Diagnostic imaging methods applied in long-term surveillance after EVAR. Will computed tomography angiography be replaced by other methods?

Stefaniak, Karolina; Stanišić, Michał; Gabriel, Marcin; Oszkinis, Grzegorz

doi:10.5114/pwki.2016.56943

Cited by 3 publications

(12 citation statements)

References 56 publications

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“…Moreover, threedimensional reconstructions with the centerline should be obtained from CTA scans to identify stent breakage. 5,23 These can also be found by careful evaluation of plain radiographs of the graft, 31,32 although overlapping stents can sometimes render the fractures difficult to ascertain. Although digital subtraction angiography is the most accurate method to differentiate the types of endoleaks, it is generally not used because it is invasive.…”

Section: Discussionmentioning

confidence: 99%

A preliminary analysis of late structural failures of the Navion stent graft in the treatment of descending thoracic aortic aneurysms

Verzini

Cieri

Kahlberg

et al. 2021

Journal of Vascular Surgery

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Objective: Patients in the Valiant Evo U.S. and international clinical trials had positive short-term outcomes; however, late structural failures, including type IIIb endoleaks have been recently discovered. Type IIIb endoleaks are serious adverse events because the repressurization of the aneurysm sac increases the risk of rupture. The purpose of the present study was to detail the imaging patterns associated with the structural failures with the aim of increasing awareness of failing graft presentation, early recognition, and prompt treatment.Methods: The Valiant Evo clinical trial was a prospective, single-arm investigation of a thoracic stent graft system. With the recent late structural failures, sites were requested to submit all available imaging studies to date to allow the core laboratory to assess for structural failures such as type IIIb endoleaks, stent ring fractures, and stent ring enlargement. Of the 100 patients originally enrolled in the trial from 2016 to 2018, the core laboratory assessed the imaging studies performed at $1 year for 83 patients.Results: No structural failures of the graft were reported through 1 year of follow-up. At 1 to 4 years, graft structural failures were detected in 11 patients with descending thoracic aortic aneurysms. Of the 11 patients, 5 had a type IIIb endoleak. Four of the five had imaging findings showing stent fractures consistent with the location of the graft seam and one had a type IIIb endoleak attributed to calcium erosion with no stent fracture or ring enlargement. Of the four patients with stent fracture in line with the graft seam, three underwent a relining procedure that successfully excluded the type IIIb endoleak. One of these three patients died 4 days later of suspected thoracic aortic rupture because the distal thoracic endovascular aortic repair extension had been landed in a previously dissected and fragile section of the aorta. The remaining six patients had had stent ring enlargement. One of the six patients had had persistent aneurysm expansion from the time of implantation onward and had died of unknown causes. The remaining five patients have continued to be monitored. Conclusions:In the present preliminary analysis, the imaging patterns associated with type IIIb endoleaks, stent fractures, and stent ring enlargement appear to be related to the loss of seam integrity or detachment of the stent rings from the surface of the graft material. The imaging patterns we have detailed should be closely monitored using computed tomography angiography surveillance to allow structural failures to be promptly identified and treated.

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Section: Discussionmentioning

confidence: 99%

A preliminary analysis of late structural failures of the Navion stent graft in the treatment of descending thoracic aortic aneurysms

Verzini

Cieri

Kahlberg

et al. 2021

Journal of Vascular Surgery

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“…Moreover, it enables rapid and reproducible acquisition of data (ensuring homogeneous results among institutions) with high diagnostic value. CTA also provides superior information related to the stent graft, such as patency, the presence of endoleaks and their type, anchoring, or kinking [10, 11]. …”

Section: Discussionmentioning

confidence: 99%

“…Some researchers suggest that CDUS can be used for the follow-up of patients after EVAR [6–8]. In turn, other authors state that CDUS alone is insufficient for endoleak identification in routine clinical practice [9–11]. …”

mentioning

confidence: 99%

Superb Micro-vascular Imaging (SMI): a Doppler ultrasound technique with potential to identify, classify, and follow up endoleaks in patients after Endovascular Aneurysm Repair (EVAR)

