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Rakemaa L, Aho PS, Tulamo R, Laine MT, Laukontaus SJ, Hakovirta H, Venermo M. Ultrasound Surveillance is Feasible After Endovascular Aneurysm Repair. Ann Vasc Surg 2024; 100:223-232. [PMID: 37926137 DOI: 10.1016/j.avsg.2023.09.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/05/2023] [Accepted: 09/09/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Surveillance after endovascular aneurysm repair (EVAR) is traditionally done with computed tomography angiography (CTA) scans that exposes patient to radiation, nephrotoxic contrast media, and potentially increased risk for cancer. Ultrasound (US) is less labor intensive and expensive and might thus provide a good alternative for CTA surveillance. The aim of this study was to evaluate in real-life patient cohorts whether US is able to detect post-EVAR aneurysm-related complications similarly to CTA. METHODS This retrospective study compared the outcome of consecutive patients who underwent EVAR for intact abdominal aortic aneurysm and were surveilled solely by CTA (CTA-only cohort, n = 168) in 2000-2010 or by combined CTA and US (CTA/US cohort, n = 300) in 2011-2016, as a standard surveillance protocol in the department of vascular surgery, Helsinki University Hospital. The CTA-only patients were imaged at 1, 3, and 12 months and annually thereafter. The CTA/US patients were imaged with CTA at 3 and 12 months, US at 6 months and annually thereafter. If there were suspicion of >5 mm aneurysm growth, CTA scan was performed. The patients were reviewed for imaging data, reinterventions, aneurysm ruptures, and death until December 2018. The 2 groups were compared for secondary rupture, aneurysm-related and cancer-related death, reintervention related to abdominal aortic aneurysm, and maximum aneurysm diameter increase ≥5 mm. The mean follow-up in the CTA-only cohort was 67 months and in CTA/US cohort 43 months. RESULTS The 2 cohorts were alike for basic characteristics and for the mean aneurysm diameter. The total number of CT scans for detecting aneurysm was 84.1/100 patient years in the CTA-only cohort compared to 74.5/100 patient years for US/CTA cohort. Forty percent of patients under combined CTA/US surveillance received 1 or more additional CTA scans. The 2 cohorts did not differ for 1-year, 5-year and 8-year freedom from aneurysm related death, secondary sac rupture, nor the incidence of rupture preventing interventions. CONCLUSIONS Based on the follow-up data of this real-life cohort of 468 patients, combined surveillance with US and additional CTA either per protocol or due to suspicion of aneurysm-related complications had comparable outcome with sole CTA-surveillance. Thus, US can be considered a reasonable alternative for the CTA. However, our study showed also that the need of additional CTAs due to suspicion of endoleak or aneurysm nonrelated reasons is substantial.
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Affiliation(s)
- Lotta Rakemaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Pekka S Aho
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Riikka Tulamo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Matti T Laine
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Sani J Laukontaus
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Harri Hakovirta
- Department of Vascular Surgery, University of Turku and Turku University Hospital, Turku, Varsinais-Suomi, Finland; Department of Surgery, Satasairaala Hospital, Pori, Satakunta, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland.
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Williams AB, Williams ZB. Imaging modalities for endoleak surveillance. J Med Radiat Sci 2021; 68:446-452. [PMID: 34145780 PMCID: PMC8655756 DOI: 10.1002/jmrs.522] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 06/02/2021] [Indexed: 11/25/2022] Open
Abstract
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 four-dimensional ultrasound, multiplanar intra-operative probes, nuclear medicine and wall stress analysis.
