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Shukla K, Messner M, Albuquerque F, Larson R, Newton D, Levy M. Safety of Utilizing Ultrasound as the Sole Modality of Follow-Up after Endovascular Aneurysm Repair. Ann Vasc Surg 2022; 92:172-177. [PMID: 36572095 DOI: 10.1016/j.avsg.2022.12.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/21/2022] [Accepted: 12/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Post endovascular aneurysm repair (EVAR), surveillance with computed tomography-aortography (CTA) remains the most common practice, per Society for Vascular Surgery (SVS) guidelines. Chronic exposure to both radiation and intravenous (IV) contrast has raised concerns about long-term CTA follow-up (FU). As we have selectively used ultrasound (US) as a sole modality for post-EVAR surveillance, we sought to review our outcomes in this subset of patients. METHODS Retrospective review of our institution's vascular database identified 213 EVAR patients from 2013 to 2021. Fenestrated-EVAR and snorkel reconstructions were excluded. Patient demographics/outcomes, abdominal aortic aneurysm (AAA) characteristics, and FU modalities and outcomes were analyzed. Unpaired Student's t-test, ANOVA, and chi-squared test were used to assess group differences. RESULTS Eighty-five of the 213 EVAR patients (39.9%) were lost to FU within 3 months. Among the 128 remaining patients, 91 underwent FU using initial US, while 37 patients underwent post-EVAR FU initially using CTA. There were no significant differences (P > 0.05) between patient age (75.5 ± 9.4 vs. 75.3 ± 8.5), body mass index (BMI) (27.7 ± 5.4 vs. 28.9 ± 7.4), or mean AAA size (5.6 ± 1.1 vs. 5.9 ± 1.2) in US-surveilled and computed tomography (CT)-surveilled groups, respectively. Of the 91 patients, initially surveilled with US, 15 patients demonstrated endoleak and/or AAA growth (>5 mm). The 15 patients with US-demonstrated endoleak and/or growth underwent confirmatory CTA, with 3 patients eventually requiring EVAR revision. Among 37 patients initially surveilled with CT, 10 demonstrated significant growth and 2 patients eventually required EVAR revision. There were no patients with AAA rupture during post-EVAR surveillance. FU data were analyzed among a select lower-risk group of patients (preoperative AAA diameter ≤5.5 cm, BMI ≤30, and no endoleak at completion of EVAR). Among this group, there were no surveilled patients who required EVAR reintervention, regardless of surveillance modality (US n = 32; CT n = 4). The average FU was 29.5 ± 26.4 months in the US group and 26.4 ± 22.3 months in the CT group (P > 0.05). CONCLUSIONS Although initial CT surveillance following EVAR remains ideal, in select lower-risk patients, US is a viable alternative even for the initial post-procedure study. Advantages include decreased radiation exposure and cost. Our data suggest that US is a safe sole modality for surveillance following EVAR in selective patients.
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Affiliation(s)
- Krunal Shukla
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Morgan Messner
- Division of Vascular Surgery at VCU Health, Richmond, VA
| | | | - Robert Larson
- Division of Vascular Surgery at VCU Health, Richmond, VA
| | - Daniel Newton
- Division of Vascular Surgery at VCU Health, Richmond, VA
| | - Mark Levy
- Division of Vascular Surgery at VCU Health, Richmond, VA.
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2
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Talebi S, Madani MH, Madani A, Chien A, Shen J, Mastrodicasa D, Fleischmann D, Chan FP, Mofrad MRK. Machine learning for endoleak detection after endovascular aortic repair. Sci Rep 2020; 10:18343. [PMID: 33110113 PMCID: PMC7591558 DOI: 10.1038/s41598-020-74936-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/30/2020] [Indexed: 12/13/2022] Open
Abstract
Diagnosis of endoleak following endovascular aortic repair (EVAR) relies on manual review of multi-slice CT angiography (CTA) by physicians which is a tedious and time-consuming process that is susceptible to error. We evaluate the use of a deep neural network for the detection of endoleak on CTA for post-EVAR patients using a novel data efficient training approach. 50 CTAs and 20 CTAs with and without endoleak respectively were identified based on gold standard interpretation by a cardiovascular subspecialty radiologist. The Endoleak Augmentor, a custom designed augmentation method, provided robust training for the machine learning (ML) model. Predicted segmentation maps underwent post-processing to determine the presence of endoleak. The model was tested against 3 blinded general radiologists and 1 blinded subspecialist using a held-out subset (10 positive endoleak CTAs, 10 control CTAs). Model accuracy, precision and recall for endoleak diagnosis were 95%, 90% and 100% relative to reference subspecialist interpretation (AUC = 0.99). Accuracy, precision and recall was 70/70/70% for generalist1, 50/50/90% for generalist2, and 90/83/100% for generalist3. The blinded subspecialist had concordant interpretations for all test cases compared with the reference. In conclusion, our ML-based approach has similar performance for endoleak diagnosis relative to subspecialists and superior performance compared with generalists.
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Affiliation(s)
- Salmonn Talebi
- Molecular Cell Biomechanics Laboratory, Departments of Bioengineering and Mechanical Engineering, University of California, 208A Stanley Hall #1762, Berkeley, CA, 94720-1762, USA
| | - Mohammad H Madani
- Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Ali Madani
- Molecular Cell Biomechanics Laboratory, Departments of Bioengineering and Mechanical Engineering, University of California, 208A Stanley Hall #1762, Berkeley, CA, 94720-1762, USA
- Salesforce Research, Palo Alto, CA, USA
| | - Ashley Chien
- Molecular Cell Biomechanics Laboratory, Departments of Bioengineering and Mechanical Engineering, University of California, 208A Stanley Hall #1762, Berkeley, CA, 94720-1762, USA
| | - Jody Shen
- Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | | | - Dominik Fleischmann
- Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Frandics P Chan
- Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA.
| | - Mohammad R K Mofrad
- Molecular Cell Biomechanics Laboratory, Departments of Bioengineering and Mechanical Engineering, University of California, 208A Stanley Hall #1762, Berkeley, CA, 94720-1762, USA.
