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Bianchini Massoni C, Perini P, Rossi G, Carli AG, Catasta A, Nabulsi B, Freyrie A. The role of narrow aortic bifurcation in affecting EVAR treatment and outcomes. Ann Vasc Surg 2024:S0890-5096(24)00240-1. [PMID: 38815912 DOI: 10.1016/j.avsg.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/14/2024] [Accepted: 03/16/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVES The narrow aortic bifurcation is considered a risk factor for endograft thrombosis after aorto-biiliac endovascular aortic repair (EVAR) for aortic or iliac aneurysm. Nowadays, no consensus on the threshold diameter for the definition of narrow aortic bifurcation is reached and other aortic bifurcation features are rarely considered. The aim of the study is to assess the EVAR outcomes using bifurcated endograft according to anatomical characteristics of aortic bifurcation. METHODS The study included patients treated with primary EVAR from 2016 to 2022. A retrospective analysis of single-center prospectively collected database was performed. Patients were classified in standard aortic bifurcation (SAB; aortic bifurcation diameter >20mm), narrow aortic bifurcation (NAB; ≤20mm and >16mm) and extremely narrow aortic bifurcation (eNAB; ≤16mm). The three groups were compared in terms of patient demographics, risk factors, procedure setting (elective or urgent/emergent), type of deployed endograft. In NAB and eNAB groups, severe calcification (SC) and length of stenotic aortic bifurcation >10mm (long-NAB) were assessed from pre-operative imaging. In SAB, NAB and eNAB groups, following outcomes were evaluated: rate of intraoperative iliac endograft stenting (unilateral or kissing stenting), primary patency (PP), freedom from endograft-related reintervention (ffER) and overall survival during follow-up. RESULTS The total number of deployed aorto-biiliac endografts was 365 (mean age: 76.6 years ±7.4; male 89.3%): SAB 298 (81.6%), NAB 57 (15.6%) and eNAB 10 (2.7%) cases. Female gender, COPD and active smokers were more frequent in patients with smaller aortic bifurcation diameter (p=.002, .039 and .010, respectively). In NAB and eNAB groups, SC was reported in 18/67 cases (26.9%) and long-NAB in 15/67 cases (25.4%). Patients with eNAB have more frequent SC of aortic bifurcation (60% vs NAB 21.1%, p=.018) and long-NAB (50% vs NAB 17.5%, p=.023). In SAB, sNAB and eNAB, intraoperative iliac endograft stenting was performed in 34/298 (11.4%), 9/57 (15.8%) and 5/10 (50%), respectively (p=.001). Kissing stenting was performed more frequently in groups with smaller aortic bifurcation diameter (p=.010). Mean follow-up was 30.2 months ±21.5. At 1, 3 and 5 years, PP was 98.5%, 96.6% and 95.6%, respectively. eNAB had lower rate of PP compared to NAB group (p=.030). Long-NAB had lower rate of PP (p=.035). At 1, 3 and 5 years, ffER was 96.8%, 86.7% and 76.7%, respectively, with no differences between three groups (p=.423). At 1, 3 and 5 years, survival was 92.5%, 77.6% and 58.1%, respectively, with no difference between SAB, sNAB and eNAB (p=. 673). CONCLUSIONS Female, COPD patients and active smokers have more frequently smaller aortic bifurcation diameter. eNAB patients have more challenging anatomical characteristics compared with NAB group, requiring higher rate of intraoperative stenting, especially kissing stenting. Mid-term PP seems to be negatively influenced by aortic bifurcation ≤16mm and long-NAB.
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Affiliation(s)
| | - Paolo Perini
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
| | - Giulia Rossi
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
| | - Anna Giulia Carli
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
| | - Alexandra Catasta
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
| | - Bilal Nabulsi
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
| | - Antonio Freyrie
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
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Morell-Hofert D, Gruber L, Gruber H, Glodny B, Gruber I, Loizides A. Contrast-Enhanced Ultrasound after Endovascular Aortic Repair: Supplement and Potential Substitute for CT in Early- and Long-Term Follow-Up. Ann Vasc Surg 2024; 102:9-16. [PMID: 38301847 DOI: 10.1016/j.avsg.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 09/03/2023] [Accepted: 11/17/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Endoleaks are the most common complication after endovascular aneurysm repair (EVAR). Computed tomography angiography (CTA) is presently the golden standard for lifelong surveillance after EVAR. Several studies and meta-analyses have shown contrast-enhanced ultrasound (CEUS) to be a good alternative. The main goal of our study was to further validate the inclusion of CEUS in follow-up examination protocols for the systematic surveillance after EVAR. METHODS A retrospective analysis of patients who had received CEUS as part of their routine surveillance after EVAR at our center was conducted. Detection rate and classification of endoleak types were compared between available postinterventional CTA/magnetic resonance angiography and follow-up CEUS examinations. Last preinterventional CTAs before EVAR served as baselines with focus on potential cofactors such as age, body mass index, maximum aortic aneurysm diameters, endoleak orientation, and distance-to-surface influencing detection rates and classification. RESULTS In total, 101 patients were included in the analysis. Forty-four endoleaks (43.5% of cases) were detected by either initial CEUS or CTA, mostly type II (37.6% of the included patients). Initial CEUS showed an endoleak sensitivity of 91.2%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 84.6%. No covariate with an influence on the correct classification could be identified either for CEUS or CT. CONCLUSIONS CEUS should be considered a valid complementary method to CTA in the lifelong surveillance after EVAR. As type II endoleaks seem to be a common early-term, sometimes spontaneously resolving complication that can potentially be missed by CTA, we suggest combined follow-up protocols including CEUS in the early on postinterventional assessment.
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Affiliation(s)
| | - Leonhard Gruber
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria.
| | - Hannes Gruber
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Bernhard Glodny
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Ingrid Gruber
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Alexander Loizides
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
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Benedetto F, Spinelli D, La Corte F, Pipitò N, Passari G, De Caridi G. Role of Contrast-Enhanced Ultrasound in the Follow-Up after Endovascular Abdominal Aortic Aneurysm Repair. Diagnostics (Basel) 2022; 12:diagnostics12123173. [PMID: 36553180 PMCID: PMC9777802 DOI: 10.3390/diagnostics12123173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/19/2022] [Accepted: 11/22/2022] [Indexed: 12/16/2022] Open
Abstract
Background: The aim of this study was to assess whether contrast-enhanced ultrasound (CEUS) shows a false negative rate close to zero and therefore is suitable as the main non-invasive follow-up strategy for long-term monitoring after endovascular aortic repair (EVAR). Methods: We included all consecutive patients who underwent CEUS as follow-up after EVAR at our center between January 2017 and December 2021.The follow-up protocol consisted of Duplex ultrasound (DUS) with CEUS at 1, 3, 6 months postoperatively and every 6 months thereafter. Results: A total of 125 patients underwent 228 CEUS. The aneurysm sac showed shrinkage in 80 (64%) patients, stability in 32 (25.6%), and enlargement in 13 (10.4%). A total of 29 (23.2%) patients showed type 2 endoleak, 6 (4.8%) patients showed type 1 endoleak and 3 (2.4%) patients showed type 3 endoleak. Thirteen patients underwent one or more reinterventions. The sensitivity of CEUS vs. DUS was 100% vs. 75% (p > 0.0001). In classifying type 2 endoleak, CEUS compared to DUS showed a sensitivity of 93.2% vs. 59.4% and a specificity of 99.3% vs. 99.3%. CEUS showed a higher sensitivity compared to DUS in the detection of type 2 endoleak. CEUS permits the identification of a subset of patients requiring a stricter follow-up protocol.
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Sultan S, Acharya Y, Hezima M, Chua Vi Long K, Soliman O, Parodi J, Hynes N. Two decades of experience in explantation and graft preserving strategies following primary endovascular aneurysm repair and lessons learned. Front Surg 2022; 9:963172. [PMID: 36570807 PMCID: PMC9774497 DOI: 10.3389/fsurg.2022.963172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/26/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives We aim to scrutinize our evolving re-intervention strategies following primary endovascular aortic aneurysm repair (EVAR) - EVAR GORE SalvAge Fabric Technique (ARAFAT), aortic sac double breasting with endograft preservation, and stent-graft explantation. Methods We performed 1,555 aortic interventions over the study period, including 910 EVARs. Factors associated with the need for reintervention and the likelihood of chronic fabric fatigue failure (CFFF) were investigated. Using conventional and innovative diagnostic modalities with Prone contrASt enHanced computed tomography Angiography (PASHA), 136 endoleaks (ELs) were identified (15 type I, 98 type II; 18 type III; 5 type IV). Results Forty-four (4.84%) patients underwent re-intervention post-primary EVAR; 18 ARAFATs, 12 double breastings, and 14 explantations. Choice of re-intervention was based on patient fitness and mode of failure. Mean EL detection duration following primary EVAR was 53.3 ± 6.82 months, while mean time to re-intervention was 70.20 ± 6.98 months. The mean sac size before the primary EVAR and re-intervention was 6.00 ± 1.75 cm and 7.51 ± 1.94 cm, respectively. Polyester (61.40%) was the most commonly employed stent-graft material. Use of more than three modular stent-graft components (3.42 ± 1.31, p = 0.846); with the proximal stent-graft diameter of 31.6 ± 3.80 cm (p = 0.651) and the use of iliac limbs more than 17 mm (p = 0.364), all added together are contributing factors. We had one peri-operative mortality following explantation due to sepsis-induced multiorgan failure. Conclusions Our re-intervention strategies matured from stent graft explantation to graft preservation with endovascular relining of the stent-graft. Graft preservation with aortic sacotomy and double breasting were used to manage concealed ELs due to aortic hygroma.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland,Galway: Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Hospital, Galway, Ireland,CORRIB-CURAM-Vascular Group, National University of Ireland, Galway, Ireland,Correspondence: Sherif Sultan ,
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland,Galway: Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Hospital, Galway, Ireland
| | - Mohieldin Hezima
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Keegan Chua Vi Long
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Osama Soliman
- CORRIB-CURAM-Vascular Group, National University of Ireland, Galway, Ireland
| | - Juan Parodi
- Department of Vascular Surgery and Biomedical Engineering Department, Alma mater, University of Buenos Aires, and Trinidad Hospital, Buenos Aires, Argentina,Winston-Salem and St. Louis: Wake Forest University, Winston-Salem, North Carolina and Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Niamh Hynes
- CORRIB-CURAM-Vascular Group, National University of Ireland, Galway, Ireland
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Karaolanis GI, Antonopoulos CN, Georgakarakos E, Lianos GD, Mitsis M, Glantzounis GK, Giannoukas A, Kouvelos G. Colour Duplex and/or Contrast-Enhanced Ultrasound Compared with Computed Tomography Angiography for Endoleak Detection after Endovascular Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11133628. [PMID: 35806912 PMCID: PMC9267587 DOI: 10.3390/jcm11133628] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/14/2022] [Accepted: 06/21/2022] [Indexed: 11/24/2022] Open
Abstract
This study aims to assess the role of Color Duplex Ultrasound with or without contrast media for surveillance following endovascular aortic aneurysm repair (EVAR). A systematic search of the literature published until April 2022 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The pooled rates of endoleak detection through Contrast-Enhanced or Color Duplex Ultrasound (CEUS or CDUS) and Computed Tomography Angiography (CTA) with 95% confidence intervals (CIs) were estimated using random-effect analysis. Thirty-eight studies were considered eligible for inclusion. The total number of patients in the included studies was 5214 between 1997 and 2021. The overall pooled rate of endoleak detection using CDUS and CTA was 82.59% and 97.22%, while the rates for CEUS and CTA were 96.67% and 92.82%, respectively. The findings of the present study support the use of the CEUS for endoleak detection. However, it should be integrated into institutional protocols for EVAR surveillance to further evaluate its clinical utility in the post-EVAR period before it can be recommended as the sole imaging modality after EVAR.