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Affiliation(s)
- Aman Berry Williams
- Department of Vascular SurgeryGold Coast University HospitalSouthportQueenslandAustralia
| | - Zoheb Berry Williams
- Department of Vascular SurgeryGold Coast University HospitalSouthportQueenslandAustralia
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Smith L, Thomas N, Arnold A, Bell R, Zayed H, Tyrrell M, Padayachee S. Editor's Choice - A Comparison of Computed Tomography Angiography and Colour Duplex Ultrasound Surveillance Post Infrarenal Endovascular Aortic Aneurysm Repair: Financial Implications and Impact of Different International Surveillance Guidelines. Eur J Vasc Endovasc Surg 2021; 62:193-201. [PMID: 34140226 DOI: 10.1016/j.ejvs.2021.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 03/21/2021] [Accepted: 04/03/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Use of colour duplex ultrasound (CDUS) and computed tomography angiography (CTA) for infrarenal endovascular aortic aneurysm repair (EVAR) surveillance differs in internationally published guidelines. This study aimed firstly to compare CDUS detection of significant sac abnormalities with CTA. Secondly, a sensitivity analysis was conducted to compare financial estimates of the, predominantly CDUS based, local and Society of Vascular Surgery (SVS) protocols, the risk stratified European Society of Vascular Surgery (ESVS) protocol, and the CTA based National Institute of Health and Care Excellence (NICE) protocol. METHODS Agreement between CDUS and CTA was assessed for detection of significant sac abnormalities. Surveillance protocols were extrapolated from published guidelines and applied to infrarenal EVAR patients active on local surveillance at a large, single centre. Surveillance intensity was dependent on presence of endoleak and subsequent risk of treatment failure in accordance with surveillance recommendations. Estimates for each surveillance protocol were inclusive of a range of published incidences of endoleak, contrast associated acute kidney injury (AKI), and excess hospital bed days, and estimated for a hypothetical five year surveillance period. RESULTS The kappa coefficient between CDUS and CTA for detecting sac abnormalities was 0.68. Maximum five year surveillance cost estimates for the 289 active EVAR patients were £272 359 for SVS, £230 708 for ESVS, £643 802 for NICE, and £266 777 for local protocols, or £1 270, £1 076, £3 003, and £1 244 per patient. Differences in endoleak incidence accounted for a 1.1 to 1.4 fold increase in costs. AKI incidence accounted for a 3.3 to 6.2 fold increase in costs. CONCLUSION A combined CTA and CDUS EVAR surveillance protocol, with CTA reserved for early seal assessment and confirmatory purposes, provides an economical approach without compromising detection of sac abnormalities. AKI, as opposed to direct imaging costs, accounted for the largest differences in surveillance cost estimates.
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Affiliation(s)
- Luke Smith
- Ultrasonic Angiology, Guy's Hospital, London, United Kingdom.
| | - Nicholas Thomas
- Ultrasonic Angiology, Guy's Hospital, London, United Kingdom
| | - Andrew Arnold
- Ultrasonic Angiology, Guy's Hospital, London, United Kingdom
| | - Rachel Bell
- Department of Vascular Surgery, St Thomas' Hospital, London, United Kingdom
| | - Hany Zayed
- Department of Vascular Surgery, St Thomas' Hospital, London, United Kingdom
| | - Mark Tyrrell
- Department of Vascular Surgery, St Thomas' Hospital, London, United Kingdom
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Faustino CB, Ventura C, Portugal MFC, Brunheroto A, Teivelis MP, Wolosker N. Experiência inicial com ultrassom Doppler com contraste por microbolhas em adição ao ultrassom Doppler convencional para seguimento de correção endovascular de aneurisma de aorta abdominal. J Vasc Bras 2021; 20:e20200093. [PMID: 35515084 PMCID: PMC9045535 DOI: 10.1590/1677-5449.200093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/11/2020] [Indexed: 12/04/2022] Open
Abstract
Background Microbubble contrast enhanced ultrasound (CEUS) is an accurate diagnostic method for follow-up after endovascular abdominal aortic aneurysm repair (EVAR) that has been well-established in international studies. However, there are no Brazilian studies that focus on this follow-up method. Objectives The objective of this study was to report initial experience with CEUS at a tertiary hospital, comparing the findings of CEUS with those of conventional Doppler ultrasound (DUS), with the aim of determining whether addition of contrast to the standard ultrasonographic control protocol resulted in different findings. Methods From 2015 to 2017, 21 patients in follow-up after EVAR underwent DUS followed by CEUS. The findings of these examinations were analyzed in terms of identification of complications and their capacity to identify the origin of endoleaks. Results There was evidence of complications in 10 of the 21 cases examined: seven patients exhibited endoleaks (33.3%); two patients exhibited stenosis of a branch of the endograft (9.52%); and one patient exhibited a dissection involving the external iliac artery (4.76%). In the 21 patients assessed, combined use of both methods identified 10 cases of post-EVAR complications. In six of the seven cases of endoleaks (85.71%), use of the methods in combination was capable of identifying the origin of endoleakage. DUS alone failed to identify endoleaks in two cases (28.5%) and identified doubtful findings in another two cases (28.5%), in which diagnostic definition was achieved after employing CEUS. Conclusions CEUS is a technique that is easy to perform and provides additional support for follow-up of infrarenal EVAR.