- Molecular Biophysics and Integrative Bioimaging Division, Lawrence Berkeley National Laboratory, Berkeley, CA, 94720, USA.
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3
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Baderkhan H, Wanhainen A, Haller O, Björck M, Mani K. Editor's Choice - Detection of Late Complications After Endovascular Abdominal Aortic Aneurysm Repair and Implications for Follow up Based on Retrospective Assessment of a Two Centre Cohort. Eur J Vasc Endovasc Surg 2020; 60:171-179. [PMID: 32209282 DOI: 10.1016/j.ejvs.2020.02.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 01/10/2020] [Accepted: 02/25/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Endovascular aortic aneurysm repair (EVAR) is associated with the risk of late complications and mandates follow up. This retrospective study assessed post-EVAR complications in a two centre cohort. The study evaluated the rate of complications presenting with symptoms vs. those detected by imaging follow up. Additionally, the agreement between DUS and CTA in detecting complications was assessed in patients with both. METHODS All EVAR patients from 1998 to 2012 in two centres were included. Complications were classified based on whether they were symptomatic or detected by imaging, as well as based on imaging detection modality (DUS or CTA). For patients who had undergone DUS and CTA within three months of each other, the kappa coefficient of agreement was assessed. RESULTS Four hundred and fifty-four patients treated by EVAR were identified. The median follow up time was 5.2 (IQR 2.8-7.6) years. One hundred and eighteen patients (26%) developed 176 complications. One hundred and six (60.2%) of the complications were asymptomatic, and 70 (39.8%) were symptomatic. Two hundred and fifty-three patients had imaging with both modalities within three months of each other; the kappa coefficient for agreement between CTA and DUS for detecting clinically significant complications was 0.91. Regarding CTA as the standard modality, DUS had a sensitivity of 88.8% (95% CI 77.3-95.8%) and a specificity of 99.4% (95% CI 97.1-99.9%). Three of the complications missed by DUS were related to loss of proximal and distal seal, all occurring in patients with short sealing length on first post-operative CT scan. CONCLUSION Approximately a quarter of the patients developed complications, the majority of which were asymptomatic, underlining the importance of adequate surveillance. There was good agreement between CTA and DUS in detecting complications. Clinically significant complications related to inadequate seal were missed by DUS, suggesting that CTA still plays an important role in EVAR surveillance.
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Affiliation(s)
- Hassan Baderkhan
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden.
| | - Anders Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Olov Haller
- Department of Radiology, Gävle Hospital, Gävle, Sweden
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
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Kalender G, Lisy M, Stock UA, Endisch A, Kornberger A. Long-term radiation exposure in patients undergoing EVAR: Reflecting clinical day-to-day practice to assess realistic radiation burden. Clin Hemorheol Microcirc 2019; 71:451-461. [PMID: 30248048 DOI: 10.3233/ch-170344] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Endovascular repair of aortic aneurysms (EVAR) has become an established treatment option currently applied in an increasing numbers of patients with aortic aneurysms. Advantages include reduced surgical trauma, procedural time, intensive care unit and hospital lengths of stay, blood loss as well as morbidity and mortality.The optimal imaging modalities in EVAR follow-up as well as the appropriate intervals between these follow-ups remain subject of controversial discussion. Objective of this study was the evaluation of the realistic radiation exposure and risk estimate postop EVAR treatment.Of the follow-ups required according to the surveillance schedule during the first year post-EVAR, only 68.3% were actually implemented. Of those required from the second year onwards, an average of 70% was actually performed. During the observation period, each patient underwent a mean of 4.3 CTAs. The median ED calculated from all CTAs was 24. 5 mSv. The minimum and maximum cumulative EDs for the entire observation period were 55 mSv and 310 mSv, respectively.
