The Assessment of Carbon Dioxide Automated Angiography in Type II Endoleaks Detection: Comparison with Contrast-Enhanced Ultrasound

Abstract

Introduction Iodinated contrast media completion angiography (ICM-A) may underestimate the presence of type II endoleak (ELII) after endovascular aortic repair (EVAR), particularly if they are at low flow. Contrast-enhanced ultrasound (CEUS) has been proposed as the gold standard in ELII detection during EVAR follow-up. Intraprocedural carbon dioxide (CO2) angiography has been shown to be useful in this setting; however no comparative studies including these three techniques are currently available. Our aim was to investigate the accuracy of a new automated CO2 angiographic (CO2-A) system in the detection of ELII, by comparing it with ICM-A and CEUS. Methods A series of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) were enrolled and submitted to ICM-A and CO2-A during the procedure. The iodinated contrast media were delivered through an automatic injector connected to a pigtail catheter in the suprarenal aorta. CO2 was delivered through a recently available automatic injector connected to a 10 F sheath positioned in the external iliac artery. All patients were blindly evaluated by CEUS within postoperative day 1. The ICM-A and CO2-A ability to detect ELII was compared with that of CEUS through Cohen's concordance Index (K). Results Twenty-one patients were enrolled in the study. One (5%), seven (33%), and four (19%) ELII were detected by ICM-A, CO2-A, and CEUS, respectively. The only ELII detected by ICM-A was also detected by CO2-A and CEUS. Three cases of ELII detected by CO2-A were not detected by CEUS. All ELII detected by CEUS were visualized by CO2-A. CEUS and ICM-A showed a poor agreement (Cohen's K: 0.35) while CEUS and CO2-A showed a substantial agreement (Cohen's K: 0.65) for ELII detection. Conclusion CO2-A is safe and effective method for ELII detection in EVAR, with a significantly higher agreement with CEUS if compared with ICM-A. This trial is registered with 155/2015/U/Oss.

Type III B endoleak leading to aortic rupture after endovascular repair: analysis of errors in follow up and treatment

“…In case of media-contrast allergy alternative contrast agents, like carbon dioxide and gadolinium, have also been evaluated and can be used in specific cases. In particular carbon dioxide with its low viscosity seems to be effective for endoleak diagnosis and may be proposed in alternative to iodine contrast in case of allergies (Nadolski & Stavropoulos, 2013; Mascoli et al, 2018).…”

“…Other cases describe a hybrid technique with aortomonoiliac endograft (Endurant II, Medtronic, or Zenith Renu, Cook) following a femoro-femoral crossover bypass. (Mascoli et al, 2018; Van der Vliet et al, 2005; Lee et al, 2006; Kansal & Nagpal, 2016) and one case reports a tentative of complete relining (Excluder, Gore) which was converted to aortouni-iliac configuration with a plug, due impossibility to cannulate contralateral gate. (Wanhainen et al, 2008) In another case where the type III B endoleak was coming from the proximal part of the ipsilateral iliac limb (Excluder, Gore) approximately 1 cm inferior to the top of the flow divider and it was treated with an iliac extension of the same type (Banno et al, 2012).…”

“…Open repair is found in some series as urgent treatment after aortic rupture, (Becquemin et al, 2002) or as treatment of recurrent type III endoleak after a first endovascular attempt. (Mascoli et al, 2018) In another series open repair was indicated for patients with symptomatic endoleaks not amenable to endovascular repair or after unsuccessful endovascular attempts, (Perini et al, 2017) in one case no secondary endograft could be placed because of the size of the neck of the aorta, and open repair was necessary. (Beebe et al, 2001) Bequemin et al report an open conversion due to the size of the aneurysm, the failure of numerous previous closure attempts, and the uncertain origin of the leak (Juszkat et al, 2009).…”

Use of carbon dioxide for therapeutic decision-making in endoleaks: a case report

“…In this situation, carbon dioxide (CO 2 ) represents an alternative method that can solve the problem. 6 We conducted a literature review and were unable to find any papers reporting use of CO 2 as being crucial for the decision on how to treat an endoleak. 7 We report a case in which an endoleak identified after EVAR was defined as type III by computed tomography angiography (CTA) and contrast-enhanced ultrasound (CEU).…”

“…In this situation, carbon dioxide (CO 2 ) represents an alternative method that can solve the problem. 6 …”