Ombretta Martinelli. UOC di Chirurgia Vascolare Policlinico Umberto I Università degli Studi di Roma Sapienza
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1 Ombretta Martinelli UOC di Chirurgia Vascolare Policlinico Umberto I Università degli Studi di Roma Sapienza
2 Ombretta Martinelli has no financial arrangement or other relationship that could be constructed as conflict of interest
3 Contemporary research suggests that, unlike open abdominal aortic aneurysm repair, EVAR requires vigilant post-implantation monitoring to rescue device failure
4 Cochrane Database of Systematic Reviews of EVAR Trials -2014
5 Endoleaks have been referred to as the Achilles heel of EVAR and is found in 20-40% during follow-up
6 Contrast-enhanced CT is still the current imaging standard after EVAR Anyhow, contrast-induced nephropathy, cumulative radiation exposure and cost are great concerns in lifelong CT surveillance
7 This has led to several cohort analyzes to evaluate the diagnostic reliability of ultrasounds (DUS and CEUS) for the post-evar surveillance
8 Assuming CTA to be a gold standard, sensitivity, specificity of 2D CEUS to detect endoleaks were 100% and 92%, respectively
9 Our experience 48 cases CTA gold standard CEUS (SonoVue) Endoleak (yes) Endoleak (no) CTA Type 2 Endoleak (yes) CTA Type 2 Endoleak (no) Sensitivity 96% Specificity 92%
10 All endoleaks directed for re-intervention by CTA were also detected by CEUS. Endoleaks detected by CTA but missed by CEUS either resolved or were insignificant in provoking sac expansion EVAR surveillance protocols can be carried out safely with CEUS
11 CT arterial phase Due to the dynamic nature, CT venous phase with a delay of 240 s it is likely that those endoleaks detected by CEUS are true leaks missed by CTA having a static nature
12 Our experience 23 treated endoleaks DSA gold standard Imaging modality True positives False positives False negatives True negatives Sensitivity Specificity DUS % 66.6% CEUS % 100% CTA % 100%
13 Compared with CTA or MRA, CEUS appears to have equal specificity and superior sensitivity to identify endoleaks
14 CT angiography cannot appreciate blood flow direction, limiting its specificity for classification of the endoleaks
15 Due to its real-time dynamic nature, CEUS provides a better classification of endoleaks than CTA It also allows to get data to forsee their outcome and to identify those ELs causing sac growth
16 CEUS can evaluate delay of endoleak detection (wash-in) disappearance (wash-out) from the beginning of contrast injection
17 the hyperdynamic endoleaks show a fast wash-in and wash-out due to the presence of inflow and outflow vessels These endoleaks may thrombose spontaneously, without increasing the aneurysm sac
18 The absence of an outflow artery (slow wash-out) identify the hypodynamic endoleaks These slow-flow endoleaks are not able to create a way out from the sac, thus causing aneurysm pressurization and progressive enlargement, independently from endoleak volume and extension They can be missed by CTA
19 CEUS can evaluate those parameters predicting aneurysm sac enlargement Bidirectional spectral Doppler waveform Cavity filling (spreading of the contrast medium within the thrombus, without concentration in a nidus of the sac) These EL characteristics suggest more frequent EVAR surveillance and are at high risk of reintervention
20
21 The 3D-CEUS achieves multiplanar reconstructions ensuring that adjacent vessels are not mistaken for endoleaks It allows confident identification and classification of even small leaks and more accurate measurements of sac diameters
22 Conclusive remarks CEUS is relatively cheap, quick to perform, and has infrequent risks to the patient CEUS seems to be at least equal or even superior to CTA and can be a first-line diagnostic tool to detect and classify endoleaks The specific value of CEUS is the detection of those endoleaks at higher risk of adverse outcomes with more certainty than CTA
23 Conclusive remarks CEUS shares limitations of all ultrasound studies: operator dependency and patient s habitus and even for highly experienced sonographers, the suprarenal area remains challenging Multiphasic CT should be used when ultrasound modalities are not diagnostics due to an unfavorable anatomy and for reintervention plannning
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Measure #347 (NQF 1534): Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non- Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital National Quality Strategy Domain:
Bifurcated system Proximal suprarenal stent Modular (aortic main body and two iliac legs) Full thickness woven polyester graft material Fully
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Physician s Vascular Interpretation Examination Content Outline
Physician s Vascular Interpretation Examination Content Outline (Outline Summary) # Domain Subdomain Percentage 1 2 3 4 5 6 Cerebrovascular Abdominal Peripheral Arterial - Duplex Imaging Peripheral Arterial
Chimney endovascular aneurysm sealing (ch-evas) for ruptured abdominal aortic aneurysms (AAA) due to type Ia endoleak following failed EVAS
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CT of Acute Thoracic Aortic Syndromes Stuart S. Sagel, M.D.
CT of Acute Thoracic Aortic Syndromes Stuart S. Sagel, M.D. Thoracic Aortic Aneurysms Atherosclerotic Dissection Penetrating ulcer Mycotic Inflammatory (vasculitis) Traumatic Aortic Imaging Options Catheter
When to use standard EVAR with EndoAnchors or CHEVAR in short-neck AAAs LINC ASIA 18
When to use standard EVAR with EndoAnchors or CHEVAR in short-neck AAAs JEAN-PAUL P.M. DE VRIES, DIRECTOR OF VASCULAR SURGERY ST.ANTONIUS HOSPITAL NIEUWEGEIN, THE NETHERLANDS. LINC ASIA-PACIFIC HongKong,