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Affiliation(s)
- G Kalender
- Department of Vascular and Endovascular Surgery, DRK Hospital Berlin Köpenick, Berlin, Germany
| | - M Lisy
- Department of Vascular and Endovascular Surgery, Krankenhaus Nordwest Frankfurt, Germany
| | - U A Stock
- Department of Cardiac and Transplant Surgery, Royal Brompton and Harefield NHS Trust, Harefield, UK
| | - A Endisch
- Department of Vascular and Endovascular Surgery, Asklepios Hospital Bad Tölz, Germany
| | - A Kornberger
- Department of Vascular, Thoracic and Cardiovascular Surgery, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
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5
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Brazzelli M, Hernández R, Sharma P, Robertson C, Shimonovich M, MacLennan G, Fraser C, Jamieson R, Vallabhaneni SR. Contrast-enhanced ultrasound and/or colour duplex ultrasound for surveillance after endovascular abdominal aortic aneurysm repair: a systematic review and economic evaluation. Health Technol Assess 2019; 22:1-220. [PMID: 30543179 DOI: 10.3310/hta22720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Endovascular abdominal aortic aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) is less invasive than open surgery, but may be associated with important complications. Patients receiving EVAR require long-term surveillance to detect abnormalities and direct treatments. Computed tomography angiography (CTA) has been the most common imaging modality adopted for EVAR surveillance, but it is associated with repeated radiation exposure and the risk of contrast-related nephropathy. Colour duplex ultrasound (CDU) and, more recently, contrast-enhanced ultrasound (CEU) have been suggested as possible, safer, alternatives to CTA. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of imaging strategies, using either CDU or CEU alone or in conjunction with plain radiography, compared with CTA for EVAR surveillance. DATA SOURCES Major electronic databases were searched, including MEDLINE, EMBASE, Science Citation Index, Scopus' Articles-in-Press, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and NHS Economic Evaluation Database from 1996 onwards. We also searched for relevant ongoing studies and conference proceedings. The final searches were undertaken in September 2016. METHODS We conducted a systematic review of randomised controlled trials and cohort studies of patients with AAAs who were receiving surveillance using CTA, CDU and CEU with or without plain radiography. Three reviewers were involved in the study selection, data extraction and risk-of-bias assessment. We developed a Markov model based on five surveillance strategies: (1) annual CTA; (2) annual CDU; (3) annual CEU; (4) CDU together with CTA at 1 year, followed by CDU on an annual basis; and (5) CEU together with CTA at 1 year, followed by CEU on an annual basis. All of these strategies also considered plain radiography on an annual basis. RESULTS We identified two non-randomised comparative studies and 25 cohort studies of interventions, and nine systematic reviews of diagnostic accuracy. Overall, the proportion of patients who required reintervention ranged from 1.1% (mean follow-up of 24 months) to 23.8% (mean follow-up of 32 months). Reintervention was mainly required for patients with thrombosis and types I-III endoleaks. All-cause mortality ranged from 2.7% (mean follow-up of 24 months) to 42% (mean follow-up of 54.8 months). Aneurysm-related mortality occurred in < 1% of the participants. Strategies based on early and mid-term CTA and/or CDU and long-term CDU surveillance were broadly comparable with those based on a combination of CTA and CDU throughout the follow-up period in terms of clinical complications, reinterventions and mortality. The economic evaluation showed that a CDU-based strategy generated lower expected costs and higher quality-adjusted life-year (QALYs) than a CTA-based strategy and has a 63% probability of being cost-effective at a £30,000 willingness-to-pay-per-QALY threshold. A CEU-based strategy generated more QALYs, but at higher costs, and became cost-effective only for high-risk patient groups. LIMITATIONS Most studies were rated as being at a high or moderate risk of bias. No studies compared CDU with CEU. Substantial clinical heterogeneity precluded a formal synthesis of results. The economic model was hindered by a lack of suitable data. CONCLUSIONS Current surveillance practice is very heterogeneous. CDU may be a safe and cost-effective alternative to CTA, with CTA being reserved for abnormal/inconclusive CDU cases. FUTURE WORK Research is needed to validate the safety of modified, more-targeted surveillance protocols based on the use of CDU and CEU. The role of radiography for surveillance after EVAR requires clarification. STUDY REGISTRATION This study is registered as PROSPERO CRD42016036475. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pawana Sharma
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Clare Robertson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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6
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Bryce Y, Lam C(K, Ganguli S, Schiro BJ, Cooper K, Cline M, Oklu R, Vatakencherry G, Peña CS, Gandhi RT. Step-by-Step Approach to Management of Type II Endoleaks. Tech Vasc Interv Radiol 2018; 21:188-195. [DOI: 10.1053/j.tvir.2018.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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7
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Bryce Y, Schiro B, Cooper K, Ganguli S, Khayat M, Lam CK, Oklu R, Vatakencherry G, Gandhi RT. Type II endoleaks: diagnosis and treatment algorithm. Cardiovasc Diagn Ther 2018; 8:S131-S137. [PMID: 29850425 DOI: 10.21037/cdt.2017.08.06] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Elective abdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm, symptomatic, or rapidly expanding more than 0.5 cm in 6 months. Seventy-five percent of AAAs today are treated with endovascular aneurysm repair (EVAR) rather than open repair. This is fostered by the lower periprocedural mortality, complications, and length of hospital stay associated with EVAR. However, some studies have demonstrated EVAR to result in higher reintervention rates than with open repair, largely due to endoleaks. Type II is the most common, making up 10-25% of all endoleaks. Type II endoleaks, can potentially enlarge and pressurize the aneurysm sac with a risk of rupture. However, many type II endoleaks spontaneously resolve or never lead to sac enlargement. Imaging surveillance and approaches to management of type II endoleaks are reviewed here.
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Affiliation(s)
- Yolanda Bryce
- Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Brian Schiro
- Division of Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, FL, USA
| | - Kyle Cooper
- Division of Interventional Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Suvranu Ganguli
- Division of Interventional Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Mamdouh Khayat
- Division of Interventional Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Cuong Ken Lam
- Division of Vascular and Interventional Radiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Mayo Clinic, Scottsdale, AZ, USA
| | - Geogy Vatakencherry
- Division of Vascular and Interventional Radiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Ripal T Gandhi
- Division of Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, FL, USA
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8
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Boos J, Brook OR, Fang J, Temin N, Brook A, Raptopoulos V. What Is the Optimal Abdominal Aortic Aneurysm Sac Measurement on CT Images during Follow-up after Endovascular Repair? Radiology 2017; 285:1032-1041. [DOI: 10.1148/radiol.2017161424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Johannes Boos
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215
| | - Olga R. Brook
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215
| | - Jieming Fang
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215
| | - Nathaniel Temin
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215
| | - Alexander Brook
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215
| | - Vasillios Raptopoulos
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215
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9
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Identification of Factors Influencing Cumulative Long-Term Radiation Exposure in Patients Undergoing EVAR. Int J Vasc Med 2017; 2017:9763075. [PMID: 29250445 PMCID: PMC5700475 DOI: 10.1155/2017/9763075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/24/2017] [Accepted: 10/03/2017] [Indexed: 02/01/2023] Open
Abstract
Patients who undergo endovascular repair of aortic aneurysms (EVAR) require life-long surveillance because complications including, in particular, endoleaks, aneurysm rupture, and graft dislocation are diagnosed in a certain share of the patient population and may occur at any time after the original procedure. Radiation exposure in patients undergoing EVAR and post-EVAR surveillance has been investigated by previous authors. Arriving at realistic exposure data is essential because radiation doses resulting from CT were shown to be not irrelevant. Efforts directed at identification of factors impacting the level of radiation exposure in both the course of the EVAR procedure and post-EVAR endovascular interventions and CTAs are warranted as potentially modifiable factors may offer opportunities to reduce the radiation. In the light of the risks found to be associated with radiation exposure and considering the findings above, those involved in EVAR and post-EVAR surveillance should aim at optimal dose management.