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Affiliation(s)
| | | | | | | | | | - Nelson Wolosker
- Hospital Israelita Albert Einstein, Brasil; Universidade de São Paulo, Brasil
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Iscan HZ, Unal EU, Akkaya B, Daglı M, Karahan M, Civelek I, Ozbek MH, Okten RS. Color Doppler ultrasound for surveillance following EVAR as the primary tool. J Card Surg 2020; 36:111-117. [PMID: 33225510 DOI: 10.1111/jocs.15194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE As aneurysm-related events and rupture is not eliminated, postoperative lifelong surveillance is mandatory after endovascular aneurysm repair (EVAR). For surveillance colored Doppler ultrasound (CDUS) is a standard method of noninvasive evaluation having the advantages of availability, cost-effectiveness, and lack of nephrotoxicity and radiation. We evaluated CDUS for primary surveillance tool after elective EVAR by comparing with computerized tomography. METHODS Between January 2018 and March 2020, 84 consecutive post-EVAR patients were evaluated. First, CDUS was performed by two Doppler operators from the Radiology Department and then computed tomographic angiography (CTA) was performed. The operators were blind to CTA reports. A reporting protocol was organized for endoleak detection and largest aneurysm diameter. RESULTS Among 84 patients, there were 11 detected endoleaks (13.1%) with CTA and seven of them was detected with CDUS (r = .884, p < .001). All Type I and III endoleaks were detected perfectly. There is an insufficiency in detecting low flow by CDUS. Eliminating this frailty, there was a strong correlation of aneurysm sac diameter measurement between CTA and CDUS (r = .777, p < .001). The sensitivity and specificity of CDUS was 63.6% and 100%, respectively. The accuracy was 95.2%. Positive and negative predictive values were 100% and 94.8%. Bland-Altman analysis and linear regression analysis showed no proportional bias (mean difference of 1.5 ± 2.2 mm, p = .233). CONCLUSIONS For surveillance, CDUS promises accurate results without missing any potential complication requiring intervention as Type I or III endoleak. Lack of detecting Type II endoleaks may be negligible as sac enlargement was the key for reintervention in this situation and CDUS has a remarkably high correlation with CTA in sac diameter measurement. CDUS may be a primary surveillance tool for EVAR and CTA will be reserved in case of aneurysm sac enlargement, detection of an endoleak, inadequate CDUS, or in case of unexplained abdominal symptomatology. By this way we not only avoid ionizing radiation and nephrotoxic agents, but also achieve cost saving issue also.
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Affiliation(s)
- Hakkı Z Iscan
- Department of Cardiovascular Surgery, Yuksek Ihtisas Cardiovascular Hospital, Ankara City Hospital Complex, Ankara, Turkey
| | - Ertekin U Unal
- Department of Cardiovascular Surgery, Yuksek Ihtisas Cardiovascular Hospital, Ankara City Hospital Complex, Ankara, Turkey
| | - Boğaçhan Akkaya
- Department of Cardiovascular Surgery, Yuksek Ihtisas Cardiovascular Hospital, Ankara City Hospital Complex, Ankara, Turkey
| | - Mustafa Daglı
- Department of Cardiovascular Surgery, Yuksek Ihtisas Cardiovascular Hospital, Ankara City Hospital Complex, Ankara, Turkey
| | - Mehmet Karahan
- Department of Cardiovascular Surgery, Yuksek Ihtisas Cardiovascular Hospital, Ankara City Hospital Complex, Ankara, Turkey
| | - Isa Civelek
- Department of Cardiovascular Surgery, Yuksek Ihtisas Cardiovascular Hospital, Ankara City Hospital Complex, Ankara, Turkey
| | - Mehmet H Ozbek
- Department of Cardiovascular Surgery, Yuksek Ihtisas Cardiovascular Hospital, Ankara City Hospital Complex, Ankara, Turkey
| | - Rıza S Okten
- Department of Radiology, Ankara City Hospital Complex, Ankara, Turkey
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Maudgil DD. Cost effectiveness and the role of the National Institute of Health and Care Excellence (NICE) in interventional radiology. Clin Radiol 2020; 76:185-192. [PMID: 33081990 PMCID: PMC7568486 DOI: 10.1016/j.crad.2020.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/16/2020] [Indexed: 12/12/2022]
Abstract
Healthcare expenditure is continually increasing and projected to accelerate in the future, with an increasing proportion being spent on interventional radiology. The role of cost effectiveness studies in ensuring the best allocation of resources is discussed, and the role of National Institute of Health and Care Excellence (NICE) in determining this. Issues with demonstrating cost effectiveness have been discussed, and it has been found that there is significant scope for improving cost effectiveness, with suggestions made for how this can be achieved. In this way, more patients can benefit from better treatment given limited healthcare budgets.