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Affiliation(s)
- Georgios I. Karaolanis
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, 455 00 Ioannina, Greece
- Correspondence:
| | - Constantine N. Antonopoulos
- Department of Vascular Surgery, “Attikon” University Hospital, National and Kapodistrian University of Athens, 124 61 Athens, Greece;
| | - Efstratios Georgakarakos
- Department of Vascular Surgery, University Hospital of Alexandroupolis, “Democritus” University of Thrace, 681 00 Alexandroupolis, Greece;
| | - Georgios D. Lianos
- Department of Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (G.D.L.); (M.M.); (G.K.G.)
| | - Michail Mitsis
- Department of Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (G.D.L.); (M.M.); (G.K.G.)
| | - Georgios K. Glantzounis
- Department of Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (G.D.L.); (M.M.); (G.K.G.)
| | - Athanasios Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, 411 10 Larissa, Greece; (A.G.); (G.K.)
| | - George Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, 411 10 Larissa, Greece; (A.G.); (G.K.)
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Caradu C, Pouncey AL, Lakhlifi E, Brunet C, Bérard X, Ducasse E. Fully automatic volume segmentation using deep learning approaches to assess aneurysmal sac evolution after infra-renal endovascular aortic repair. J Vasc Surg 2022; 76:620-630.e3. [PMID: 35618195 DOI: 10.1016/j.jvs.2022.03.891] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 03/29/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Endovascular aortic repair (EVAR) surveillance relies on serial measurements of maximal diameter despite significant inter- and intra-observer variability. Volumetric measurements are more sensitive but general use is hampered by the time required for their implementation. An innovative fully automated software (PRAEVAorta® from Nurea), using artificial intelligence (AI), previously demonstrated fast and robust detection of infra-renal abdominal aortic aneurysm's (AAA) characteristics on pre-operative imaging. This study aimed to assess the robustness of these data on post-EVAR computed tomography (CT) scans. METHODS Comparison was made between fully automatic and semi-automatic segmentation manually corrected by a senior surgeon on a dataset of 48 patients (48 early post-EVAR CT scans with 6466 slices, and a total of 101 follow-up CT scans with 13708 slices). RESULTS The analyses confirmed an excellent correlation of post-EVAR volumes and surfaces, as well as, proximal neck and maximum aneurysm diameters measured with the fully automatic and manually corrected segmentation methods (Pearson's coefficient correlation >.99, p<.0001). Comparison between the fully automatic and manually corrected segmentation method revealed a mean Dice Similarity Coefficient of 0.950±0.015, Jaccard index of 0.906±0.028, Sensitivity of 0.929±0.028, Specificity of 0.965±0.016, Volumetric Similarity (VS) of 0.973±0.018 and mean Hausdorff Distance/slice of 8.7±10.8mm. The mean VS reached 0.873±0.100 for the lumen and 0.903±0.091 for the thrombus. The segmentation time was 9 times faster with the fully automatic method (2.5 vs 22 min/patient with the manually corrected method; p<.0001). Preliminary analysis also demonstrated that a diameter increase of 2mm can actually represent >5% volume increase. CONCLUSION PRAEVAorta® enables a fast, reproducible, and fully automated analysis of post-EVAR AAA sac and neck characteristics, with comparison between different time points. It could become a crucial adjunct for EVAR follow-up through early detection of sac evolution, which may reduce the risk of secondary rupture.
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Affiliation(s)
- Caroline Caradu
- Bordeaux University Hospital, department of vascular surgery, 33000 Bordeaux, France
| | | | - Emilie Lakhlifi
- Bordeaux University Hospital, department of vascular surgery, 33000 Bordeaux, France
| | - Céline Brunet
- Bordeaux University Hospital, department of vascular surgery, 33000 Bordeaux, France
| | - Xavier Bérard
- Bordeaux University Hospital, department of vascular surgery, 33000 Bordeaux, France
| | - Eric Ducasse
- Bordeaux University Hospital, department of vascular surgery, 33000 Bordeaux, France.
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Contrast Ultrasound, Sonothrombolysis and Sonoperfusion in Cardiovascular Disease: Shifting to Theragnostic Clinical Trials. JACC Cardiovasc Imaging 2022; 15:345-360. [PMID: 34656483 PMCID: PMC8837667 DOI: 10.1016/j.jcmg.2021.07.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/23/2021] [Indexed: 02/03/2023]
Abstract
Contrast ultrasound has a variety of applications in cardiovascular medicine, both in diagnosing cardiovascular disease as well as providing prognostic information. Visualization of intravascular contrast microbubbles is based on acoustic cavitation, the characteristic oscillation that results in changes in the reflected ultrasound waves. At high power, this acoustic response generates sufficient shear that is capable of enhancing endothelium-dependent perfusion in atherothrombotic cardiovascular disease (sonoperfusion). The oscillation and collapse of microbubbles in response to ultrasound also induces microstreaming and jetting that can fragment thrombus (sonothrombolysis). Several preclinical studies have focused on identifying optimal diagnostic ultrasound settings and treatment regimens. Clinical trials have been performed in acute myocardial infarction, stroke, and peripheral arterial disease often with improved outcome. In the coming years, results of ongoing clinical trials along with innovation and improvements in sonothrombolysis and sonoperfusion will determine whether this theragnostic technique will become a valuable addition to reperfusion therapy.
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8
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Intraoperative cone beam computed tomography to improve outcomes after infra-renal endovascular aortic repair. J Vasc Surg 2021; 75:1021-1029.e2. [PMID: 34923068 DOI: 10.1016/j.jvs.2021.08.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/06/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate whether a combination of intraoperative ceCBCT and postoperative contrast enhanced ultrasound (CEUS) assessment after infra-renal endovascular aortic repair (EVAR) could reduce late stent-graft related complications and consequently re-interventions. METHODS All consecutive patients receiving infra-renal bifurcated stent-grafts in our hybrid room (IGS 730, GE Healthcare) during two discrete periods were included in this study: i) from November 2012 to September 2013, a 2D completion angiogram was performed after each EVAR, followed by computed tomography angiography (CTA) before discharge (group 1), ii) from October 2013 to January 2015, an intraoperative ceCBCT was performed, followed by CEUS within the first postoperative days (group 2). Comparative analyses of outcomes were undertaken. The primary endpoint was late stent-graft related complications, a composite factor incorporating aneurysm-related death, type 1 or 3 endoleaks, kink or occlusion of iliac limb and aortic sac enlargement beyond the first 30 postoperative days. The secondary endpoint was all stent-graft related re-interventions. All-cause and aneurysm related deaths were also reported. RESULTS Overall, 100 consecutive patients (50 in group 1 and 50 in group 2) were enrolled with a median follow up of 60 months [IQR 41-69]. At 60 months from the index procedure, freedom from late stent-graft related complications in each group was 61.6% (95 % CI [47.0-80.6]) for group 1 and 81.7% (95 % CI [70.1-95.2]) for group 2 (p=.033). Intraoperative CBCT was independently associated with a reduced rate of late stent-graft related complications after multivariate analysis (HR = 0.39, 95% CI 0.16-0.95, p=.038), but did not appear to significantly protect against stent-graft related re-interventions (HR=0.53; 95% CI 0.20-1.39, p=.198) or all cause death (p=.47). CONCLUSION This study is the first to report the influence of routine ceCBCT on late outcomes after EVAR and shows a potential reduction in late stent-graft related complications associated with its use.