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10
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Schaeffer JS, Shakhnovich I, Sieck KN, Kallies KJ, Davis CA, Cogbill TH. Duplex Ultrasound Surveillance After Uncomplicated Endovascular Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2017; 51:295-300. [PMID: 28535732 DOI: 10.1177/1538574417708131] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Health-care costs and risks of radiation and intravenous contrast exposure challenge computed tomography angiography (CTA) as the standard surveillance method after endovascular abdominal aortic aneurysm repair (EVAR). We reviewed our experience using Duplex ultrasound scan (DUS) as an initial and subsequent surveillance technique after uncomplicated EVAR. METHODS The medical records of patients who underwent EVAR from 2004 to 2014 with at least 1 postoperative imaging study were retrospectively reviewed. Duplex ultrasound scan was the primary modality, with CTA reserved for patients with suspicious findings. RESULTS Mean follow-up was 3.2 years for 266 patients. Fifty-seven endoleaks (7 type I, 50 type II) were detected in 51 patients (19%). Nineteen (33%) endoleaks were identified and monitored by DUS alone. Nine (16%) endoleaks were identified on CTA without prior DUS. Twenty-two (39%) endoleaks were identified on DUS and confirmed by CTA; 6 of these patients had a secondary intervention. When compared to subsequent CTA, there were 7 discordant results: 4 false-negative and 3 false-positive endoleaks on DUS. Two of these patients with discordant results required intervention. Follow-up CTA was not obtained for the other 2 patients due to severe comorbidities including renal disease. One of these patients eventually developed abdominal aortic aneurysm rupture and death. Among 88 patients with both DUS and CTA, positive predictive value and negative predictive value for DUS were 0.88 and 0.94, respectively. Sac size on DUS compared to CTA resulted in an interclass correlation coefficient of r = .84. CONCLUSIONS In our experience, DUS was safe and effective for initial and follow-up surveillance after uncomplicated EVAR.
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Affiliation(s)
- Jacob S Schaeffer
- 1 General Surgery Residency, Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Irina Shakhnovich
- 2 Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI, USA
| | - Kyle N Sieck
- 3 Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Kara J Kallies
- 3 Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Clark A Davis
- 2 Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI, USA
| | - Thomas H Cogbill
- 2 Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI, USA
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11
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David E, Cantisani V, Grazhdani H, Di Marzo L, Venturini L, Fanelli F, Di Segni M, Di Leo N, Brunese L, Calliada F, Ciccariello M, Bottari A, Ascenti G, D'Ambrosio F. What is the role of contrast-enhanced ultrasound in the evaluation of the endoleak of aortic endoprostheses? A comparison between CEUS and CT on a widespread scale. J Ultrasound 2016; 19:281-287. [PMID: 27965719 DOI: 10.1007/s40477-016-0222-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/10/2016] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To evaluate the accuracy of contrast-enhanced ultrasound (CEUS) in comparison to CT angiography (CTA) to identify and classify endoleaks following abdominal aortic aneurism repair with endoprosthesis. MATERIALS AND METHODS A retrospective analysis of 181 patients treated with EVAR, from September 2009 to September 2014, was performed. Patients were evaluated with CEUS, CTA and angiography in the cases requiring treatment. Sac diameter, sac integrity, identification and classification of endoleaks were taken into consideration. Sensitivity, specificity, accuracy and negative predictive values were considered for each modality of endoleak identification. RESULTS Forty-two endoleaks (23.2%; type II: 39 cases, type III: 3 cases) were documented. Sensitivity and specificity of CEUS and CT were, respectively, 97.6 and 90.5, 100 and 100%. In two cases, CEUS was able to better classify endoleaks compared to CT. CONCLUSIONS CEUS accuracy to identify endoleaks following EVAR is similar to CT. CEUS should be considered as an effective modality for the long-term surveillance of EVAR because of its capability to correctly classify endoleaks with no ionizing radiation exposure.