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Affiliation(s)
- D D Maudgil
- Radiology Department, Wexham Park Hospital, Frimley Health Foundation Trust, Wexham Street, Slough, Berks, SL2 4HL, UK.
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Väärämäki S, Salenius J, Pimenoff G, Uurto I, Suominen V. Overall outcome after endovascular aneurysm repair with a first-generation stent graft (Vanguard): A 20-year single-center experience. J Vasc Surg 2020; 72:896-903. [PMID: 32139310 DOI: 10.1016/j.jvs.2019.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/03/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The problems with first-generation stent grafts for endovascular aneurysm repair are well known, but their long-term outcome remains to be established. The purpose of the study was to characterize the outcome of patients treated for abdominal aortic aneurysm (AAA) with a first-generation stent graft, Vanguard (Boston Scientific, Natick, Mass), in a single academic center with a follow-up of up to 20 years. METHODS There were 48 AAA patients electively treated with a Vanguard stent graft between February 1997 and November 1999. The patients were monitored annually until the end of 2018. The outcomes were overall survival and the number of graft-related complications and reinterventions. RESULTS The mean age was 70 years (range, 54-85 years), and the mean follow-up was 107 months (range, 6-262 months). All stent grafts were successfully implanted, but 90% of the patients encountered graft-related complications during follow-up. The most common complications were endoleaks (type I, 27%; type II, 29%; type III, 31%), stent fracture (46%), graft thrombosis (31%), and migration (40%). A total of 40 (83%) patients required a secondary procedure during long-term follow-up. The endovascular method for treating the complication was successful in 73 (87%) of 84 cases. There were no primary conversions, but 10 patients (21%) required a late conversion. In five cases, the complications required relining with a newer device. There were four AAA ruptures (8.3%), two of them fatal. The cumulative overall survival rates were 94%, 69%, 33%, 15%, and 13% at 1 year, 5 years, 10 years, 15 years, and 20 years, respectively. CONCLUSIONS The use of the Vanguard, a first-generation stent graft, was associated with multiple graft-related complications. However, these complications could mainly be treated by endovascular means. The Vanguard stent graft is a good example of how new technology can cause unpredictable problems that can magnify the workload and endanger the patient's well-being even decades after the initial procedure.
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Affiliation(s)
- Suvi Väärämäki
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland.
| | - Juha Salenius
- Division of Vascular Surgery, Department of Surgery, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Georg Pimenoff
- Division of Interventional Radiology, Department of Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Ilkka Uurto
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Velipekka Suominen
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
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D'Oria M, Mastrorilli D, Ziani B. Natural History, Diagnosis, and Management of Type II Endoleaks after Endovascular Aortic Repair: Review and Update. Ann Vasc Surg 2020; 62:420-431. [PMID: 31376537 DOI: 10.1016/j.avsg.2019.04.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/02/2019] [Accepted: 04/28/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Mayo Clinic Gonda Vascular Center, Rochester, MN; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy.