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Williams AB, Williams ZB. Imaging modalities for endoleak surveillance. J Med Radiat Sci 2021; 68:446-452. [PMID: 34145780 PMCID: PMC8655756 DOI: 10.1002/jmrs.522] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 06/02/2021] [Indexed: 11/25/2022] Open
Abstract
As the global population ages, the issue of abdominal aortic aneurysm continues to grow. With the evolution of new devices and refined operative technique, aneurysm treatment via endovascular aortic repair is becoming increasingly favourable. This, however, is not without drawbacks, where regular surveillance is paramount to long-term success and detection of post-procedure complications. Of these complications, endoleak is the most notable and poses the greatest risk of potential future aortic rupture. The purpose of this review paper is to discuss the armada of imaging modalities used in the detection and evaluation of endoleak and their varying usefulness. Plain abdominal X-ray is a cost-effective tool in detecting gross graft abnormalities such as stent migration or deformity (kinking or fracture). Though it may raise suspicion for endoleak, X-ray does not allow accurate classification of endoleak type when used alone. Duplex ultrasonography quantifies both aortic anatomy and real time flow dynamics. Most screening programmes are conducted using two-dimensional ultrasound. Unfortunately, observer and equipment variability may lead to surveillance discrepancies-but reduced when utilising a dedicated vascular sonography laboratory. Contrast enhanced ultrasonography is a promising alternative to computed tomography, though still is emerging. Computed tomography angiography certainly has disadvantages (ionising radiation, contrast-nephropathy, limited differentiation of endoleak type)-however, it provides near-real surgical dimensions and highlights graft complications and concomitant disease (such as neighbouring infection). With widespread availability and short scan time, it certainly remains valuable in surveillance. Magnetic resonance angiography has a similar sensitivity to computed tomography (minus the radiation), however is plagued by movement and metal artefact. Other novel modalities in endoleak surveillance include four-dimensional ultrasound, multiplanar intra-operative probes, nuclear medicine and wall stress analysis.
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Affiliation(s)
- Aman Berry Williams
- Department of Vascular SurgeryGold Coast University HospitalSouthportQueenslandAustralia
| | - Zoheb Berry Williams
- Department of Vascular SurgeryGold Coast University HospitalSouthportQueenslandAustralia
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Bianchini Massoni C, Perini P, Fanelli M, Ucci A, Azzarone M, Rossi G, D'Ospina RM, Freyrie A. The Utility of Intraoperative Contrast-enhanced Ultrasound for Immediate Treatment of Type Ia Endoleak during EVAR: Initial Experience. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021046. [PMID: 33988179 PMCID: PMC8182572 DOI: 10.23750/abm.v92i2.9154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/15/2020] [Indexed: 12/02/2022]
Abstract
Objectives: Type Ia endoleak (EL) after endovascular abdominal aortic repair (EVAR) may be misdiagnosed at completion angiography. Intraoperative contrast-enhanced ultrasound (CEUS) may play a role in early detection and immediate treatment of type Ia EL. Methods: From January 2017 to April 2018, patients treated with EVAR underwent intraoperative CEUS. After endograft deployment and ballooning, digital subtraction angiography (DSA) and intraoperative CEUS were performed in a blinded fashion. All cases of type Ia EL at DSA or CEUS were considered. Results: Type Ia EL detected at intraoperative CEUS and undetected at DSA was defined in 2 patients. The former was solved with intraoperative re-ballooning; in the latter case, a Palmaz stent deployment was required. The resolution of type Ia EL was detected at intraoperative CEUS control and post-operative computed tomography angiography (CTA). In another patient, the DSA detected a type Ia EL, but intraoperative CEUS reveal a type II EL from lumbar arteries. Post-operative CTA confirm the type II EL. Conclusions: The reported cases prove the clinical utility of the intraoperative CEUS, permitting the early identification of 2 type Ia EL. In addition, the intraoperative CEUS is useful in case of dubious type Ia EL at DSA, avoiding unnecessary intraoperative adjunctive procedure or post-operative CTA. (www.actabiomedica.it)
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Gonzalez-Urquijo M, Lozano-Balderas G, Fabiani MA. Type II Endoleaks After EVAR: A Literature Review of Current Concepts. Vasc Endovascular Surg 2020; 54:718-724. [PMID: 32744153 DOI: 10.1177/1538574420945448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Endoleak is the most frequent complication following endovascular aneurysm repair, which is not present in the surgical counterpart. The most frequent type of endoleak corresponds to type II, and its natural history remains poorly understood. Therefore, their treatment continues to be a topic of debate. The vast majority of the studies found in the literature are of a retrospective nature, and there are no prospective studies comparing intervention versus a conservative approach. Future studies should aim to compare not only different approaches to resolve type II endoleak but also when should be the right time to treat them, with the primary purpose of avoiding sac rupture. The objective of this review is to provide the reader with a literature overview about type II endoleaks to help in the decision-making process on this topic.
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Affiliation(s)
| | - Gerardo Lozano-Balderas
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, México
| | - Mario Alejandro Fabiani
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, México
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Long-term Efficacy of EVAR in Patients Aged Less Than 65 Years with an Infrarenal Abdominal Aortic Aneurysm and Favorable Anatomy. Ann Vasc Surg 2020; 67:283-292. [PMID: 32283305 DOI: 10.1016/j.avsg.2020.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/21/2020] [Accepted: 03/22/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The aim of this study was to compare early and long-term outcomes of endovascular aneurysm repair (EVAR) versus open surgical repair (OSR) in patients aged ≤ 65 years. METHODS Data of patients aged ≤65 years undergoing infrarenal abdominal aortic aneurysm repair, between 2005 and 2013, were retrospectively reviewed. All EVAR procedures were performed according to the instruction for use, and only OSR procedures with an infrarenal aortic cross-clamping were included in the study. RESULTS In this group of 115 patients (EVAR: 58 patients, 51% and OSR: 57 patients, 49%), EVAR and OSR patients had similar comorbidities, except for obesity (EVAR: 38% vs. OSR: 19%; P = 0.03). A stay in the intensive care unit (ICU) was necessary in 19% of patients with EVAR versus 79% with OSR (P = 0.001), and the amount of blood transfusion was 236 ± 31 mL for EVAR versus 744 ± 98 mL for OSR (P = 0.001). The hospital stay was 4 ± 2 days for EVAR versus 9 ± 6 days for OSR (P = 0.03). The overall 30-day mortality was 1% (EVAR: 0% vs. OSR: 2%; P = 0.30). Five patients (4%) required reinterventions within 30 days (EVAR: 0% vs. OSR: 8%, P = 0.001). The mean follow-up was 86 ± 38 months. Freedom from reintervention at 10 years after EVAR was 81% versus OSR 74%; (P = 0.77). Late reinterventions were reported in 13 patients (23%) with OSR and in 10 patients (17%) with EVAR. Postoperative retrograde ejaculation occurred more often in patients with OSR (31%) versus EVAR (2%) (P = 0.001). During the follow-up, cancer was found in 19 (17%) patients with no difference between EVAR and OSR (P = 0.83). The global survival at 10 years was 72% (EVAR: 79% vs. OSR: 70%; P = 0.94). CONCLUSIONS In this study, EVAR was associated with a shorter hospital stay, less need for the ICU, and less early reinterventions than OSR. Survival and reinterventions during the follow-up were not significantly different between EVAR and OSR. According to these results, EVAR may be considered for patients aged ≤65 years with a favorable anatomy.
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Mascoli C, Faggioli G, Gallitto E, Pini R, Gargiulo M. Intraoperative contrast enhanced ultrasound adds some important details to the endovascular aortic aneurysm repair completion control. ANNALS OF TRANSLATIONAL MEDICINE 2020; 7:S280. [PMID: 32015999 DOI: 10.21037/atm.2019.11.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Chiara Mascoli
- Policlinico S. Orsola Malpighi, Vascular Surgery, University of Bologna, DIMES, Bologna, Italy
| | - Gianluca Faggioli
- Policlinico S. Orsola Malpighi, Vascular Surgery, University of Bologna, DIMES, Bologna, Italy
| | - Enrico Gallitto
- Policlinico S. Orsola Malpighi, Vascular Surgery, University of Bologna, DIMES, Bologna, Italy
| | - Rodolfo Pini
- Policlinico S. Orsola Malpighi, Vascular Surgery, University of Bologna, DIMES, Bologna, Italy
| | - Mauro Gargiulo
- Policlinico S. Orsola Malpighi, Vascular Surgery, University of Bologna, DIMES, Bologna, Italy
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D'Oria M, Mastrorilli D, Ziani B. Natural History, Diagnosis, and Management of Type II Endoleaks after Endovascular Aortic Repair: Review and Update. Ann Vasc Surg 2020; 62:420-431. [PMID: 31376537 DOI: 10.1016/j.avsg.2019.04.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/02/2019] [Accepted: 04/28/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Mayo Clinic Gonda Vascular Center, Rochester, MN; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy.
| | - Davide Mastrorilli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Barbara Ziani
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
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Velocities of type II endoleaks on Doppler ultrasonography predict outcome. J Vasc Surg 2019; 71:1719-1725. [PMID: 31619352 DOI: 10.1016/j.jvs.2019.07.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 07/18/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We sought to determine whether flow velocities measured using Doppler ultrasonography after endovascular aortic aneurysm repair (EVAR) can predict for resolution of type II endoleaks without intervention. We also assessed the relationship of the flow velocities to sac growth and the need for intervention. We hypothesized that hemodynamic properties suggesting low flow velocity would predict for resolution of type II endoleaks. METHODS The data from 23 patients with type II endoleaks identified on Doppler ultrasonography after EVAR from January 2014 to December 2017 were retrospectively analyzed. The 23 patients with type II endoleaks were split into two groups. Group 1 included the 13 patients with resolved endoleaks or shrinking sac size and group 2, the 10 patients with an increasing sac size or those requiring intervention to seal the endoleak because of an increased sac size. We analyzed the velocities of the endoleak nidus. RESULTS Doppler ultrasound velocities were significantly lower in patients with resolved type II endoleaks and those with a shrinking aneurysm sac size compared with those demonstrating an increase in aneurysm sac size (42.6 ± 25.2 cm/s vs 219.5 ± 84.1 cm/s; P < .0001). Of the 10 patients in group 2, nine had required intervention with either translumbar embolization or transarterial embolization, with only two experiencing complete resolution of the type II endoleak, despite the intervention. All patients in group 2 had had ≥1 duplex ultrasound scan with endoleak nidus velocities >100 cm/s. In contrast, no patient in group 1 had had any duplex ultrasound scan with endoleak nidus velocities >100 cm/s. CONCLUSIONS The Doppler ultrasound velocities of type II endoleaks might be able to predict for spontaneous resolution of type II endoleaks or increased sac growth. Type II endoleaks on Doppler ultrasonography with endoleak nidus velocities >100 cm/s can persistent, even with attempted treatment.
