Incidence and significance of nonaneurysmal-related computed tomography scan findings in patients undergoing endovascular aortic aneurysm repair

Patients with atherosclerotic peripheral arterial disease have a high risk of lung cancer: Systematic review and meta-analysis of literature

PURPOSE

Lung cancer and atherosclerosis share common risk factors. Literature data suggest that the prevalence of lung malignancy in patients with peripheral arterial disease (PAD) is higher than in the general population. Our goal was to determine, through a systematic literature review, the prevalence of lung cancer in patients with PAD.

METHODS

We consulted available publications in the Cochrane library, MEDLINE, PUBMED, EMBASE, and ClinicalTrials.gov. We included all articles, written in English or French, published between 1990 and 2020 reporting the prevalence of lung cancer in patients with PAD (atherosclerotic aortic aneurysm or peripheral occlusive diseases). Patients with coronary artery disease, cardiac valvulopathy or carotid stenosis were not included. We did not include case reports. We performed a critical analysis of each article. Data were collected from two independent readers. A fixed effect model meta-analysis allowed to estimate a summary prevalence rate.

RESULTS

We identified 303 articles, and selected 19 articles according to selection criteria. A total of 16849 patients were included (mean age 68.3 years, 75.1% of males). Aortic aneurysms were found in 29% of patients and atherosclerotic occlusive disease in 66% of patients. Lung cancer was identified in 538 patients, representing a prevalence of 3%.

DISCUSSION

Lung cancer is found in 3% of patients with atherosclerotic PAD. This prevalence is higher than that found in lung cancer screening programs performed in the general population of smokers and former smokers. These patients should be screened for lung cancer. Their selection may dramatically increase the benefit of lung cancer screening.

Late-Onset Malignant Neoplasms and Their Prognostic Factors after Abdominal Aortic Aneurysm Repair

BACKGROUND

Little is known about late-onset primary malignant neoplasms after repair of abdominal aortic aneurysms (AAAs) despite malignancy being one of the primary causes of late death. We investigated the incidence and prognostic factors related to the occurrence of malignancy after AAA repair.

METHODS

We performed a retrospective analysis of 589 patients who underwent AAA repair, including 264 endovascular AAA repairs and 325 open surgical repairs; 482 patients had no history of previous malignancy or concomitant malignancy, 72 had previous malignancy, and 35 had concomitant malignancy in remission at the time of AAA repair. The cumulative incidence rates of late-onset malignancy occurrence and cancer death were estimated using the cumulative incidence function in the presence of competing risks, that is, noncancer death, and prognostic factors were investigated using the Fine-Gray hazard model.

RESULTS

After hospital discharge, 128 malignancies occurred in 116 patients. Overall cumulative incidence rates of late-onset malignancy occurrence at 1, 3, 5, and 10 years were 4.0%, 11.7%, 18.2%, and 38.1%, respectively. Multivariate analysis revealed that significant prognostic factors for late-onset malignancy included history of previous malignancy, current smoker, higher intraoperative blood loss, absence of allogeneic blood transfusion, lower C-reactive protein levels, and lower serum high-density lipoprotein-cholesterol levels. The type of surgical procedures for AAA repair did not affect the occurrence of malignancy. In addition, current smoker and higher intraoperative blood loss significantly increased the risk of cancer death.

CONCLUSIONS

Current smoker and higher intraoperative blood loss were independent risk factors for late-onset malignancy after AAA repair. Late-onset malignancy after AAA repair should be monitored among patients at high risk and requires aggressive management to improve long-term survival.

There Is Limited Value in the One Month Post Endovascular Aortic Aneurysm Repair Surveillance Computed Tomography Scan

BACKGROUND

Endovascular aortic aneurysm repair (EVAR) is the preferred first-line treatment for abdominal aortic aneurysms. Current postprocedure surveillance recommendations by manufacturers are a 1-month computed tomography angiography (CTA) followed by a 12-month CTA in most circumstances. The objective of this study is to determine the utility of the 1-month CTA following elective EVAR and determine if initial surveillance at 6-month CTA is appropriate.

METHODS

A single-center retrospective chart review of all elective EVARs at a tertiary medical center over a 12-year period was conducted. Patients were excluded if postoperative surveillance imaging was not available. Data analysis encompassed demographics, chart review, and imaging including angiogram and cross-sectional imaging to asses for endoleaks and other findings.