| | - Davide Mastrorilli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Barbara Ziani
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
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Brazzelli M, Hernández R, Sharma P, Robertson C, Shimonovich M, MacLennan G, Fraser C, Jamieson R, Vallabhaneni SR. Contrast-enhanced ultrasound and/or colour duplex ultrasound for surveillance after endovascular abdominal aortic aneurysm repair: a systematic review and economic evaluation. Health Technol Assess 2019; 22:1-220. [PMID: 30543179 DOI: 10.3310/hta22720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Endovascular abdominal aortic aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) is less invasive than open surgery, but may be associated with important complications. Patients receiving EVAR require long-term surveillance to detect abnormalities and direct treatments. Computed tomography angiography (CTA) has been the most common imaging modality adopted for EVAR surveillance, but it is associated with repeated radiation exposure and the risk of contrast-related nephropathy. Colour duplex ultrasound (CDU) and, more recently, contrast-enhanced ultrasound (CEU) have been suggested as possible, safer, alternatives to CTA. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of imaging strategies, using either CDU or CEU alone or in conjunction with plain radiography, compared with CTA for EVAR surveillance. DATA SOURCES Major electronic databases were searched, including MEDLINE, EMBASE, Science Citation Index, Scopus' Articles-in-Press, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and NHS Economic Evaluation Database from 1996 onwards. We also searched for relevant ongoing studies and conference proceedings. The final searches were undertaken in September 2016. METHODS We conducted a systematic review of randomised controlled trials and cohort studies of patients with AAAs who were receiving surveillance using CTA, CDU and CEU with or without plain radiography. Three reviewers were involved in the study selection, data extraction and risk-of-bias assessment. We developed a Markov model based on five surveillance strategies: (1) annual CTA; (2) annual CDU; (3) annual CEU; (4) CDU together with CTA at 1 year, followed by CDU on an annual basis; and (5) CEU together with CTA at 1 year, followed by CEU on an annual basis. All of these strategies also considered plain radiography on an annual basis. RESULTS We identified two non-randomised comparative studies and 25 cohort studies of interventions, and nine systematic reviews of diagnostic accuracy. Overall, the proportion of patients who required reintervention ranged from 1.1% (mean follow-up of 24 months) to 23.8% (mean follow-up of 32 months). Reintervention was mainly required for patients with thrombosis and types I-III endoleaks. All-cause mortality ranged from 2.7% (mean follow-up of 24 months) to 42% (mean follow-up of 54.8 months). Aneurysm-related mortality occurred in < 1% of the participants. Strategies based on early and mid-term CTA and/or CDU and long-term CDU surveillance were broadly comparable with those based on a combination of CTA and CDU throughout the follow-up period in terms of clinical complications, reinterventions and mortality. The economic evaluation showed that a CDU-based strategy generated lower expected costs and higher quality-adjusted life-year (QALYs) than a CTA-based strategy and has a 63% probability of being cost-effective at a £30,000 willingness-to-pay-per-QALY threshold. A CEU-based strategy generated more QALYs, but at higher costs, and became cost-effective only for high-risk patient groups. LIMITATIONS Most studies were rated as being at a high or moderate risk of bias. No studies compared CDU with CEU. Substantial clinical heterogeneity precluded a formal synthesis of results. The economic model was hindered by a lack of suitable data. CONCLUSIONS Current surveillance practice is very heterogeneous. CDU may be a safe and cost-effective alternative to CTA, with CTA being reserved for abnormal/inconclusive CDU cases. FUTURE WORK Research is needed to validate the safety of modified, more-targeted surveillance protocols based on the use of CDU and CEU. The role of radiography for surveillance after EVAR requires clarification. STUDY REGISTRATION This study is registered as PROSPERO CRD42016036475. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pawana Sharma
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Clare Robertson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Current Status of Endovascular Preservation of the Internal Iliac Artery with Iliac Branch Devices (IBD). Cardiovasc Intervent Radiol 2019; 42:935-948. [DOI: 10.1007/s00270-019-02199-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/06/2019] [Indexed: 02/06/2023]