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Perini P, Bianchini Massoni C, Mariani E, D'ospina RM, Rossi G, Carli AG, Bramucci A, Azzarone M, Freyrie A. Late open conversions after failed EVAR. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.19.01419-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bianchini Massoni C, Perini P, Fanelli M, Ucci A, Rossi G, Azzarone M, Tecchio T, Freyrie A. Intraoperative contrast-enhanced ultrasound for early diagnosis of endoleaks during endovascular abdominal aortic aneurysm repair. J Vasc Surg 2019; 70:1844-1850. [PMID: 31147132 DOI: 10.1016/j.jvs.2019.02.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 02/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the feasibility and utility of intraoperative contrast-enhanced ultrasound (CEUS) for early detection of endoleaks (ELs) during endovascular abdominal aortic aneurysm repair (EVAR) compared with completion digital subtraction angiography. METHODS Patients undergoing elective EVAR from January 2017 to April 2018 were consecutively enrolled in this prospective study. After endograft deployment, two-digital subtraction angiography (2DSA) with orthogonal C-arm angulations (anteroposterior and sagittal view) were routinely performed. After the endovascular treatment of clear, high-flow type I/III ELs detected by 2DSA, intraoperative CEUS was carried out in sterile conditions on the surgical field before guidewire removal. Presence and type of EL were evaluated with 2DSA and CEUS. CEUS was performed with the vascular surgeon blinded to the 2DSA findings. The primary end point was the level of agreement between 2DSA and CEUS to detect any type of EL and type II EL. Agreement between two diagnostic methods was calculated using Cohen's kappa. The secondary end point was utility of CEUS for intraoperative adjunctive procedure guidance. RESULTS Sixty patients were enrolled (mean age, 78 ± 6 years; 90% male). 2DSA revealed 11 ELs (18%; 1 type IA, 10 type II), and CEUS 25 ELs (42%; 2 type IA, 23 type II). 2DSA and CEUS were in agreement in 39 cases (65%; 32 no ELs, 7 type II ELs). CEUS detected 17 ELs not identified by 2DSA (28%; 2 type IA, 15 type II); 2DSA detected three ELs not identified by CEUS (5%; 3 type II). In one case, 2DSA and CEUS detected type II and type IA ELs, respectively. For EL and type II EL detection, Cohen's kappa was 0.255 and 0.250, respectively (both "fair agreement"). Intraoperative adjunctive sac embolization was performed under CEUS control in 4 cases and technical success was 100%. CONCLUSIONS Intraoperative CEUS during EVAR is feasible and can detect a greater number of ELs than 2DSA, in particular type II ELs. Further studies are necessary to assess the reliability of this intraoperative diagnostic examination. In type II ELs, CEUS may represent an additional, useful tool for intraoperative sac embolization guidance.
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Affiliation(s)
| | - Paolo Perini
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Mara Fanelli
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Alessandro Ucci
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Giulia Rossi
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Matteo Azzarone
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Tiziano Tecchio
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Antonio Freyrie
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
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Current Status of Endovascular Preservation of the Internal Iliac Artery with Iliac Branch Devices (IBD). Cardiovasc Intervent Radiol 2019; 42:935-948. [DOI: 10.1007/s00270-019-02199-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/06/2019] [Indexed: 02/06/2023]
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Harky A, Zywicka E, Santoro G, Jullian L, Joshi M, Dimitri S. Is contrast-enhanced ultrasound (CEUS) superior to computed tomography angiography (CTA) in detection of endoleaks in post-EVAR patients? A systematic review and meta-analysis. J Ultrasound 2019; 22:65-75. [PMID: 30771104 DOI: 10.1007/s40477-019-00364-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/08/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE The purpose of this systematic review and meta-analysis was to assess the sensitivity and specificity of contrast-enhanced ultrasound (CEUS) compared to computed tomography angiography (CTA) for the detection of endoleaks within endovascular aortic aneurysm repair (EVAR) surveillance at time of follow up. METHODS A comprehensive literature search was undertaken among the four major databases (PubMed, Embase, Scopus and Ovid) to identify all articles assessing diagnostic specificity and accuracy with comparative modality (CEUS vs CTA) for endoleaks in adult patients at time of follow-up following EVAR. Databases where evaluated and assessed to October 2018. RESULTS A total of 1773 patients were analysed from across 18 included studies in the quantitative analysis of the parameters of interest. There was no significant difference in detection rate of endoleak type I with detection rate 4.3% for both groups OR 1.09, 95% CI [0.78, 1.53], p = 0.62; type II endoleak detection rate was 22% in the CEUS group vs 23% in the CTA group OR 1.16, 95% CI [0.75-1.79], p = 0.50; while type III detection rate was 1.8% in CEUS group vs 2% in CTA group OR 0.85, 95% CI [0.43, 1.68], p = 0.64. However, the sensitivity rate for endoleak detection was higher in CEUS (p = 0.001) while no difference in specificity rate was noted (p = 0.28). There was higher rate of missed endoleaks in CTA groups (n = 12 vs n = 20). CONCLUSION Evidences from this study suggest that contrast-enhanced ultrasound scan post-EVAR can be utilised as safe and effective method in screening for endoleaks during post-EVAR surveillance without exposing the patient for additional risk of radiation and contrast. CEUS conveys no inferiority to CTA in detecting endoleaks.
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Affiliation(s)
- Amer Harky
- Department of Vascular Surgery, Countess of Chester Hospital, Chester, CH2 1UL, UK.
| | - Ewa Zywicka
- Department of Vascular Surgery, Countess of Chester Hospital, Chester, CH2 1UL, UK
| | - Giovanni Santoro
- Department of General Surgery, Warrington and Halton NHS Foundation Trust, Warrington, WA5 1QG, UK
| | - Lucas Jullian
- Department of Cardiac Surgery, Barts Heart Centre, London, EC1A 7BE, UK
| | - Mihika Joshi
- Department of Vascular Surgery, Countess of Chester Hospital, Chester, CH2 1UL, UK
| | - Sameh Dimitri
- Department of Vascular Surgery, Countess of Chester Hospital, Chester, CH2 1UL, UK
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A Narrative Review on Contrast-Enhanced Ultrasound in Aortic Endograft Endoleak Surveillance. Ultrasound Q 2019; 34:170-175. [PMID: 29596299 DOI: 10.1097/ruq.0000000000000353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Endovascular repair of abdominal aortic aneurysms have been performed successfully since 1991. However, 20% to 50% of these patients may develop an endoleak or continued aneurysmal sac expansion or perfusion despite stent graft coverage. Current recommendations suggest lifelong surveillance with computed tomographic angiography (CTA) at least 1 month after intervention and yearly after that. In select patients with a stable aneurysm sac on computed tomography performed 1 year after treatment, future screening could be performed with ultrasonography. However, color Doppler ultrasound can fail to detect as many as 31% of endoleaks. Contrast-enhanced ultrasound (CEUS) provides an alternative approach to excluded aneurysm sac follow-up imaging. The Society for Vascular Surgery notes a need for further research on the role of CEUS in endovascular aortic repair surveillance. The European Federation of Societies for Ultrasound in Medicine and Biology suggests that early results are promising. Meta-analyses report pooled sensitivities and specificities of CEUS compared with CTA for the detection of endoleak between 89% and 98% and 86% and 88%, respectively. Owing to the dynamic flow information it provides, CEUS may actually be more sensitive than CTA at detection and characterization in select circumstances. Challenges with adoption, patient selection, and operator dependency remain, but current and future research suggests a role for CEUS in endoleak surveillance.
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Kapetanios D, Kontopodis N, Mavridis D, McWilliams RG, Giannoukas AD, Antoniou GA. Meta-analysis of the accuracy of contrast-enhanced ultrasound for the detection of endoleak after endovascular aneurysm repair. J Vasc Surg 2019; 69:280-294.e6. [DOI: 10.1016/j.jvs.2018.07.044] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 07/30/2018] [Indexed: 11/16/2022]
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Superb Micro-vascular Imaging (SMI): a Doppler ultrasound technique with potential to identify, classify, and follow up endoleaks in patients after Endovascular Aneurysm Repair (EVAR). Abdom Radiol (NY) 2018; 43:3479-3486. [PMID: 29876784 PMCID: PMC6208813 DOI: 10.1007/s00261-018-1633-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose The aim of the study was to assess the effectiveness of Superb Micro-vascular Imaging (SMI) as an alternative to Contrast-Enhanced Ultrasound (CEUS) and Computed Tomography Angiography (CTA) for endoleak detection and classification in patients followed up after endovascular abdominal aortic aneurysm repair (EVAR). Materials and methods From May 2015 to January 2017, 30 patients underwent post-EVAR follow-up with Color Doppler Ultrasound (CDUS), CEUS, SMI, and CTA examinations. Aneurysmal sac diameter and graft patency were evaluated; endoleaks were identified and classified. Sensitivity, specificity, and accuracy values were calculated for each of the four diagnostic methods of endoleak detection. A percentage of agreement and Cohen’s Kappa coefficient were calculated for comparison of methods in terms of endoleak identification. Results CTA revealed fifteen endoleaks (50%): three type Ia, nine type II, and three type III. The sensitivity of CDUS, CEUS, and SMI relative to CTA was 27%, 100%, and 100%, respectively. Specificity was 93%, 93%, and 93%, respectively. Accuracy was 60%, 97%, and 97%, respectively. There were no differences between SMI and CEUS in terms of sensitivity, specificity, or accuracy (100%, 93%, and 97%). We do not observe statistically significant differences between CTA, CEUS, and SMI concerning endoleak identification ability. The weakest method in endoleak identification was CDUS. Conclusions The analysis showed that SMI is effective, repeatable, and comparable with the CEUS modality in identification endoleaks after EVAR; it may be considered as a potential tool to monitor patients after EVAR implantation, especially those with renal insufficiency or with an allergy to any contrast media.