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Affiliation(s)
- E David
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - V Cantisani
- Department of Radiology, Oncology, and Anatomo Pathology, "Sapienza" University of Rome, Rome, Italy
| | - H Grazhdani
- Associazione dei Cavalieri Italiani Sovrano Militare Ordine di Malta; Poliambulatorio Roma, Eur Piazza Guglielmo Marconi 12, 00144 Rome, Italy
| | - L Di Marzo
- Department of Surgery Pietro Valdoni, Sapienza University, Rome, Italy
| | - L Venturini
- Department of Surgery Pietro Valdoni, Sapienza University, Rome, Italy
| | - F Fanelli
- Department of Radiology, Oncology, and Anatomo Pathology, "Sapienza" University of Rome, Rome, Italy
| | - M Di Segni
- Department of Radiology, Oncology, and Anatomo Pathology, "Sapienza" University of Rome, Rome, Italy
| | - N Di Leo
- Department of Radiology, Oncology, and Anatomo Pathology, "Sapienza" University of Rome, Rome, Italy
| | - L Brunese
- Department of Medicine and Health Sciences, University of Molise, Contrada Tappino, 86100 Campobasso, Italy
| | - F Calliada
- University Hospital of Pavia, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - M Ciccariello
- Department of Radiology, Oncology, and Anatomo Pathology, "Sapienza" University of Rome, Rome, Italy
| | - A Bottari
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - G Ascenti
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - F D'Ambrosio
- Department of Radiology, Oncology, and Anatomo Pathology, "Sapienza" University of Rome, Rome, Italy
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12
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Slama R, Long B, Koyfman A. The emergency medicine approach to abdominal vascular graft complications. Am J Emerg Med 2016; 34:2014-2017. [PMID: 27519454 DOI: 10.1016/j.ajem.2016.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 06/30/2016] [Accepted: 07/02/2016] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Abdominal aortic aneurysm (AAA) is a deadly condition, particularly with rupture. Emergency physicians provide vital frontline care to the diagnosis and treatment of this disease. Endovascular aortic repair (EVAR) has become the gold standard for treatment of AAA, but the management of EVAR complications is not well discussed in the emergency medicine literature. OBJECTIVE OF THIS REVIEW The purpose of this article is to provide an emergency medicine-focused review of the complications of EVAR. DISCUSSION Although many complications may arise after AAA repair, the most common include aortoenteric fistula, endoleak, limb ischemia, and graft infection. All potential complications should receive vascular surgery consultation and hemodynamic resuscitation. Aortoenteric fistula often presents nonspecifically with gastrointestinal (GI) bleeding, abdominal pain, and vomiting. Computed tomography with intravenous contrast is required for diagnosis. An endoleak is defined by vascular flow outside of the graft. The optimal diagnostic modality includes triple phase computed tomographic scan (noncontrast, arterial, delayed phase). Limb ischemia may occur before 2 months, or in a later period, with symptoms ranging from claudication to complete neurovascular compromise. Graft infection is most commonly due to Staphylococcus aureus, and imaging can suggest the diagnosis. Definitive diagnosis requires tissue or fluid sampling. Through an understanding of these complications, emergency physicians may improve patient outcomes. CONCLUSIONS With the growing use of EVAR, emergency physician exposure to complications of this procedure is increasing. Knowledge of the complication presentations, diagnoses, and management can play an integral role patient care.
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Affiliation(s)
- Richard Slama
- Naval Medical Center Portsmouth, Department of Emergency Medicine, 620 John Paul Jones Cir, Portsmouth, VA 23708, USA.
| | - Brit Long
- San Antonio Military Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, USA.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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de Bruin JL, Karthikesalingam A, Holt PJ, Prinssen M, Thompson MM, Blankensteijn JD, Grobbee D, Blankensteijn J, Bak A, Buth J, Pattynama P, Verhoeven E, van Voorthuisen A, Blankensteijn J, Balm R, Buth J, Cuypers P, Grobbee D, Prinssen M, van Sambeek M, Verhoeven E, Baas A, Hunink M, van Engelshoven J, Jacobs M, de Mol B, van Bockel J, Balm R, Reekers J, Tielbeek X, Verhoeven E, Wisselink W, Boekema N, Heuveling L, Sikking I, Prinssen M, Balm R, Blankensteijn J, Buth J, Cuypers P, van Sambeek M, Verhoeven E, de Bruin J, Baas A, Blankensteijn J, Prinssen M, Buth J, Tielbeek A, Blankensteijn J, Balm R, Reekers J, van Sambeek M, Pattynama P, Verhoeven E, Prins T, van der Ham A, van der Velden J, van Sterkenburg S, ten Haken G, Bruijninckx C, van Overhagen H, Tutein Nolthenius R, Hendriksz T, Teijink J, Odink H, de Smet A, Vroegindeweij D, van Loenhout R, Rutten M, Hamming J, Lampmann L, Bender M, Pasmans H, Vahl A, de Vries C, Mackaay A, van Dortmont L, van der Vliet A, Schultze Kool L, Boomsma J, van H, de Mol van Otterloo J, de Rooij T, Smits T, Yilmaz E, Wisselink W, van den Berg F, Visser M, van der Linden E, Schurink G, de Haan M, Smeets H, Stabel P, van Elst F, Poniewierski J, Vermassen F. Predicting reinterventions after open and endovascular aneurysm repair using the St George's Vascular Institute score. J Vasc Surg 2016; 63:1428-1433.e1. [DOI: 10.1016/j.jvs.2015.12.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/15/2015] [Indexed: 12/01/2022]
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14
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Kok M, de Haan MW, Mihl C, Eijsvoogel NG, Hendriks BM, Sailer AM, Derks K, Schnerr RS, Schurink GWH, Wildberger JE, Das M. Individualized CT Angiography Protocols for the Evaluation of the Aorta: A Feasibility Study. J Vasc Interv Radiol 2016; 27:531-8. [DOI: 10.1016/j.jvir.2016.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 01/02/2016] [Accepted: 01/02/2016] [Indexed: 01/16/2023] Open
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Tacher V, Desgranges P, You K, Ridouani F, Marzelle J, Kobeiter H. Feasibility of Three-Dimensional MR Angiography Image Fusion Guidance for Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Interv Radiol 2016; 27:188-93. [DOI: 10.1016/j.jvir.2015.08.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 08/27/2015] [Accepted: 08/27/2015] [Indexed: 11/25/2022] Open