RESULTS

There were 363 patients who underwent elective EVAR and had available postoperative imaging during the study period. Within the 1-month follow-up, a CTA group of 316 patients was detected with 98 (31%) endoleaks. Of these, 5 (1.5%) required intervention: 1 for infolding of an iliac limb and 4 for type I endoleak which was present on completion angiogram-3 in patients treated outside of instructions for use and 1 with a type Ib endoleak on intraoperative completion imaging. In the 158 patients with 1 and 3-month CTAs, there were 47 persistent endoleaks, 9 previously undetected endoleaks not seen in 1-month CTA, and 13 resolved endoleaks. Three patients (1.2%) underwent intervention for type II endoleak and aneurysm expansion. In 47 patients with only a 6-month CTA, there were 16 endoleaks not seen on completion angiography and 2 of which were treated with reintervention-1 for a type I endoleak and 1 for a type II endoleak.

CONCLUSIONS

There is limited utility to 1-month surveillance CTA in patients undergoing elective EVAR within the device instructions for use that has no evidence of type I endoleak on completion angiography. It is safe to start routine EVAR surveillance at 6 months in this patient population. This has implications when considering bundled and value-based payments in the longitudinal care of abdominal aortic aneurysm patients.

Incidental extravascular findings in CT angiograms in patients post endovascular abdominal aortic aneurysm repair: clinical relevance and frequency

Background

To evaluate the incidence and clinical relevance of extravascular incidental findings (EVIF), particularly malignancies, in planning and follow-up CT angiograms (CTA) of the abdominal aorta in patients who underwent endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm. Retrospective study of 2203 planning and follow-up CTAs of 418 patients who underwent EVAR in a single tertiary centre between 2006 and 2015. CTA reports were scrutinized for EVIFs, which were classified according to clinical relevance, into (I) immediate, (II) potential and (III) no clinical relevance. Clinical follow-up and management were reviewed for significant findings. Follow-up CTAs of patients with incidental malignancies were re-reviewed by two consultant radiologists to evaluate if early missed malignant findings on previous CTAs were present.

Results

In total, 950 EVIFs were noted in 418 patients [31 females (7.4%), 387 males (92.6%); age range 63–93, mean age 79.0 years]. The number of patients with findings in each category were; Category I (115), Category II (165), Category III (304). Incidental malignant findings were reported in 51 patients (12.2%), of which 27 were noted on the initial CTA (6.5%) and 24 on follow-up CTAs (5.7%). Of the 24 patients with malignancies on follow-up CTAs, 13 had early malignant findings missed or misinterpreted on previous CTAs, while 11 had no significant abnormality even on retrospective review.

Conclusion

A high number of significant EVIFs, particularly incidental malignancies, can be identified in follow-up CTAs of patients who undergo EVAR. Specific ‘review areas’ when reporting surveillance CTAs can be recommended based on the findings of our study.

Split-bolus intravenous contrast material injection vs. single-bolus injection in patients following endovascular abdominal aortic repair (EVAR)

PURPOSE

To investigate the feasibility and accuracy of a split-bolus contrast injection CTA (SB-CTA) compared to a single-bolus injection CTA (SI-CTA) protocol of post-EVAR patients.

MATERIALS AND METHODS

In this IRB-approved study, patients who underwent SB-CTA and SI-CTA after EVAR were evaluated. Attenuation and contrast-to-noise ratio (CNR) of vessels and parenchymal organs were assessed. Subjective enhancement of vessels, quality of 3D reconstructions, and enhancement phase of parenchymal organs were assessed by two independent readers. Endoleak visibility and incidental findings were evaluated.

RESULTS

Fifty-six patients with SB-CTA and SI-CTA at two different time points after EVAR were included in the study (112 imaging studies, mean age 75 ± 9 years). There was no difference in attenuation and CNR for aorta between SB-CTA and SI-CTA (310 ± 87 vs. 311 ± 80 HU, p = 0.88; 31.1 ± 12.6 vs. 29.0 ± 12.2, p = 0.20), although both were improved in the venous structures and parenchymal organs with SB-CTA (portal vein: 149 ± 33 vs. 88 ± 32 HU, 11.6 ± 5.6 vs. 4.3 ± 3.4; liver: 91 ± 19 vs. 68 ± 20 HU, 4.4 ± 2.8 vs. 2.1 ± 2.0; pancreas: 108 ± 27 vs. 82 ± 23 HU, 6.4 ± 3.1 vs. 3.6 ± 2.4; p < 0.0001). Subjectively, enhancement of veins, liver, spleen, bowel, and kidneys was improved (p < 0.001), while there was no difference for the aorta (p = 0.46) and 3D reconstructions (p = 0.58). None of the 18/56 (32.1%) endoleaks was missed with the SB-CTA. More incidental findings were detected with SB-CTA (158/56) compared to SI-CTA (135/56), p < 0.001. SB-CTA was able to adequately characterize 7/15 (47%) of the findings that needed further evaluation in SI-CTA. 4/15 (26%) incidental findings that were missed with SI-CTA but seen with SB-CTA required further evaluation.

