Comparison of Three Workstations For Abdominal Aortic Aneurysm Sizing: Impact in Decision Making and Graft Selection

PURPOSE

The aim of this study was to assess the agreement of multiplanar reconstruction (MPR) and semiautomated central lumen line (CLL) analysis of abdominal aortic aneurysms (AAA), with 3 different software workstations (WS1, WS2, WS3) and 2 experienced practitioners as well as to analyze its eventual impact in graft selection.

MATERIALS AND METHODS

Twenty computed tomography (CT) angiography data sets were randomly chosen from a series of 100 consecutive studies. Measurements were performed twice by each reader, in random order, and included 8 parameters (5 diameters and 3 lengths). Each observer performed a complete set of 60 studies. Intra-observer and interobserver variability for every WS was assessed. Measurements were evaluated using Bland-Altman analysis, correlation coefficients (r), and concordance correlation coefficients (CCC [95% confidence interval (CI)]).

RESULTS

A high overall agreement between repeated measurements for both observers was obtained (r=0.989; CCC=0.988 [0.982-0.992] and r=0.998; CCC=0.996 [0.994-0.997], for observers 1 and 2, respectively). However, reproducibility for individual parameters was excellent for observer 2 and only moderate for observer 1. A high overall agreement was obtained for interobserver concordance (r=0.987; CCC=0.986 [0.982-0.989]). When analyzing for individual parameters, greatest interobserver differences were found at CLL measurement of the diameter of aortic neck (WS2) and bifurcation (WS1 and WS2) as well as iliac diameter in all 3 WS for both CLL and MPR. Similar differences were observed in paired comparison between WS when involving these parameters. Careful inspection of Bland-Altman charts revealed some cases of disagreement between WS and observers that would affect decision making on graft selection, changing the neck diameter to a different size, in 2 cases when measuring with WS1, and iliac diameter in 4 cases (2 of them with WS1 and 2 with WS2). Greatest discordance was observed regarding ipsilateral iliac length affecting 7 measurements that would lead to change the length of the selected limb graft (2 with WS1, 3 with WS2, and 2 with WS3).

CONCLUSIONS

Although a high agreement between different observers using different WS for AAA measurements is to be expected, small differences may lead to the selection of a different graft size. The use of a single software by experienced users, and double check by a different one, may be advisable.

CLINICAL IMPACT

Influence of inter and intraobserver variability in CT measurements during planning of endovascular aneurysm repair (EVAR) has been extensively reviewed. However, its impact in graft selection (final choose of diameter and lengths) has been scarcely analyzed. The results of this study suggest that, although a high agreement between different observers using different workstations for AAA measurements is to be expected, small differences may lead to the selection of a different graft size. The use of a single software by experienced users, and double check by a different one, may be advisable.

Trans-popliteal hybrid retrograde technique for revascularization of chronic total occlusions of the superficial femoral artery

OBJECTIVES

We present the technical description and preliminary results of a hybrid approach for the treatment of chronic total occlusions of superficial femoral artery in the setting of critical limb-threatening ischemia (CLTI).

METHODS

A retrospective analysis of selected case series was performed. A trans-popliteal hybrid technique was carried out in seven limbs (six patients). Open exposure of above-the-knee popliteal artery was performed over its maximum calcification zone. After retrograde recanalization and graft-stenting of the entire superficial femoral artery, endarterectomy of the popliteal artery was performed for debulking and widening of the distal landing zone of the endoprosthesis. The latter is included in the bovine patch suture to avoid leaving a segment untreated.

RESULTS

Technical success, haemodynamic and clinical improvement were achieved in all procedures. Median length of treated occlusion was 19.8 cm. After a mean follow-up of 12 months (range 6-26 months), the primary patency was 85.7% (only one asymptomatic occlusion occurred). There were no major cardiovascular or limb adverse events. No re-interventions were required.

CONCLUSION

This less-invasive, one-incision technique is safe and effective for the restoration of in-line flow from groin to ankle, currently recommended in CLTI revascularization. It could be especially useful in highly calcified popliteal artery lesions, hostile groins or those at high risk of infection and in cases of vein absence for bypass surgery.

Long-term results of intra-arterial onyx injection for type II endoleaks following endovascular aneurysm repair

Purpose

The aim of this paper is to report our experience of type II endoleak treatment after endovascular aneurysm repair with intra-arterial injection of the embolizing liquid material, Onyx liquid embolic system.

Methods

From 2005 to 2012, we performed a retrospective review of 600 patients, who underwent endovascular repair of an abdominal aortic aneurysm. During this period, 18 patients were treated with Onyx for type II endoleaks.

Principal findings

The source of the endoleak was the internal iliac artery in seven cases, inferior mesenteric artery in seven cases and lumbar arteries in four cases. Immediate technical success was achieved in all patients and no endoleak from the treated vessel recurred. During a mean follow-up of 19 months, no major morbidity or mortality occurred, and one-year survival was 100%.

Conclusions

Treatment of type II endoleaks with Onyx is safe and effective over a significant time period.

Reverse Retrograde Approach: An Alternative Method for Ipsilateral Access to the Superficial Femoral Artery

Access for endovascular treatment of the superficial femoral artery (SFA) is usually gained through an antegrade approach from the ipsilateral common femoral artery (CFA), or by crossing over from the contralateral CFA. In this technical note, an alternative method, based on retrograde access of the ipsilateral iliac artery (IA), and conversion into an antegrade approach to the SFA, is described. Successful reverse ipsilateral catheterisation was obtained in 15/16 patients. Calcification of the CFA and IA required a crossover approach in one case. There were no complications related to the technique, except for moderate bleeding in relation to the deployment of a closure device.

Venous giant post-thrombotic chronic ulcer: successful treatment with Bosentan

OBJECTIVE

To report a case of a refractory post-thrombotic chronic venous ulcer managed with an off-label treatment.

METHOD

We present the case of an 82-year-old woman with a previous medical history of severe hypertension and a deep vein thrombosis three years before. A refractory giant chronic venous ulcer in her left leg was treated with Bosentan.

RESULTS

The appearance of the ulcer improved in the first 45 days, worsened after an unintended stop of the treatment and was almost resolved after 90 days of treatment. Ulcer-associated pain improved very quickly and so, in only one week, opioid treatment was stopped. Bosentan treatment was well tolerated, with only mild and manageable side effects.

CONCLUSION

Treatment with Bosentan has been successful in the treatment of this case of refractory chronic venous ulcer.