "I"'" «f"iI of .rut •• I><lorun.l ".,., """""""'-• .,... tom"'" =-iow . nd mct._."" ly>;'. J \~oc """ >(lo:)!,; ·!~ , "r-~ .

>< lIolst J, " •• "h 1 ', l"'n<'<v~, lljono K. D ... S, Undt.bd H .. aI. E.ely ,00 int<rn>«i .. ,. ""'CQmo< uf """'goner "ndov.o<ul., '=ry><n "1" ;' of "'P<""'" jn[",,,,n . ] "",", """my"'" • , j",o<­«ntr< oxp<rio<n« of9<l <'<><>'OCU tivo p .. _ . fill J V.,C eroov,"", ""'" ' «j'-) ;r41J-9·

9 . . \1.>y"- D, pro""",,,,,, T, R.n,", Z. 1I",h.lh.m""" l, "'lhelm .. , vdh Ij .. nJ 10 y'"'''' of ~ "ndov.SN!", ~ "-1"iI for ruptu=l . Ixiomri.o.l """"'l"-, >n" "1""'" b.ano "'<n«!. Ann ""<' _'OO\>,"\9 ,~ I I)-~

10. Diu.."", 10', Muluk »C, ""broun .\lS. Improvi", <nOucy>m--<cl .. _ od ""''''''''''~ = tlon .... <i< b<ncf .. of ..-.>0" •• <,,[,, '"P'''. J "'K ""'l' >OO"A}oI·i/i-<l ; w.cu."on <1-'.

11. G'l<. KA, Po mpooodU F, EI>mJ..o A, ")"= M, jh,.. rl A, SciK '''K,bcm ML. I"=<"", ., '=l.".".~"'d <1<,,1> • ., t1K "'" of .oo.ov.",-"lu- • .,...,,\"Hn '"P'''. J "'K So'l' 2({J9-,4H·U-S<:>, diocuuK><> SO--1.

"- G",co G . F.go<ov. ", A",",,,,,,n "L, G.h .,. A, "=1<""",, A, N<>WJWOd " .. , • . ~. of ....."..><lliu ""''''''''' of rup<u=l . Ixiomin.>l >O<bc .n""'T'm •. J ''''"' _'mg ll106AH~Y!.

H L= CR,!,., l .. bropoulao ". w-.do I, HOOrisu<> l IE, K>.lm= I'G . To ", h,' oxtonl h .. "OOo,.,,,ul,, ,,,,,u 'T"" "1"i, iril ... n=d . ixiomi""l "",,", ""' , .,.,... =g<UKr.< <n ,IK .. "'" of Ill;no;,'! v"", >u '" .100' ;41 ,l-&!-- ,j.

1 • . '-<>I'=""~' An<l<.""n C. Si",o' N, ".""" II, ."',n io .\lJ. ¥.xp.n_ <lin>< " "'" of <ID«gcn'f =<Iov •• cub, "'I"i, for rupt=d .bdom· jn,] "Xli, "''''''y''''', rn.p,,,,", • ., """""". f,,,,,, • "",;c",.,·i<l< f'<"''f'''<' jve. J \~ .. So", >008;, -, Il M--:'0; rnocu..oon -:-0- 1.

l~ . . \keh.., J, h l. m ; " EI. Am". "J •. " "." .... L", Sch.n"', A. Fmo,=u l", " .. 'm«>< of ruptu",d .bdom"",1 ><><ti, """"""",,, ;n ,i>" ,-"t.o ",t<. (AXll-X(l6), • ..,., ifoe, n' .m vlv'! I"""" O"V«

,

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