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Bryce Y, Rogoff P, Romanelli D, Reichle R. Endovascular repair of abdominal aortic aneurysms: vascular anatomy, device selection, procedure, and procedure-specific complications. Radiographics 2016; 35:593-615. [PMID: 25763741 DOI: 10.1148/rg.352140045] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abdominal aortic aneurysm (AAA) is abnormal dilatation of the aorta, carrying a substantial risk of rupture and thereby marked risk of death. Open repair of AAA involves lengthy surgery time, anesthesia, and substantial recovery time. Endovascular aneurysm repair (EVAR) provides a safer option for patients with advanced age and pulmonary, cardiac, and renal dysfunction. Successful endovascular repair of AAA depends on correct selection of patients (on the basis of their vascular anatomy), choice of the correct endoprosthesis, and familiarity with the technique and procedure-specific complications. The type of aneurysm is defined by its location with respect to the renal arteries, whether it is a true or false aneurysm, and whether the common iliac arteries are involved. Vascular anatomy can be divided more technically into aortic neck, aortic aneurysm, pelvic perfusion, and iliac morphology, with grades of difficulty with respect to EVAR, aortic neck morphology being the most common factor to affect EVAR appropriateness. When choosing among the devices available on the market, one must consider the patient's vascular anatomy and choose between devices that provide suprarenal fixation versus those that provide infrarenal fixation. A successful technique can be divided into preprocedural imaging, ancillary procedures before AAA stent-graft placement, the procedure itself, postprocedural medical therapy, and postprocedural imaging surveillance. Imaging surveillance is important in assessing complications such as limb thrombosis, endoleaks, graft migration, enlargement of the aneurysm sac, and rupture. Last, one must consider the issue of radiation safety with regard to EVAR.
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Affiliation(s)
- Yolanda Bryce
- From the Department of Radiology, Mount Auburn Hospital, 330 Mount Auburn St, Cambridge, MA 02138
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Compliance of postendovascular aortic aneurysm repair imaging surveillance. J Vasc Surg 2016; 63:589-95. [PMID: 26781078 DOI: 10.1016/j.jvs.2015.09.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/09/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Imaging surveillance after endovascular aortic aneurysm repair (EVAR) is critical. In this study we analyzed compliance with imaging surveillance after EVAR and its effect on clinical outcomes. METHODS Retrospective analysis of prospectively collected data of 565 EVAR patients (August 2001-November 2013), who were followed using duplex ultrasound and/or computed tomography angiography. Patients were considered noncompliant (NC) if they did not have any follow-up imaging for 2 years and/or missed their first post-EVAR imaging over 6 months. A Kaplan-Meier analysis was used to compare compliance rates in EVAR patients with hostile neck (HN) vs favorable neck (FN) anatomy (according to instructions for use). A multivariate analysis was also done to correlate compliance and comorbidities. RESULTS Forty-three percent were compliant (7% had no follow-up imaging) and 57% were NC. The mean follow-up for compliant patients was 25.4 months (0-119 months) vs 31.4 months for NC (0-140 months). The mean number of imaging was 3.5 for compliant vs 2.6 for NC (P < .0001). Sixty-four percent were NC for HN patients vs 50% for FN patients (P = .0007). The rates of compliance at 1, 2, 3, 4, and 5 years for all patients were 78%, 63%, 55%, 45%, and 32%; and 84%, 68%, 61%, 54%, and 40% for FN patients; and 73%, 57%, 48%, 37%, and 25% for HN patients (P = .009). The NC rate for patients with late endoleak and/or sac expansion was 58% vs 54% for patients with no endoleak (P = .51). The NC rate for patients with late reintervention was 70% vs 53% for patients with no reintervention (P = .1254). Univariate and multivariate analyses showed that patients with peripheral arterial disease had an odds ratio of 1.9 (P = .0331), patients with carotid disease had an odds ratio of 2 (P = .0305), and HN patients had an odds ratio of 1.8 (P = .0007) for NC. Age and residential locations were not factors in compliance. CONCLUSIONS Overall, compliance of imaging surveillance after EVAR was low, particularly in HN EVAR patients, and additional studies are needed to determine if strict post-EVAR surveillance is necessary, and its effect on long-term clinical outcome.
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Coulston J, Baigent A, Selvachandran H, Jones S, Torella F, Fisher R. Lack of Iliac Engagement Correlates With Iliac Limb Complications Following Standard EVAR. Vasc Endovascular Surg 2015; 49:201-5. [DOI: 10.1177/1538574415614403] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: An adequate distal sealing zone is a prerequisite for successful endovascular aneurysm repair (EVAR). Poor engagement of iliac limbs within the common iliac artery potentially increases the risk of limb-related complications. The aim of this study was to investigate the proportion of common iliac artery used for distal sealing as a predictor of iliac limb complications following standard EVAR. Methods: This was a retrospective case controlled study where an iliac complication group was compared to a larger control group from the unit database. Core analysis of postoperative computed tomography scans was used to ascertain the percentage engagement of the iliac limb of the stent graft within the native iliac artery in both groups. Results: There were 240 limbs in the control group and 33 limbs in the complications group. Complications included 10 endoleaks, 1 iliac limb dislocation, 2 insufficient engagement, 4 occlusions, and 16 kinks. The proportion of common iliac artery engagement was significantly higher in the control group compared with the complications group (75.3:68.6%, P = .003). Conclusions: Increased engagement in the common iliac artery following standard EVAR reduces the risks of limb complications. A clinical guide utilization of more than 70% of the total length of common iliac artery could be used as this was associated with a significantly lower rate of iliac limb complications following standard EVAR.