CONCLUSION

Split-bolus injection CTA in the follow-up of EVAR patients allows reliable visualization of endoleaks with improved subjective and objective image quality.

The prevalence and significance of thoracic findings in patients undergoing extended coverage computed tomography for assessment of abdominal aortic aneurysms

OBJECTIVE

Many major vascular centres, including ours, incorporate coverage of the thoracic aorta in CT scans evaluating abdominal aortic aneurysms (AAAs) (extended coverage contrast-enhanced CT (EC-CECT) scan]. We sought to determine the prevalence of thoracic pathology in a large consecutive series of patients with AAA undergoing EC-CECT.

METHODS

All patients who underwent EC-CECT for AAA between April 2013 and 2014 were identified from our radiology information system. Reports were retrospectively reviewed and for each study, sex, age and reported thoracic aortic and other non-vascular findings were extracted. Findings were initially categorized into "major" or "minor" depending on if they were mentioned in the report impression/conclusion. Any major thoracic pathology was termed "significant" if there was a new diagnosis/patient intervention/investigation and a change in patient management.

RESULTS

Of the 150 scans included in the study, 97 (65%) had at least one thoracic finding. These findings included 24 scans (16%) with major findings and 73 scans (48%) with minor findings. In 13 scans (9%), the findings were significant and resulted in a delay (n = 11) or cancellation (n = 2) of AAA repair.

CONCLUSION

Pre-procedural EC-CECT helps to identify significant intrathoracic findings in patients with AAA, which can have a major impact on AAA repair. This study supports the routine use of pre-procedural EC-CECT in planning AAA repair.

ADVANCES IN KNOWLEDGE

This study describes the prevalence of significant thoracic pathology, which can impact on AAA repair. This information could potentially change the pre-procedure imaging protocol for patients with AAA.

Postoperative CT Evaluation After EVAR

Purpose: To compare the postoperative computed tomography angiography (CTA) assessment made by vascular surgeons and interventional radiologists after endovascular aneurysm repair (EVAR) at a tertiary vascular clinic to an outside core review facility. Methods: One hundred patients (mean age 78.7 years, range 88–55; 84 men) with consecutive, elective, routine CTA controls after EVAR were retrospectively studied. Consultant vascular surgeons or radiologists had evaluated all original scans and written the original report. All scans were then reevaluated by an independent core clinic. Findings were classified as vascular or extravascular and stratified as clinically significant or clinically nonsignificant by an independent external reviewer. Results: The number of vascular findings detected by the vascular clinic was 72 vs 69 by the core clinic. The vascular clinic reported more clinically significant findings (primarily stent compression or kinks) as well as endoleaks and their origin. The core clinic reported more pseudoaneurysms (24 vs 12). None of the patients with puncture complications needed reintervention. Interrater analysis of all findings between the 2 clinics showed good agreement when comparing endoleaks overall (without subclassification) and moderate agreement when assessing aneurysm growth. The core clinic reported extravascular findings in 58 patients; 37 of these were classified as clinically significant. The vascular clinic reported extravascular findings in 23 patients; 7 of these were clinically significant. The core clinic also reported 2 cases of suspected malignancies, which had not been reported by the vascular clinic. Conclusion: During routine CTA follow-up after EVAR, a significant number of vascular and nonvascular findings are detected. Whereas a highly dedicated vascular clinic identifies most vascular findings regardless of the specialty of the reader, some extravascular findings are missed. However, the frequency of clinically significant findings or findings that might warrant reintervention was low in this study.

Two-year survival of patients screened for transcatheter aortic valve replacement with potentially malignant incidental findings in initial body computed tomography

Aims

Recently, transcatheter aortic valve replacement (TAVR) has evolved as the standard treatment in patients with inoperable aortic valve stenosis. According to TAVR guidelines, body computed tomography (CT) is recommended for pre-procedural planning. Due to the advanced age of these patients, multiple radiological potentially malignant incidental findings (pmIFs) appear in this cohort. It is unknown how pmIFs influence the decision by the heart team to intervene and the mortality.