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Li X, Staub D, Rafailidis V, Al-Natour M, Kalva S, Partovi S. Contrast-enhanced ultrasound of the abdominal aorta - current status and future perspectives. VASA 2018; 48:115-125. [PMID: 30324867 DOI: 10.1024/0301-1526/a000749] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Ultrasound has been established as an important diagnostic tool in assessing vascular abnormalities. Standard B-mode and Doppler techniques have inherent limitations with regards to detection of slow flow and small vasculature. Contrast-enhanced ultrasound (CEUS) is a complementary tool and is useful in assessing both the macro- and microvascular anatomy of the aorta. CEUS can also provide valuable physiological information in real-time scanning sessions due to the physical and safety profiles of the administered microbubbles. From a macrovascular perspective, CEUS has been used to characterize aortic aneurysm rupture, dissection and endoleaks post-EVAR repair. With regard to microvasculature CEUS enables imaging of adventitial vasa vasorum thereby assessing aortic inflammation processes, such as monitoring treatment response in chronic periaortitis. CEUS may have additional clinical utility since adventitial vasa vasorum has important implications in the pathogenesis of aortic diseases. In recent years, there have been an increasing number of studies comparing CEUS to cross-sectional imaging for aortic applications. For endoleak surveillance CEUS has been shown to be equal or in certain cases superior in comparison to CT angiography. The recent advancement of CEUS software along with the ongoing development of drug-eluting contrast microbubbles has allowed improved targeted detection and real-time ultrasound guided therapy for aortic vasa vasorum inflammation and neovascularization in animal models. Therefore, CEUS is uniquely suited to comprehensively assess and potentially treat aortic vascular diseases in the future.
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Affiliation(s)
- Xin Li
- 1 Department of Radiology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Daniel Staub
- 2 Angiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Vasileios Rafailidis
- 3 AHEPA University Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mohammed Al-Natour
- 1 Department of Radiology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sanjeeva Kalva
- 4 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sasan Partovi
- 5 Section of Interventional Radiology, Department of Radiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Late open conversions after endovascular abdominal aneurysm repair in an urgent setting. J Vasc Surg 2018; 69:423-431. [PMID: 30126779 DOI: 10.1016/j.jvs.2018.04.055] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/21/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVES We report a multicenter experience of urgent late open conversion (LOC), with the goal of identifying the mode of presentation, technical aspects, and outcomes of this cohort of patients. METHODS A retrospective analysis of endovascular aneurysm repair (EVAR) requiring LOC (>30 days after implantation) from 1996 to 2016 in six vascular centers was performed. Patients with aneurysm rupture or other conditions requiring urgent surgery (<24 hours) were included. Patient demographics, time interval between EVAR and LOC, endograft characteristics, previous attempts at endovascular correction, indications, operative technique, 30-day mortality and morbidity, and long-term survival were analyzed. RESULTS There were 42 patients (88.1% men; mean age, 75.8 ± 9.0 years) included. Among the 42 explanted grafts, 33 were bifurcated, 1 tube, 6 aortouni-iliac, and 2 side-branch devices. Suprarenal fixation was present in 78.6%. Twelve patients (28.6%) underwent endovascular reintervention before LOC. Indications for urgent LOC were aneurysm rupture in 24 of the 42 cases (57.1%), endograft infection in 11 (26.2%), endoleak associated with aneurysm growth and pain in 6 (14.3%), and recurrent endograft thrombosis in 2 (4.8%). The proximal aortic cross-clamping site was infrarenal in 38.1% of cases, suprarenal in 19.1%, and supraceliac in 42.9%. Complete removal of the endograft was performed in 32 patients (76.2%) and partial removal in 10 (proximal preservation in 7 of 10). Reconstructions were performed with Dacron grafts in 33 of the 42 cases, cryopreserved arterial allografts in 5, and endograft removal associated with prosthetic axillobifemoral bypass in 4. The 30-day mortality was 23.8%; hemorrhagic shock was an independent risk factor of early mortality (odds ratio, 10.5; 95% confidence interval, 1.5-73.7; P = .018). During a mean follow-up of 23.9 ± 36.0 months, two late aneurysm-related deaths occurred. The estimated 1- and 5-year survival rates were 62.1% and 46.1%, respectively. CONCLUSIONS Urgent LOC after EVAR are associated with high postoperative mortality rates and poor long-term survival. Further studies are necessary to define the timing and the best treatment option for failing EVAR.
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Monastiriotis S, Lau I, Loh S, Ferretti J, Tassiopoulos A, Labropoulos N. Evolution of type II endoleaks based on different ultrasound-identified patterns. J Vasc Surg 2018; 67:1074-1081. [DOI: 10.1016/j.jvs.2017.08.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/13/2017] [Indexed: 11/16/2022]
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Bredahl K, Mestre XM, Coll RV, Ghulam QM, Sillesen H, Eiberg J. Contrast-Enhanced Ultrasound in Vascular Surgery: Review and Update. Ann Vasc Surg 2017; 45:287-293. [DOI: 10.1016/j.avsg.2017.05.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/19/2017] [Accepted: 05/26/2017] [Indexed: 01/24/2023]
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Sun Z, Ng CKC. Use of Synchrotron Radiation to Accurately Assess Cross-Sectional Area Reduction of the Aortic Branch Ostia Caused by Suprarenal Stent Wires. J Endovasc Ther 2017; 24:870-879. [PMID: 28922970 DOI: 10.1177/1526602817732315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To compare in vivo the use of synchrotron radiation to computed tomography angiography (CTA) for the measurement of cross-sectional area (CSA) reduction of the aortic branch ostia caused by suprarenal stent-graft wires. METHODS This study was performed with a Zenith stent-graft placed in a phantom of the human aorta to simulate treatment of abdominal aortic aneurysm. Synchrotron radiation scans were performed using beam energies between 40 and 100 keV and spatial resolution of 19.88 μm per pixel. CSA reduction of the aortic branch ostia by suprarenal stent wires was calculated based on these exposure factors and compared with measurements from CTA images acquired on a 64-row scanner with slice thicknesses of 1.0, 1.5, and 2.0 mm. RESULTS Images acquired with synchrotron radiation showed <10% of the CSA occupied by stent wires when a single wire crossed a renal artery ostium and <20% for 2 wires crossing a renovisceral branch ostium. The corresponding areas ranged from 24% to 25% for a single wire and from 40% to 48% for double wires crossing the branch ostia when measured on CT images. The stent wire was accurately assessed on synchrotron radiation with a diameter between 0.38±0.01 and 0.53±0.03 mm, which is close to the actual size of 0.47±0.01 mm. The wire diameter measured on CT images was greatly overestimated (1.15±0.01 to 1.57±0.02 mm). CONCLUSION CTA has inferior spatial resolution that hinders accurate assessment of CSA reduction. This experiment demonstrated the superiority of synchrotron radiation over CTA for more accurate assessment of aortic stent wires and CSA reduction of the aortic branch ostia.