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Affiliation(s)
- James Coulston
- Liverpool Vascular and Endovascular Service, Regional Vascular Unit, Royal Liverpool Hospital, Liverpool, England
| | - Amy Baigent
- Liverpool Vascular and Endovascular Service, Regional Vascular Unit, Royal Liverpool Hospital, Liverpool, England
| | - Haran Selvachandran
- Liverpool Vascular and Endovascular Service, Regional Vascular Unit, Royal Liverpool Hospital, Liverpool, England
| | - Steven Jones
- Liverpool Vascular and Endovascular Service, Regional Vascular Unit, Royal Liverpool Hospital, Liverpool, England
| | - Francesco Torella
- Liverpool Vascular and Endovascular Service, Regional Vascular Unit, Royal Liverpool Hospital, Liverpool, England
| | - Robert Fisher
- Liverpool Vascular and Endovascular Service, Regional Vascular Unit, Royal Liverpool Hospital, Liverpool, England
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Oliveira‐Pinto J, Sampaio S, Rocha‐Neves J, Castro‐Ferreira R, Costa‐Lima J, Leite‐Moreira A, Mansilha A, Teixeira JF. Fatores de risco para crescimento do saco aneurismático pós‐endovascular aneurysm repair: revisão de literatura. ANGIOLOGIA E CIRURGIA VASCULAR 2015. [DOI: 10.1016/j.ancv.2015.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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20
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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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21
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Karthikesalingam A, Attallah O, Ma X, Bahia SS, Thompson L, Vidal-Diez A, Choke EC, Bown MJ, Sayers RD, Thompson MM, Holt PJ. An Artificial Neural Network Stratifies the Risks of Reintervention and Mortality after Endovascular Aneurysm Repair; a Retrospective Observational study. PLoS One 2015; 10:e0129024. [PMID: 26176943 PMCID: PMC4503678 DOI: 10.1371/journal.pone.0129024] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/03/2015] [Indexed: 12/16/2022] Open
Abstract
Background Lifelong surveillance after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) is considered mandatory to detect potentially life-threatening endograft complications. A minority of patients require reintervention but cannot be predictively identified by existing methods. This study aimed to improve the prediction of endograft complications and mortality, through the application of machine-learning techniques. Methods Patients undergoing EVAR at 2 centres were studied from 2004-2010. Pre-operative aneurysm morphology was quantified and endograft complications were recorded up to 5 years following surgery. An artificial neural networks (ANN) approach was used to predict whether patients would be at low- or high-risk of endograft complications (aortic/limb) or mortality. Centre 1 data were used for training and centre 2 data for validation. ANN performance was assessed by Kaplan-Meier analysis to compare the incidence of aortic complications, limb complications, and mortality; in patients predicted to be low-risk, versus those predicted to be high-risk. Results 761 patients aged 75 +/- 7 years underwent EVAR. Mean follow-up was 36+/- 20 months. An ANN was created from morphological features including angulation/length/areas/diameters/volume/tortuosity of the aneurysm neck/sac/iliac segments. ANN models predicted endograft complications and mortality with excellent discrimination between a low-risk and high-risk group. In external validation, the 5-year rates of freedom from aortic complications, limb complications and mortality were 95.9% vs 67.9%; 99.3% vs 92.0%; and 87.9% vs 79.3% respectively (p<0.001) Conclusion This study presents ANN models that stratify the 5-year risk of endograft complications or mortality using routinely available pre-operative data.
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Affiliation(s)
- Alan Karthikesalingam
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
| | - Omneya Attallah
- College of Engineering and Applied Science, Aston University, Birmingham, B4 7ET, United Kingdom
- Department of Electronics and Communications Engineering, Arab Academy for Science and Technology and Maritime Transport, Alexandria, Egypt
| | - Xianghong Ma
- College of Engineering and Applied Science, Aston University, Birmingham, B4 7ET, United Kingdom
| | - Sandeep Singh Bahia
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
- * E-mail:
| | - Luke Thompson
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
| | - Alberto Vidal-Diez
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
- Department of Community Health Sciences, St George’s University of London, London, SW17 0QT, United Kingdom
| | - Edward C. Choke
- Vascular Surgery Group, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, United Kingdom
| | - Matt J. Bown
- Vascular Surgery Group, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, United Kingdom
| | - Robert D. Sayers
- Vascular Surgery Group, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, United Kingdom
| | - Matt M. Thompson
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
| | - Peter J. Holt
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
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Karthikesalingam A, Vidal-Diez A, De Bruin JL, Thompson MM, Hinchliffe RJ, Loftus IM, Holt PJ. International validation of a risk score for complications and reinterventions after endovascular aneurysm repair. Br J Surg 2015; 102:509-15. [DOI: 10.1002/bjs.9758] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 09/02/2014] [Accepted: 11/26/2014] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Lifelong surveillance is considered mandatory after endovascular repair (EVAR) of abdominal aortic aneurysms to detect endograft complications and prevent aneurysm rupture. Current protocols are not cost-effective or clinically effective. The international validity of the St George's Vascular Institute (SGVI) score for EVAR complications was examined.
Methods
The ENGAGE registry recruited patients undergoing EVAR at 79 centres in 30 countries. Reinterventions and endograft complications were recorded for up to 3 years after surgery. Preoperative aneurysm morphology was extracted from the registry database, and used to predict whether patients would be at low or high risk of complications after EVAR based on the SGVI score. Kaplan–Meier analysis was used to compare the incidence of endograft complications and reinterventions in patients predicted to be at low risk compared with those predicted to be at high risk.