Methods and results

We evaluated in a retrospective single-centre observational study 414 participants screened for TAVR with dual-source CT between October 2010 and December 2012. pmIFs are common and appeared in 18.7% of all patients screened for TAVR. The decision to intervene by TAVR or surgical aortic valve replacement (SAVR) was made by an interdisciplinary heart team and the role of pmIF in decision-making and time to treatment with TAVR or SAVR was analysed, retrospectively. The appearance of a pmIF vs. no pmIF did not significantly influence therapeutic decisions [odds ratio (OR) 1.14; P = 0.835] or time to treatment (91 ± 152 vs. 61 ± 109 days, respectively). Several findings, which are highly suspicious for malignancy, were less likely associated with invasive treatment (OR 0.207; P = 0.046). Patient survival was evaluated for at least 2 years until January 2014. Two-year survival of patients after TAVR or SAVR, treated according to the heart team decision, was ∼75% and independent from the presence of a non-severe (P = 0.923) or severe (P = 0.823) pmIF.

Conclusion

The study indicates that frequently occurring radiologic pmIF did not influence 2-year survival after a decision to intervene was made by an interdisciplinary heart team.

Incidental findings in computed tomographic angiography for planning percutaneous aortic valve replacement: advanced age, increased cancer prevalence?

BACKGROUND

Increased age is linked with a higher cancer risk according to model calculations. Patients with severe atherosclerotic aortic stenosis are of old age, therefore, a high incidence of malignancies should be found.

PURPOSE

To evaluate the prevalence of clinically significant and potentially malignant incidental findings at computed tomographic angiography (CTA) performed in patients with severe aortic stenosis being assessed as to their suitability for transcatheter aortic valve replacement (TAVR).

MATERIAL AND METHODS

Between August 2008 and April 2010, CTA of the thoraco-abdominal aorta and the pelvic arterial vessels was performed in 131 patients. There were 62 women (47%) and 69 men (53%); the mean age was 81.6 years (range, 64-91 years). Incidental findings were recorded and categorized as potentially malignant, clinically significant, and clinically insignificant. Clinically significant findings were defined as those requiring immediate therapy, intervention or imaging, or follow-up examination.

RESULTS

Of the 131 study patients, 31 (23.7%) presented significant extravascular incidental findings, 19 (14.5%) in the thorax, and 12 (9.2%) in the abdomen. Five lesions (3.8%) were considered potentially malignant, three of them (2.3%) were new and highly suspicious for malignancies (two renal cell carcinomas and one hepatocellular carcinoma). In two patients (1.5%) mediastinal lymphadenopathy was found (recurrent malignant lymphoma und new metastases from known bladder cancer).

CONCLUSION

The prevalence of highly suspicious malignant incidental findings in patients undergoing TAVR is 3.8% with an average age of 81.6 years which is not high compared to prevalence in the literature dealing with patients aged <70 years.

Incidental Findings on Routine Thoracoabdominal Computed Tomography in Blunt Trauma Patients

BACKGROUND:: Thoracoabdominal MultiDetector-row Computed Tomography (MDCT) is frequently used as a diagnostic tool in trauma patients. One potential side-effect of performing MDCT is the detection of incidental findings and their subsequent consequences on medical treatment. The objective was to evaluate frequency and effects of incidental findings in trauma patients. METHODS:: The reports of 1,047 consecutive blunt trauma patients (mean age, 40 years) who underwent routine contrast-enhanced thoracoabdominal MDCT were evaluated. Incidental findings were categorized by a trauma radiologist into four hierarchic categories based on their clinical consequences. We recorded additional diagnostic workup and treatment performed in conjunction with these incidental findings. RESULTS:: Of the 1,047 patients, 372 (mean age, 56 years; 61% male) had one or more incidental findings on thoracoabdominal MDCT. Complementary investigation or therapy was performed in 72 of these 372 patients; 29 of these patients required additional invasive evaluation or treatment. Nineteen patients underwent surgery due to an incidental finding. Nine patients were diagnosed with a not previously identified malignancy. CONCLUSIONS:: Routine thoracoabdominal MDCT in the evaluation of trauma patients revealed a significant number of incidental findings. Based on radiologic findings it is possible to decide whether additional follow-up or treatment is necessary.