et al. 2018

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PurposeThe aim of the study was to assess the effectiveness of Superb Micro-vascular Imaging (SMI) as an alternative to Contrast-Enhanced Ultrasound (CEUS) and Computed Tomography Angiography (CTA) for endoleak detection and classification in patients followed up after endovascular abdominal aortic aneurysm repair (EVAR).Materials and methodsFrom May 2015 to January 2017, 30 patients underwent post-EVAR follow-up with Color Doppler Ultrasound (CDUS), CEUS, SMI, and CTA examinations. Aneurysmal sac diameter and graft patency were evaluated; endoleaks were identified and classified. Sensitivity, specificity, and accuracy values were calculated for each of the four diagnostic methods of endoleak detection. A percentage of agreement and Cohen’s Kappa coefficient were calculated for comparison of methods in terms of endoleak identification.ResultsCTA revealed fifteen endoleaks (50%): three type Ia, nine type II, and three type III. The sensitivity of CDUS, CEUS, and SMI relative to CTA was 27%, 100%, and 100%, respectively. Specificity was 93%, 93%, and 93%, respectively. Accuracy was 60%, 97%, and 97%, respectively. There were no differences between SMI and CEUS in terms of sensitivity, specificity, or accuracy (100%, 93%, and 97%). We do not observe statistically significant differences between CTA, CEUS, and SMI concerning endoleak identification ability. The weakest method in endoleak identification was CDUS.ConclusionsThe analysis showed that SMI is effective, repeatable, and comparable with the CEUS modality in identification endoleaks after EVAR; it may be considered as a potential tool to monitor patients after EVAR implantation, especially those with renal insufficiency or with an allergy to any contrast media.

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“…While CDUS has a positive predictive value as low as 42%, 19 it consistently performs with a high specificity, approaching 99% 7,9,12,14,16,20 and a negative predictive around 94-100%. 15,19 Colour duplex ultrasonography deserves a spotlight for several other reasons.…”

Section: Duplex Ultrasonographymentioning

confidence: 93%

“…This phenomenon has been supported in the literature in a number of individual studies and reviews. 9,13,15,20 Further, CTA is less accurate in classifying the type of endoleak than duplex or CEUS. 19,29 It is unclear whether the type of CTA protocol has an impact on the accuracy of the CTA in classifying the type of endoleak.…”

Section: Computed Tomography Angiographymentioning

confidence: 99%

Imaging modalities for endoleak surveillance

Williams

2021

J of Medical Radiation Sci

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As the global population ages, the issue of abdominal aortic aneurysm continues to grow. With the evolution of new devices and refined operative technique, aneurysm treatment via endovascular aortic repair is becoming increasingly favourable. This, however, is not without drawbacks, where regular surveillance is paramount to long-term success and detection of post-procedure complications. Of these complications, endoleak is the most notable and poses the greatest risk of potential future aortic rupture. The purpose of this review paper is to discuss the armada of imaging modalities used in the detection and evaluation of endoleak and their varying usefulness. Plain abdominal X-ray is a cost-effective tool in detecting gross graft abnormalities such as stent migration or deformity (kinking or fracture). Though it may raise suspicion for endoleak, X-ray does not allow accurate classification of endoleak type when used alone. Duplex ultrasonography quantifies both aortic anatomy and real time flow dynamics. Most screening programmes are conducted using two-dimensional ultrasound. Unfortunately, observer and equipment variability may lead to surveillance discrepancies-but reduced when utilising a dedicated vascular sonography laboratory. Contrast enhanced ultrasonography is a promising alternative to computed tomography, though still is emerging. Computed tomography angiography certainly has disadvantages (ionising radiation, contrast-nephropathy, limited differentiation of endoleak type)-however, it provides near-real surgical dimensions and highlights graft complications and concomitant disease (such as neighbouring infection). With widespread availability and short scan time, it certainly remains valuable in surveillance. Magnetic resonance angiography has a similar sensitivity to computed tomography (minus the radiation), however is plagued by movement and metal artefact. Other novel modalities in endoleak surveillance include fourdimensional ultrasound, multiplanar intra-operative probes, nuclear medicine and wall stress analysis.

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Diagnostic imaging methods applied in long-term surveillance after EVAR. Will computed tomography angiography be replaced by other methods?

Cited by 3 publications

References 56 publications

A preliminary analysis of late structural failures of the Navion stent graft in the treatment of descending thoracic aortic aneurysms

A preliminary analysis of late structural failures of the Navion stent graft in the treatment of descending thoracic aortic aneurysms

Superb Micro-vascular Imaging (SMI): a Doppler ultrasound technique with potential to identify, classify, and follow up endoleaks in patients after Endovascular Aneurysm Repair (EVAR)

Imaging modalities for endoleak surveillance

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