“When I relocated to Lebanon, I was the only person with practical experience and expertise in EVAR [endovascular aneurysm repair] in the Middle East.” It was thus that Aghiad Al-Kutoubi became the first in the Arab world to perform this procedure, in doing so changing the face of interventional radiology (IR) practice in the region. Now adjunct professor of diagnostic and interventional radiology at the American University of Beirut Medical Center (AUBMC; Beirut, Lebanon), Al-Kutoubi tells Interventional News how he came to embark on his IR career; recounts the obstacles he overcame to develop an IR service in Beirut, as well as those encountered in practising IR in the country more broadly; and imparts his knowledge on how best to train interventional radiologists.
What attracted you to a career in IR?
This really happened by chance. I was attracted to radiology because of the potential of contributing to the diagnosis of disease in multiple organs and the interaction with different medical teams. My career in radiology started when I was accepted for training at St Mary’s Hospital (London, UK) in September 1977. The head of the department was David Sutton, a pioneer of angiography and its application in systems including the heart and central nervous system. I was mesmerised by the art of diagnostic angiography.
Interventional procedures were only just emerging—treatment of gastrointestinal bleeding with vasoconstrictive medication, preoperative embolization of renal tumours, venous procedures, etc. I still vividly remember the first iliac angioplasty procedure that I assisted in as a registrar in 1978 and the impressive result. At the same time, ultrasound and computed tomography (CT) scanning became established tools. These modalities offered opportunities for biopsy and drainage procedures. I think I benefitted from these developments and unconsciously became an interventionalist as well as a diagnostician.
Who were your mentors?
In my earlier years, I was influenced by many people—my parents, some teachers at school and university, and close associates in my home country, Syria. In my radiology career, I owe gratitude to David Sutton for inspiring me and Oscar Craig for his wisdom and guidance. I must also mention Averil Mansfield, who provided the best collaboration, knowledge and support.
Could you describe a particularly memorable case of yours?
There are so many, but I will mention two. The first was in the UK—a patient who developed an arteriovenous fistula between the origin of the left carotid artery and innominate vein after pinning for clavicular fracture. Suitable stent grafts were not available commercially and the case was treated with the combined efforts of IR and vascular surgery, who provided a segment of the saphenous vein that I attached to a Palmaz stent and placed it at the origin of the left carotid artery through a direct carotid approach with balloon occlusion of the innominate vein. A second similar stent was needed but we were elated that the procedure was clinically successful, and the patient avoided thoracotomy.
The second was in Lebanon, a few months after I performed the first endovascular aortic case. A patient presented to the emergency room with type B dissection and a large leak from the distal aortic arch into the left thorax, as well as lower limb ischaemia. As luck would have had it, I had a thoracic stent graft for another elective case that was the appropriate size for sealing the point of bleeding. Balloon fenestration of the abdominal aorta treated his limb ischaemia. I saw this patient repeatedly until he passed away 20 years later from complications of lymphoma.
What were the challenges involved in building up the IR service at the AUBMC?
Although some IR procedures were being performed by colleagues, there were challenges at multiple levels. These included acceptance of new procedures; perception of competition by other specialties such as vascular surgery; acceptance of new treatment methods by insurance and third-party payers; the cost of procedures to patients; availability of appropriate equipment and paramedical staff; anaesthesia and sedation requirements; availability of devices; and the volume of cases versus training requirements for residents. Some of these challenges required a gentle approach, with firmness and perseverance required in others. The result was of benefit not only to the AUBMC, but to the practice of IR in other centres in Lebanon and in the Middle East as experiences were exchanged and knowledge shared.
Having practised in both the UK and Lebanon, what are the main differences/similarities associated with IR in these two geographical areas?
I think the fundamental difference is financial. In the UK, my practice was mainly in the UK’s National Health Service (NHS), where the person with the most expertise would be the one to perform the medical procedure and this was also true in the private sector. In Lebanon, the health system is spearheaded mainly by established and respected private institutions, for example, the American University of Beirut. In contrast, the public sector provides a relatively small proportion of healthcare with limited resources and lags behind in terms of state of-the-art treatments. Private healthcare requires someone to pay for the treatment of the patient be it the patients themselves, insurance companies or other third-party payers who have to accept the value of the treatment procedure and frequently find reasons for not paying in full.
The other issue is remuneration of medical staff. Whereas in the NHS the physician is not paid per procedure, in Lebanon, the income of the physician is dependent on referral and case numbers. Therefore, a surgeon may choose not to refer the patient for an IR procedure because he would lose income. Joint arrangements for management became necessary to provide a balanced approach to the treatment of patients and to avoid ‘competition’.
How did you come to be the first to carry out an EVAR in the Arab world? What do you remember about how it came about, and the impact it has had since?
At St Mary’s, we had embraced this new approach to the treatment of aortic aneurysms early on, and I, with my vascular surgical colleague John Wolfe, treated a few patients with stent grafts for aortic aneurysms using the first-generation devices. When I relocated to Lebanon, I was the only person with practical experience and expertise in this field in the Middle East. Despite this, I had a hard time convincing colleagues of the value of this method and was, in fact, the target of efforts to stop its introduction until we had a patient who developed a false aneurysm of the thoracic aorta after coarctation surgery. I had, by that time, modernised the angiography suite and was able to convince the cardiothoracic surgeon Munir Obeid that this was an ideal case for stent graft placement. With his help, and that of Ghattas Khoury, another surgical colleague, I treated this patient successfully and she went home the following day. The publicity that followed resulted in referrals and soon patients were treated by various EVAR devices—the people who had resisted were now interested! I was able to present my work at various regional fora and got colleagues in other Arab countries to pursue this approach. The rest is history!
As someone who has a passion for educating the next generation, both in the UK and in the Arab world, what would you say are the priorities when it comes to making sure interventional radiologists-in-the-making receive the highest standard of training possible?
Interesting question! I think one of most important factors is the commitment of the trainers to training! Commitment of the trainee is no less important. Secondly, establishment of a comprehensive curriculum to take into account the modern, and ever-changing IR landscape—this is pivotal to ensuring the standard of training. After these first two steps, finding training centres that have the breadth of practice and case volume to meet the curriculum objectives is relatively easy. It may prove necessary for trainees to visit other centres to observe/train in procedures that are not done at their primary training centre.
What are your hobbies and interests outside of medicine?
I have pursued many sporting hobbies over the years but had to give some up after injuries. I now do scuba diving and golf, which I wish I could play better and more! Arabic calligraphy is a skill I was taught by my grandfather and I practise it occasionally, but I hope to spend more time at it. I guess grandparenting is the main ‘hobby’ now.