Pre-uterine artery embolization MRI: beyond fibroids

Uterine leiomyomata, or fibroids, although benign, cause debilitating symptoms in many women. Symptoms are often nonspecific and may be the presenting complaint in a number of other conditions. Furthermore, because the presence of fibroids may be coincident with other symptomatic conditions that result in similar complaints, there may be diagnostic difficulty and consequent difficulty in planning therapeutic strategy. Uterine artery embolization (UAE) is a safe and effective treatment for symptomatic fibroids and is increasingly being performed. Magnetic resonance imaging (MRI) evaluation before and after treatment is routine practice with the potential to significantly alter management in up to a fifth of patients. It is well recognized that significant incidental findings may be demonstrated during imaging investigations, and in particular that abnormalities that are not directly related to the clinical question may be overlooked. Radiologists evaluating pre-UAE MRI studies must be aware of the MRI appearances of gynecological pathologies that may cause similar symptoms or that may affect the success or complication rates of UAE, and they must also be wary of "satisfaction of search," reviewing imaging thoroughly so that relevant other pathologies are not missed. We demonstrate the appearances of coincidental pathologies found on pre-UAE MRI, with the potential to change patient management.

Computed tomography for the diagnosis and management of abdominal aortic aneurysms

Computed tomography (CT) is useful in the detection and diagnosis of abdominal aortic aneurysms (AAA). Rupture risk can be assessed by accurately measuring diameter, tortuosity, thrombus extent, and wall stress. CT can aid in accurately determining anatomic variants as well as AAA etiology. Evaluation for surgical intervention is made by close examination of AAA morphology and specific anatomic features.

Prevalence of extravascular collateral findings during 64-slice CT angiography of the abdominal aorta and lower limbs

PURPOSE

The aim of this study was to assess the prevalence of extravascular collateral findings during 64-slice CT angiography of the abdominal aorta (AA-CTA) and lower limbs (LL-CTA).

MATERIALS AND METHODS

The images of 536 AA-CTA and LL-CTA examinations performed for suspected aortic and peripheral vascular disease in 500 patients were retrospectively reviewed. Two radiologists evaluated the 5-mm axial images independently using appropriate window settings for the area under investigation. Collateral findings were divided according to their clinical significance into significant, nonsignificant and meriting further investigation.

RESULTS

No collateral findings were identified in 97/500 patients (19.4%). In the remaining patients, 821 collateral findings were detected, of which 43 (5.24%) were classified as significant, 135 (16.44%) as meriting further investigation and 643 (78.32%) as nonsignificant. The findings indicative of the presence of a malignant lesion totalled 36 (4.5%).

CONCLUSIONS

AA-CTA and LL-CTA demonstrate a nonnegligible prevalence of collateral findings, many of them major. It therefore appears that the evaluation should focus not only on the image reconstructions to identify vascular disease, but also on the native axial images to detect incidental findings.

Is there a benefit of frequent CT follow-up after EVAR?

OBJECTIVE

Imaging follow-up (FU) after endovascular aneurysm repair (EVAR) is usually performed by periodic contrast-enhanced computed tomography (CT) scans. This study aims to evaluate the effectiveness of CT-FU after EVAR.

METHODS

In this study, 279 of 304 consecutive patients (261 male, aged 74 years (interquartile range (IQR): 70-79 years) with a median abdominal aortic aneurysm (AAA) diameter of 58 mm (IQR: 53-67 mm)) underwent at least one of the yearly CT scans and plain abdominal films after EVAR. All patients received Zenith stent-grafts for non-ruptured AAAs at a single institution. Patients were considered asymptomatic when a re-intervention was done solely due to an imaging FU finding. The data were prospectively entered in a computer database and retrospectively analysed.

RESULTS

As a follow-up, 1167 CT scans were performed at a median of 54 months (IQR: 34-74 months) after EVAR. Twenty-seven patients exhibited postoperative AAA expansion (a 5-year expansion-free rate of 88+/-2%), and 57 patients underwent 78 postoperative re-interventions with a 5-year secondary success rate of 91+/-2%. Of the 279 patients, 26 (9.3%) undergoing imaging FU benefitted from the yearly CT scans, since they had re-interventions based on asymptomatic imaging findings: AAA diameter expansion with or without endoleaks (n=18), kink in the stent-graft limbs (n=4), endoleak type III due to stent-graft limb separation without simultaneous AAA expansion (n=2), isolated common iliac artery expansion (n=1) and superior mesenteric artery malperfusion due to partial coverage by the stent-graft fabric (n=1).

CONCLUSIONS

Less than 10% of the patients benefit from the yearly CT-FU after EVAR. Only one re-intervention due to partial coverage of a branch by the stent-graft would have been delayed if routine FU had been based on simple diameter measurements and plain abdominal radiograph. This suggests that less-frequent CT is sufficient in the majority of patients, which may simplify the FU protocol, reduce radiation exposure and the total costs of EVAR. Contrast-enhanced CT scans continue, nevertheless, to be critical when re-interventions are planned.