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Affiliation(s)
- Zhonghua Sun
- 1 Department of Medical Radiation Sciences, Curtin University, Perth, Western Australia, Australia
| | - Curtise K C Ng
- 1 Department of Medical Radiation Sciences, Curtin University, Perth, Western Australia, Australia
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Abraha I, Luchetta ML, De Florio R, Cozzolino F, Casazza G, Duca P, Parente B, Orso M, Germani A, Eusebi P, Montedori A. Ultrasonography for endoleak detection after endoluminal abdominal aortic aneurysm repair. Cochrane Database Syst Rev 2017; 6:CD010296. [PMID: 28598495 PMCID: PMC6481872 DOI: 10.1002/14651858.cd010296.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND People with abdominal aortic aneurysm who receive endovascular aneurysm repair (EVAR) need lifetime surveillance to detect potential endoleaks. Endoleak is defined as persistent blood flow within the aneurysm sac following EVAR. Computed tomography (CT) angiography is considered the reference standard for endoleak surveillance. Colour duplex ultrasound (CDUS) and contrast-enhanced CDUS (CE-CDUS) are less invasive but considered less accurate than CT. OBJECTIVES To determine the diagnostic accuracy of colour duplex ultrasound (CDUS) and contrast-enhanced-colour duplex ultrasound (CE-CDUS) in terms of sensitivity and specificity for endoleak detection after endoluminal abdominal aortic aneurysm repair (EVAR). SEARCH METHODS We searched MEDLINE, Embase, LILACS, ISI Conference Proceedings, Zetoc, and trial registries in June 2016 without language restrictions and without use of filters to maximize sensitivity. SELECTION CRITERIA Any cross-sectional diagnostic study evaluating participants who received EVAR by both ultrasound (with or without contrast) and CT scan assessed at regular intervals. DATA COLLECTION AND ANALYSIS Two pairs of review authors independently extracted data and assessed quality of included studies using the QUADAS 1 tool. A third review author resolved discrepancies. The unit of analysis was number of participants for the primary analysis and number of scans performed for the secondary analysis. We carried out a meta-analysis to estimate sensitivity and specificity of CDUS or CE-CDUS using a bivariate model. We analysed each index test separately. As potential sources of heterogeneity, we explored year of publication, characteristics of included participants (age and gender), direction of the study (retrospective, prospective), country of origin, number of CDUS operators, and ultrasound manufacturer. MAIN RESULTS We identified 42 primary studies with 4220 participants. Twenty studies provided accuracy data based on the number of individual participants (seven of which provided data with and without the use of contrast). Sixteen of these studies evaluated the accuracy of CDUS. These studies were generally of moderate to low quality: only three studies fulfilled all the QUADAS items; in six (40%) of the studies, the delay between the tests was unclear or longer than four weeks; in eight (50%), the blinding of either the index test or the reference standard was not clearly reported or was not performed; and in two studies (12%), the interpretation of the reference standard was not clearly reported. Eleven studies evaluated the accuracy of CE-CDUS. These studies were of better quality than the CDUS studies: five (45%) studies fulfilled all the QUADAS items; four (36%) did not report clearly the blinding interpretation of the reference standard; and two (18%) did not clearly report the delay between the two tests.Based on the bivariate model, the summary estimates for CDUS were 0.82 (95% confidence interval (CI) 0.66 to 0.91) for sensitivity and 0.93 (95% CI 0.87 to 0.96) for specificity whereas for CE-CDUS the estimates were 0.94 (95% CI 0.85 to 0.98) for sensitivity and 0.95 (95% CI 0.90 to 0.98) for specificity. Regression analysis showed that CE-CDUS was superior to CDUS in terms of sensitivity (LR Chi2 = 5.08, 1 degree of freedom (df); P = 0.0242 for model improvement).Seven studies provided estimates before and after administration of contrast. Sensitivity before contrast was 0.67 (95% CI 0.47 to 0.83) and after contrast was 0.97 (95% CI 0.92 to 0.99). The improvement in sensitivity with of contrast use was statistically significant (LR Chi2 = 13.47, 1 df; P = 0.0002 for model improvement).Regression testing showed evidence of statistically significant effect bias related to year of publication and study quality within individual participants based CDUS studies. Sensitivity estimates were higher in the studies published before 2006 than the estimates obtained from studies published in 2006 or later (P < 0.001); and studies judged as low/unclear quality provided higher estimates in sensitivity. When regression testing was applied to the individual based CE-CDUS studies, none of the items, namely direction of the study design, quality, and age, were identified as a source of heterogeneity.Twenty-two studies provided accuracy data based on number of scans performed (of which four provided data with and without the use of contrast). Analysis of the studies that provided scan based data showed similar results. Summary estimates for CDUS (18 studies) showed 0.72 (95% CI 0.55 to 0.85) for sensitivity and 0.95 (95% CI 0.90 to 0.96) for specificity whereas summary estimates for CE-CDUS (eight studies) were 0.91 (95% CI 0.68 to 0.98) for sensitivity and 0.89 (95% CI 0.71 to 0.96) for specificity. AUTHORS' CONCLUSIONS This review demonstrates that both ultrasound modalities (with or without contrast) showed high specificity. For ruling in endoleaks, CE-CDUS appears superior to CDUS. In an endoleak surveillance programme CE-CDUS can be introduced as a routine diagnostic modality followed by CT scan only when the ultrasound is positive to establish the type of endoleak and the subsequent therapeutic management.
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Affiliation(s)
- Iosief Abraha
- Regional Health Authority of UmbriaHealth Planning ServicePerugiaItaly06124
| | | | - Rita De Florio
- Local Health UnitAzienda SanitariaLocale USL 1, Medicina GeneralePerugiaItaly
| | - Francesco Cozzolino
- Regional Health Authority of UmbriaVia Mario Angeloni 61PerugiaUnbriaItaly06124
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
| | - Piergiorgio Duca
- Ospedale Luigi SaccoL.I.T.A. Polo UniversitarioVia G.B. Grassi, 74MilanoItaly20157
| | - Basso Parente
- Azienda Ospedaliera di PerugiaChirurgia VascolareSant' Andrea delle FrattePerugiaItaly06156
| | - Massimiliano Orso
- Regional Health Authority of UmbriaHealth Planning ServicePerugiaItaly06124
| | - Antonella Germani
- Azienda Unita' Sanitaria Locale Umbria N. 2Servizio Immunotrasfusionalevia ArcamoneFolignoItaly06034
| | - Paolo Eusebi
- Regional Health Authority of UmbriaEpidemiology DepartmentVia Mario Angeloni 61PerugiaUmbriaItaly06124
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Lowe C, Abbas A, Rogers S, Smith L, Ghosh J, McCollum C. Three-dimensional contrast-enhanced ultrasound improves endoleak detection and classification after endovascular aneurysm repair. J Vasc Surg 2017; 65:1453-1459. [DOI: 10.1016/j.jvs.2016.10.082] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 10/08/2016] [Indexed: 11/16/2022]
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Cantisani V, David E, Ferrari D, Fanelli F, Di Marzo L, Catalano C, Benedetto F, Spinelli D, Katsargyris A, Blandino A, Ascenti G, D'Ambrosio F. Color Doppler Ultrasound with Superb Microvascular Imaging Compared to Contrast-enhanced Ultrasound and Computed Tomography Angiography to Identify and Classify Endoleaks in Patients Undergoing EVAR. Ann Vasc Surg 2017; 40:136-145. [DOI: 10.1016/j.avsg.2016.06.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 05/31/2016] [Accepted: 06/22/2016] [Indexed: 12/18/2022]
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Zimmermann H, Rübenthaler J, Rjosk-Dendorfer D, Helck A, Reimann R, Reiser M, Clevert DA. Comparison of portable ultrasound system and high end ultrasound system in detection of endoleaks. Clin Hemorheol Microcirc 2017; 63:99-111. [PMID: 26484713 DOI: 10.3233/ch-152011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE To compare the value of a portable ultrasound system and a high end ultrasound system in detection of endoleaks after EVAR. MATERIAL AND METHODS In this retrospective study, a cohort of 25 patients underwent both standard examination using a portable ultrasound system (Philips VISIQ) and a second examination using a high end ultrasound system (Philips EPIQ 7). The examination included B-mode and color Doppler in detection of endoleaks. Additional the maximum diameter of the aneurysm was measured in two planes (right-left and ventral-dorsal). The gold standard was contrast-enhanced ultrasound (CEUS) in detection of endoleaks. RESULTS 25 patients were included in the study. Patients were predominantly male (n = 23) with an average age of 73,30±7.82 years (range 54-85). Diameters of the treated aneurysms were in the right-left plane 5,32±1.88 cm and ventral-dorsal 4,99±1.78 cm using the high end system. Diameters of the treated aneurysms were in the right-left plane 5,30±1.82 cm and ventral-dorsal 4,87±1.74 cm using portable ultrasound system. In 80% of the cases CEUS could detect an endoleak. Whereas the high end system could detect in B-mode 40% and color Doppler 45% of the cases an endoleak. The portable system could detect in B-mode 30% and in color Doppler 35% of the cases an endoleak. On both systems in B-mode a false positive endoleak was found on the same patient. All high flow endoleaks, which needed intervention, could be detected on all systems. CONCLUSION The high end ultrasound system does not seem to have an additional advantage in the measurement of the aneurysm diameter. Due to a higher resolution, more endoleaks could be detected in B-mode and color Doppler by using the high end system. The presence of small endoleaks could only be detected by using contrast enhanced ultrasound on an high end ultrasound system. High flow endoleaks could be reliable seen on both systems.
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Bredahl K, Taudorf M, Lönn L, Vogt K, Sillesen H, Eiberg J. Contrast Enhanced Ultrasound can Replace Computed Tomography Angiography for Surveillance After Endovascular Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2016; 52:729-734. [DOI: 10.1016/j.ejvs.2016.07.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 07/06/2016] [Indexed: 11/25/2022]
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Meinel FG, Haack M, Weidenhagen R, Hellbach K, Rottenkolber M, Armbruster M, Jerkku T, Thierfelder KM, Plum JL, Koeppel TA, Rubin GD, Sommer WH. Effect of endoleaks on changes in aortoiliac volume after endovascular repair for abdominal aortic aneurysm. Clin Hemorheol Microcirc 2016; 64:135-147. [DOI: 10.3233/ch-162052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Felix G. Meinel
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Mareike Haack
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Rolf Weidenhagen
- Department of Vascular and Endovascular Surgery, Munich Municipal Hospital Group, Klinikum Neuperlach, Munich, Germany
| | - Katharina Hellbach
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Marietta Rottenkolber
- Institute for Medical Information Sciences, Biometry and Epidemiology, Munich, Germany
| | - Marco Armbruster
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Thomas Jerkku
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Kolja M. Thierfelder
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Jessica L.V. Plum
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Thomas A. Koeppel
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
| | | | - Wieland H. Sommer
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Munich, Germany
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Abdominal Aortic Aneurysm Repair: Results from a Series of Young Patients. BIOMED RESEARCH INTERNATIONAL 2016; 2016:7893413. [PMID: 27777952 PMCID: PMC5061946 DOI: 10.1155/2016/7893413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/19/2016] [Accepted: 09/04/2016] [Indexed: 12/15/2022]
Abstract
Objectives. To compare durability and survival after endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysms (AAAs) in young patients. Material and Methods. A retrospective study was conducted between 2005 and 2014 on all consecutive patients of 60 years of age or younger. Measures considered for analysis were reintervention related to AAA, laparotomy and access vessel injury during EVAR, and all-cause mortality during hospitalization and follow-up. Results. Seventy out of 119 patients were treated by OR (58.8%) and 49 (41.2%) by EVAR, 9 in off-label fashion (18.3%). Technical success was achieved in all cases. No AAA-related death was recorded. Overall in-hospital mortality was zero and the reintervention rate was 2.5% (3/119: 1/70 OR, 2/49 EVAR, p = 0.36). There is no death at 30-day or 1-year follow-up. Thirty-day reintervention rate was 1.6% (2/119; 0/70 OR, 2/49 EVAR, p = 0.16), while the 1-year rate was 2.5% (3/119; 1/70 OR, 2/49 EVAR, p = 0.36). At the mean follow-up of 56.8 ± 42.7 months, mortality and reintervention rates were 5.8% (7/119; 3/70 OR, 4/49 EVAR, p = 0.38) and 10% (12/119; 8/70 OR, 4/49 EVAR, p = 0.39), respectively. The overall reintervention rate, mortality, and freedom from adverse events did not differ between the two groups. No differences in outcome were recorded between patients treated by EVAR in on-label versus off-label fashion. Conclusion. Our (albeit limited) experience suggests that, in an unselected young patient population undergoing elective AAA repair, OR or EVAR can be performed safely with similar immediate and long term outcomes.