Results
Some 1207 patients underwent EVAR, with follow-up of up to 3 years. The SGVI score accurately discriminated freedom from reinterventions (90·5 versus 79·3 per cent in low- versus high-risk patients; P < 0·001), freedom from endograft complications (77·9 versus 69·6 per cent in low- versus high-risk patients; P = 0·012), and freedom from a composite outcome measure of reinterventions or endograft complications (75·0 versus 66·1 per cent in low- versus high-risk patients; P = 0·006) during mid-term follow-up.
Conclusion
This study has provided international validation of a morphological risk score that predicts mid-term reinterventions and endograft complications. The results may enable risk-stratified surveillance after EVAR.
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Affiliation(s)
- A Karthikesalingam
- Department of Outcomes Research, St George's Vascular Institute, London, UK
| | - A Vidal-Diez
- Department of Outcomes Research, St George's Vascular Institute, London, UK
| | - J L De Bruin
- Department of Outcomes Research, St George's Vascular Institute, London, UK
| | - M M Thompson
- Department of Outcomes Research, St George's Vascular Institute, London, UK
| | - R J Hinchliffe
- Department of Outcomes Research, St George's Vascular Institute, London, UK
| | - I M Loftus
- Department of Outcomes Research, St George's Vascular Institute, London, UK
| | - P J Holt
- Department of Outcomes Research, St George's Vascular Institute, London, UK
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Tse DML, Tapping CR, Patel R, Morgan R, Bratby MJ, Anthony S, Uberoi R. Surveillance After Endovascular Abdominal Aortic Aneurysm Repair. Cardiovasc Intervent Radiol 2014; 37:875-88. [DOI: 10.1007/s00270-014-0916-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 04/03/2014] [Indexed: 02/05/2023]
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Bahia SS, Karthikesalingam A, Thompson MM. Abdominal aortic aneurysms: endovascular options and outcomes - proliferating therapy, but effective? Prog Cardiovasc Dis 2013; 56:19-25. [PMID: 23993235 DOI: 10.1016/j.pcad.2013.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abdominal aortic aneurysm (AAA) has a reported prevalence rate of 1.4% in the US. AAA rupture accounts for an estimated 15,000 deaths per year, rendering it the 10th leading cause of death in men over the age of 55. Endovascular repair (EVR) has proliferated in the last two decades as an increasingly popular alternative to traditional open surgery, and is now the default treatment in the majority of centres worldwide. This review article outlines the evidence supporting this stance. The development of EVR is reviewed, alongside trends in utilisation of this therapy over time. The evidence for the relative short-term and long-term outcomes of EVR and open AAA repair is discussed, and ongoing controversies surrounding the use of EVR are considered.
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Affiliation(s)
- Sandeep S Bahia
- Department of Cardiovascular Sciences, St George's Vascular Institute, London.
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Marone E, Mascia D, Coppi G, Tshomba Y, Bertoglio L, Kahlberg A, Chiesa R. Delayed Open Conversion after Endovascular Abdominal Aortic Aneurysm: Device-specific Surgical Approach. Eur J Vasc Endovasc Surg 2013; 45:457-64. [DOI: 10.1016/j.ejvs.2012.12.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 12/27/2012] [Indexed: 11/25/2022]
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Wolstenhulme S, Froggett J, Nicholls M. Surveillance of Endovascular Aneurysm Repair: An Audit of Sonographer-Led Ultrasound and Radiologist-Led Computed Tomography Services. ULTRASOUND 2013. [DOI: 10.1258/ult.2013.012029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives Postoperative complications associated with endovascular aneurysm repair (EVAR) mandate the need for lifelong surveillance. The aim of this audit was to compare the detection rates of endoleaks during the first 10 months of a combined sonographer-led colour Doppler ultrasound (CDUS) and radiologist-led contrast-enhanced computed tomography (CECT), postoperative EVAR surveillance programme, within a single National Health Service Hospital. Methods A prospective audit was carried out of all patients with EVAR, who had same-day CECT and CDUS surveillance examinations between March 2010 and January 2011. CECT examinations were reported by three consultant vascular radiologists. Of 66 CDUS examinations, 64 (97%) were performed and reported by four certified vascular sonographers. The reports of dual-modality, same-day scans were compared, to establish agreement on the presence and classification of the type, or absence of endoleaks. CECT was used as the gold standard, against which the sensitivity and specificity of CDUS in endoleak detection was determined. Results Sixty-six paired same-day CECT and CDUS reports were compared. Ten endoleaks were identified by CECT (15% incidence) and eight (80%) of 10 were type II. The number of observed agreements was 58 (88%) of 66; CDUS missed six endoleaks (five type II) and suggested two false-positives. CDUS had a sensitivity of 40% and a specificity of 96%. Conclusions: In our study, CDUS demonstrated an excellent specificity but had a low sensitivity for endoleak detection. We agree CDUS cannot effectively replace CECT as the sole imaging modality. Research to determine an international consensus for an effective and efficient postoperative EVAR surveillance patient pathway is required.
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Affiliation(s)
- S Wolstenhulme
- G.16, School of Healthcare, Baines Wing, University of Leeds, Leeds LS2 9JT, UK
| | - Js Froggett
- G.16, School of Healthcare, Baines Wing, University of Leeds, Leeds LS2 9JT, UK
| | - Mj Nicholls
- Department of Radiology, York Teaching Hospital NHS Foundation Trust, York YO31 8HE, UK
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