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Guo Q, Zhao J, Huang B, Yuan D, Yang Y, Zeng G, Xiong F, Du X. A Systematic Review of Ultrasound or Magnetic Resonance Imaging Compared With Computed Tomography for Endoleak Detection and Aneurysm Diameter Measurement After Endovascular Aneurysm Repair. J Endovasc Ther 2016; 23:936-943. [PMID: 27542700 DOI: 10.1177/1526602816664878] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To analyze the literature comparing ultrasound [duplex (DUS) or contrast-enhanced (CEUS)] or magnetic resonance imaging (MRI) with computed tomography angiography (CTA) for endoleak detection and aneurysm diameter measurement after endovascular aneurysm repair (EVAR). METHODS A systematic review identified 31 studies that included 3853 EVAR patients who had paired scans (DUS or CEUS vs CTA or MRI vs CTA) within a 1-month interval for identification of endoleaks during EVAR surveillance. The primary outcome was the number of patients with an endoleak detected by one test but undetected by another test. Results are presented for all endoleaks and for types I and III endoleaks only. Aneurysm diameter measurements between CTA and ultrasound were examined using meta-analysis. RESULTS Endoleaks were seen in 25.6% (985/3853) of patients after EVAR. Fifteen studies compared DUS with CTA for the detection of all endoleak types. CTA had a significantly higher proportion of additional endoleaks detected (214/2346 vs 77/2346 for DUS). Of 19 studies comparing CEUS with CTA for the detection of all endoleak types, CEUS was more sensitive (138/1694) vs CTA (51/1694). MRI detected 42 additional endoleaks that were undetected by CTA during the paired scans, whereas CTA detected 2 additional endoleaks that MRI did not show. CTA had a similar proportion of additional types I and III endoleaks undetected by CEUS or MRI. Of 9 studies comparing ultrasound vs CTA for post-EVAR aneurysm diameter measurement, the aneurysm diameter measured by CTA was greater than ultrasound (mean difference -1.70 mm, 95% confidence interval -2.45 to -0.96, p<0.001). CONCLUSION This study demonstrated that CEUS and MRI are more accurate than CTA for the detection of post-EVAR endoleaks, but they are no better than CTA for detecting types I and III endoleaks specifically. Aneurysm diameter differences between CTA and ultrasound should be considered when evaluating the change in aneurysm diameter postoperatively.
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Affiliation(s)
- Qiang Guo
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Yang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Guojun Zeng
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fei Xiong
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaojiong Du
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Mazzei MA, Guerrini S, Mazzei FG, Cioffi Squitieri N, Notaro D, de Donato G, Galzerano G, Sacco P, Setacci F, Volterrani L, Setacci C. Follow-up of endovascular aortic aneurysm repair: Preliminary validation of digital tomosynthesis and contrast enhanced ultrasound in detection of medium- to long-term complications. World J Radiol 2016; 8:530-536. [PMID: 27247719 PMCID: PMC4882410 DOI: 10.4329/wjr.v8.i5.530] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 12/29/2015] [Accepted: 02/17/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To validate the feasibility of digital tomosynthesis of the abdomen (DTA) combined with contrast enhanced ultrasound (CEUS) in assessing complications after endovascular aortic aneurysm repair (EVAR) by using computed tomography angiography (CTA) as the gold standard.
METHODS: For this prospective study we enrolled 163 patients (123 men; mean age, 65.7 years) referred for CTA for EVAR follow-up. CTA, DTA and CEUS were performed at 1 and 12 mo in all patients, with a maximum time interval of 2 d.
RESULTS: Among 163 patients 33 presented complications at CTA. DTA and CTA correlated for the presence of complications in 32/33 (96.96%) patients and for the absence of complications in 127/130 (97.69%) patients; the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of DTA were 97%, 98%, 91%, 99%, and 98%, respectively. CEUS and CTA correlated for the presence of complications in 19/33 (57.57%) patients and for the absence of complications in 129/130 (99.23%) patients; the sensitivity, specificity, PPV, NPV and accuracy of CEUS were 58%, 99%, 95%, 90%, and 91%, respectively. Sensitivity, specificity and accuracy of combining DTA and CEUS together in detecting EVAR complications were 77%, 98% and 95%, respectively.
CONCLUSION: Combining DTA and CEUS in EVAR follow-up has the potential to limit the use of CTA only in doubtful cases.
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Scaife M, Giannakopoulos T, Al-Khoury GE, Chaer RA, Avgerinos ED. Contemporary Applications of Ultrasound in Abdominal Aortic Aneurysm Management. Front Surg 2016; 3:29. [PMID: 27303669 PMCID: PMC4882338 DOI: 10.3389/fsurg.2016.00029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 05/09/2016] [Indexed: 11/17/2022] Open
Abstract
Ultrasound (US) is a well-established screening tool for detection of abdominal aortic aneurysms (AAAs) and is currently recommended not only for those with a relevant family history but also for all men and high-risk women older than 65 years of age. The advent of minimally invasive endovascular techniques in the treatment of AAAs [endovascular aneurysm repair (EVAR)] has increased the need for repeat imaging, especially in the postoperative period. Nevertheless, preoperative planning, intraoperative execution, and postoperative surveillance all mandate accurate imaging. While computed tomographic angiography and angiography have dominated the field, repeatedly exposing patients to the deleterious effects of cumulative radiation and intravenous nephrotoxic contrast, US technology has significantly evolved over the past decade. In addition to standard color duplex US, 2D, 3D, or 4D contrast-enhanced US modalities are revolutionizing AAA management and postoperative surveillance. This technology can accurately measure AAA diameter and volume, and most importantly, it can detect endoleaks post-EVAR with high sensitivity and specificity. 4D contrast-enhanced US can even provide hemodynamic information about the branch vessels following fenestrated EVARs. The need for experienced US operators and accredited vascular labs is mandatory to guarantee the reliability of the results. This review article presents a comprehensive overview of the literature on the state-of-art US imaging in AAA management, including post-EVAR follow-up, techniques, and diagnostic accuracy.
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Affiliation(s)
- Mark Scaife
- Division of Vascular Surgery, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | | | - Georges E Al-Khoury
- Division of Vascular Surgery, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
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Yang X, Chen YX, Zhang B, Jiang YX, Liu CW, Zhao RN, Wu Q, Zhang DM. Contrast-enhanced Ultrasound in Detecting Endoleaks with Failed Computed Tomography Angiography Diagnosis after Endovascular Abdominal Aortic Aneurysm Repair. Chin Med J (Engl) 2016; 128:2491-7. [PMID: 26365968 PMCID: PMC4725553 DOI: 10.4103/0366-6999.164935] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Endovascular aneurysm repair (EVAR) is one of the first-line therapies of abdominal aortic aneurysms. Postoperative endoleak is the most common complication of EVAR. Computed tomography angiography (CTA), which is routine for follow-up, has side effects (e.g., radiation) and also has a certain percentage of missed diagnosis. Preliminary studies on contrast-enhanced ultrasound (CEUS) have shown that the sensitivity of CEUS for detecting endoleak is no lower than that of CTA. To investigate the advantages of CEUS, we conducted CEUS examinations of post-EVAR cases in which CTA failed to detect endoleak or could not verify the type of endoleak. Methods: Post-EVAR patients, who were clinically considered to have endoleak and met the inclusion criteria were enrolled between March 2013 and November 2014. All of the patients underwent color Doppler flow imaging (CDFI) and a CEUS examination. Size, location, microbubble dispersion, and hemodynamic characteristics of leaks were recorded. Comparison between the diagnosis of CEUS and CDFI was conducted using Fisher's exact test and clinical outcomes of all patients were followed up. Results: Sixteen patients were enrolled, and 12 (75%) had endoleaks with verified types by CEUS. Among 12 cases of endoleaks were positive by CEUS, 10 were CDFI-positive, and the four CEUS-negative cases were all negative by CDFI. The diagnostic values of CEUS and CDFI were statistically different (P = 0.008). Six patients with high-pressure endoleaks received endovascular re-intervention guided by CEUS results. One patient with type III endoleak had open surgery when endovascular repair failed. Conclusions: CEUS is a new, safe, and effective means for detection of endoleaks post-EVAR. This technique can be used as a supplement for routine CTA follow-up to provide more detailed information on endoleak and its category.
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Affiliation(s)
| | | | | | - Yu-Xin Jiang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Maitrias P, Kaladji A, Plissonnier D, Amiot S, Sabatier J, Coggia M, Magne JL, Reix T. Treatment of sac expansion after endovascular aneurysm repair with obliterating endoaneurysmorrhaphy and stent graft preservation. J Vasc Surg 2016; 63:902-8. [DOI: 10.1016/j.jvs.2015.10.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/13/2015] [Indexed: 01/10/2023]
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Endofugas tipo 2 en una población tratada con endoprótesis Gore® Excluder: incidencia, persistencia y crecimiento del saco aneurismático. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2015.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Cantisani V, Grazhdani H, Clevert DA, Iezzi R, Aiani L, Martegani A, Fanelli F, Di Marzo L, Wlderk A, Cirelli C, Catalano C, Di Leo N, Di Segni M, Malpassini F, D’Ambrosio F. EVAR: Benefits of CEUS for monitoring stent-graft status. Eur J Radiol 2015. [DOI: 10.1016/j.ejrad.2015.07.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Sobocinski J, Briffa F, Holt PJ, Martin Gonzalez T, Spear R, Azzaoui R, Maurel B, Haulon S. Evaluation of the Zenith low-profile abdominal aortic aneurysm stent graft. J Vasc Surg 2015; 62:841-7. [PMID: 26243207 DOI: 10.1016/j.jvs.2015.04.452] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Low-profile (LP) stent grafts are now commercially available in Europe for endovascular aortic aneurysm repair (EVAR). In this study the midterm outcomes and characteristics of patients treated with this last generation of stent grafts were compared with a cohort of patients treated with "standard-profile" (SP) stent grafts. METHODS The current study enrolled all patients treated for elective EVAR by the SP Zenith Flex stent graft (Cook Medical, Bloomington, Ind) between March 2010 and November 2011 and patients treated for elective EVAR by the Zenith LP stent graft (Cook Medical) between November 2011 and March 2013. All patients had a follow-up >18 months. Preoperative computed tomography angiograms were analyzed on a dedicated three-dimensional workstation. All data were prospectively collected in an electronic database and retrospectively analyzed. A comparative study was conducted. RESULTS The present study included 208 patients (107 SP and 101 LP). Patients' physiologic characteristics were similar in both groups. The iliac anatomy was considered "more challenging" in LP patients: respectively, 7% and 22% (P = .002) of SP and LP patients had bilateral external iliac diameter <7 mm; and 16% and 34% (P = .005) had a combination of an external iliac diameter <7 mm and an iliac tortuosity ratio index >1.5. No 30-day deaths were documented. The 24-month freedom from reintervention and overall survival rates after SP and LP were, respectively, 88% and 91% (P = .450) and 92% and 96% (P = .153). The 24-month rates for freedom from sac expansion and from limb occlusion were 96.4% and 98.7% (P = .320) and 92% and 95% (P = .293), respectively. One patient in each group presented with a type I endoleak during follow-up, and two LP patients presented with a type III endoleak (P = .235). CONCLUSIONS This study demonstrates that the last-generation LP stent grafts have favorable midterm outcomes similar to SP stent grafts despite being used to treat more patients with unfavorable iliac anatomy.
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Affiliation(s)
- Jonathan Sobocinski
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France.
| | - Florent Briffa
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Peter J Holt
- St George's Vascular Institute, University of London, London, United Kingdom
| | - Teresa Martin Gonzalez
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Rafaëlle Spear
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Richard Azzaoui
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Blandine Maurel
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Stéphan Haulon
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
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Abstract
Contrast-enhanced ultrasound (CEUS) is increasingly being used to evaluate patients with known or suspected atherosclerosis. The administration of a microbubble contrast agent in conjunction with ultrasound results in an improved image quality and provides information that cannot be assessed with standard B-mode ultrasound. CEUS is a high-resolution, noninvasive imaging modality, which is safe and may benefit patients with coronary, carotid, or aortic atherosclerosis. CEUS allows a reliable assessment of endocardial borders, left ventricular function, intracardiac thrombus and myocardial perfusion. CEUS results in an improved detection of carotid atherosclerosis, and allows assessment of high-risk plaque characteristics including intraplaque vascularization, and ulceration. CEUS provides real-time bedside information in patients with a suspected or known abdominal aortic aneurysm or aortic dissection. The absence of ionizing radiation and safety of the contrast agent allow repetitive imaging which is particularly useful in the follow-up of patients after endovascular aneurysm repair. New developments in CEUS-based molecular imaging will improve the understanding of the pathophysiology of atherosclerosis and may in the future allow to image and directly treat cardiovascular diseases (theragnostic CEUS). Familiarity with the strengths and limitations of CEUS may have a major impact on the management of patients with atherosclerosis.
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Affiliation(s)
- Arend F L Schinkel
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands.
| | - Mathias Kaspar
- Division of Angiology, Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Daniel Staub
- Division of Angiology, Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
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Hertault A, Maurel B, Pontana F, Martin-Gonzalez T, Spear R, Sobocinski J, Sediri I, Gautier C, Azzaoui R, Rémy-Jardin M, Haulon S. Benefits of Completion 3D Angiography Associated with Contrast Enhanced Ultrasound to Assess Technical Success after EVAR. Eur J Vasc Endovasc Surg 2015; 49:541-8. [DOI: 10.1016/j.ejvs.2015.01.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/19/2015] [Indexed: 01/11/2023]
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45
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Ormesher DC, Lowe C, Sedgwick N, McCollum CN, Ghosh J. Use of three-dimensional contrast-enhanced duplex ultrasound imaging during endovascular aneurysm repair. J Vasc Surg 2014; 60:1468-72. [DOI: 10.1016/j.jvs.2014.08.095] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022]
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46
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Gargiulo M, Gallitto E, Serra C, Freyrie A, Mascoli C, Bianchini Massoni C, De Matteis M, De Molo C, Stella A. Could Four-dimensional Contrast-enhanced Ultrasound Replace Computed Tomography Angiography During Follow up of Fenestrated Endografts? Results of a Preliminary Experience. Eur J Vasc Endovasc Surg 2014; 48:536-42. [DOI: 10.1016/j.ejvs.2014.05.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 05/29/2014] [Indexed: 10/25/2022]
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47
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Karanikola E, Dalainas I, Karaolanis G, Zografos G, Filis K. Duplex Ultrasound versus Computed Tomography for the Postoperative Follow-Up of Endovascular Abdominal Aortic Aneurysm Repair. Where Do We Stand Now? Int J Angiol 2014; 23:155-64. [PMID: 25317026 DOI: 10.1055/s-0034-1387925] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
In the last decade, endovascular aneurysm repair (EVAR) has rapidly developed to be the preferred method for infrarenal abdominal aortic aneurysm repair in patients with suitable anatomy. EVAR offers the advantage of lower perioperative mortality and morbidity but carries the cost of device-related complications such as endoleak, graft migration, graft thrombosis, and structural graft failure. These complications mandate a lifelong surveillance of EVAR patients and their endografts. The purpose of this study is to review and evaluate the safety of color-duplex ultrasound (CDU) as compared with computed tomography (CT), based on the current literature, for post-EVAR surveillance. The post-EVAR follow-up modalities, CDU versus CT, are evaluated questioning three parameters: (1) accuracy of aneurysm size, (2) detection and classification of endoleaks, and (3) detection of stent-graft deformation. Studies comparing CDU with CT scan for investigation of post-EVAR complications have produced mixed results. Further and long-term research is needed to evaluate the efficacy of CDU versus CT, before CDU can be recommended as the primary imaging modality for EVAR surveillance, in place of CT for stable aneurysms.
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Affiliation(s)
- Evridiki Karanikola
- First Propaedeutic Department of Surgery, Vascular Surgery Unit, University of Athens Medical School, Hippokration Hospital, Athens, Greece
| | - Ilias Dalainas
- Department of Vascular Surgery, University of Athens Medical School, Attikon Hospital, Athens, Greece
| | - Georgios Karaolanis
- Second Propaedeutic Department of Surgery, University of Athens Medical School, Laikon Hospital, Athens, Greece
| | - Georgios Zografos
- First Propaedeutic Department of Surgery, Vascular Surgery Unit, University of Athens Medical School, Hippokration Hospital, Athens, Greece
| | - Konstantinos Filis
- First Propaedeutic Department of Surgery, Vascular Surgery Unit, University of Athens Medical School, Hippokration Hospital, Athens, Greece
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48
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Laroche JP, Diard A, Giordana P, Sarlon-Bartoli G. [Duplex ultrasound detection of type II endoleaks after endovascular aneurysm repair: Interest of contrast enhancement. Another point of view]. ACTA ACUST UNITED AC 2014; 39:288-93. [PMID: 24925793 DOI: 10.1016/j.jmv.2014.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 04/27/2014] [Indexed: 11/18/2022]
Affiliation(s)
- J-P Laroche
- Hôpital Saint-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex, France.
| | - A Diard
- Hôpital Saint-André, CHU de Bordeaux, 1, rue Jean-Burguet, 33075 Bordeaux, France
| | - P Giordana
- Hôpital Pasteur, CHU de Nice, 30, avenue de la Voie-Romaine, 06000 Nice, France
| | - G Sarlon-Bartoli
- Hôpital de la Timone, CHU de Marseille, 264, rue Saint-Pierre, 13005 Marseille, France
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49
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Sousaris N, McCutcheon J, Barr R. Incidental detection of an aortic stent endoleak with contrast-enhanced sonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:738-740. [PMID: 24658958 DOI: 10.7863/ultra.33.4.738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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50
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Symonette CJ, Gan BS. Computed tomography-based preoperative vascular imaging in autologous breast reconstruction: A Canadian perspective. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2014; 21:11-4. [PMID: 24431929 DOI: 10.1177/229255031302100107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There appears to be increased use of computed tomography angiography (CTA) in the preoperative planning of autologous perforator flap breast reconstruction. Despite the advantages of providing superior anatomical detail, concerns regarding cost and radiation exposure of this technique remain. In the current study, a paper-based survey was distributed to 44 plastic surgeons with a special interest in breast reconstruction at 19 different centres across Canada to collect their perspectives and practice characteristics with respect to the use of CTA as a preoperative imaging modality in breast reconstruction. The response rate of the survey was 75%. The majority of respondents commonly use perforator flap breast reconstruction and CTA in their breast reconstruction practice. Surgeons identified particular benefits of CTA in patients who had previously undergone abdominal surgery. However, more than one-half of the overall cohort was concerned about radiation exposure associated with CTA. A review of the literature suggests that it may be worthwhile to reduce the unnecessary risks of additional radiation exposure to the breast cancer population. A prospective study may help to better define the group of patients in whom CTA will provide optimal benefits in terms of reducing perioperative microvascular morbidity.
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Affiliation(s)
- Caitlin Jane Symonette
- Schulich School of Medicine and Dentistry, Western University, London, Ontario ; Department of Surgery, Division of Plastic Surgery, Western University, London, Ontario
| | - Bing Siang Gan
- Schulich School of Medicine and Dentistry, Western University, London, Ontario ; Department of Surgery, Division of Plastic Surgery, Western University, London, Ontario ; Department of Medical Biophysics, Western University, London, Ontario
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