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Francois CJ, Skulborstad EP, Majdalany BS, Chandra A, Collins JD, Farsad K, Gerhard-Herman MD, Gornik HL, Kendi AT, Khaja MS, Lee MH, Sutphin PD, Kapoor BS, Kalva SP. ACR Appropriateness Criteria ® Abdominal Aortic Aneurysm: Interventional Planning and Follow-Up. J Am Coll Radiol 2018; 15:S2-S12. [DOI: 10.1016/j.jacr.2018.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 12/17/2022]
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Abraha I, Luchetta ML, De Florio R, Cozzolino F, Casazza G, Duca P, Parente B, Orso M, Germani A, Eusebi P, Montedori A. Ultrasonography for endoleak detection after endoluminal abdominal aortic aneurysm repair. Cochrane Database Syst Rev 2017; 6:CD010296. [PMID: 28598495 PMCID: PMC6481872 DOI: 10.1002/14651858.cd010296.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND People with abdominal aortic aneurysm who receive endovascular aneurysm repair (EVAR) need lifetime surveillance to detect potential endoleaks. Endoleak is defined as persistent blood flow within the aneurysm sac following EVAR. Computed tomography (CT) angiography is considered the reference standard for endoleak surveillance. Colour duplex ultrasound (CDUS) and contrast-enhanced CDUS (CE-CDUS) are less invasive but considered less accurate than CT. OBJECTIVES To determine the diagnostic accuracy of colour duplex ultrasound (CDUS) and contrast-enhanced-colour duplex ultrasound (CE-CDUS) in terms of sensitivity and specificity for endoleak detection after endoluminal abdominal aortic aneurysm repair (EVAR). SEARCH METHODS We searched MEDLINE, Embase, LILACS, ISI Conference Proceedings, Zetoc, and trial registries in June 2016 without language restrictions and without use of filters to maximize sensitivity. SELECTION CRITERIA Any cross-sectional diagnostic study evaluating participants who received EVAR by both ultrasound (with or without contrast) and CT scan assessed at regular intervals. DATA COLLECTION AND ANALYSIS Two pairs of review authors independently extracted data and assessed quality of included studies using the QUADAS 1 tool. A third review author resolved discrepancies. The unit of analysis was number of participants for the primary analysis and number of scans performed for the secondary analysis. We carried out a meta-analysis to estimate sensitivity and specificity of CDUS or CE-CDUS using a bivariate model. We analysed each index test separately. As potential sources of heterogeneity, we explored year of publication, characteristics of included participants (age and gender), direction of the study (retrospective, prospective), country of origin, number of CDUS operators, and ultrasound manufacturer. MAIN RESULTS We identified 42 primary studies with 4220 participants. Twenty studies provided accuracy data based on the number of individual participants (seven of which provided data with and without the use of contrast). Sixteen of these studies evaluated the accuracy of CDUS. These studies were generally of moderate to low quality: only three studies fulfilled all the QUADAS items; in six (40%) of the studies, the delay between the tests was unclear or longer than four weeks; in eight (50%), the blinding of either the index test or the reference standard was not clearly reported or was not performed; and in two studies (12%), the interpretation of the reference standard was not clearly reported. Eleven studies evaluated the accuracy of CE-CDUS. These studies were of better quality than the CDUS studies: five (45%) studies fulfilled all the QUADAS items; four (36%) did not report clearly the blinding interpretation of the reference standard; and two (18%) did not clearly report the delay between the two tests.Based on the bivariate model, the summary estimates for CDUS were 0.82 (95% confidence interval (CI) 0.66 to 0.91) for sensitivity and 0.93 (95% CI 0.87 to 0.96) for specificity whereas for CE-CDUS the estimates were 0.94 (95% CI 0.85 to 0.98) for sensitivity and 0.95 (95% CI 0.90 to 0.98) for specificity. Regression analysis showed that CE-CDUS was superior to CDUS in terms of sensitivity (LR Chi2 = 5.08, 1 degree of freedom (df); P = 0.0242 for model improvement).Seven studies provided estimates before and after administration of contrast. Sensitivity before contrast was 0.67 (95% CI 0.47 to 0.83) and after contrast was 0.97 (95% CI 0.92 to 0.99). The improvement in sensitivity with of contrast use was statistically significant (LR Chi2 = 13.47, 1 df; P = 0.0002 for model improvement).Regression testing showed evidence of statistically significant effect bias related to year of publication and study quality within individual participants based CDUS studies. Sensitivity estimates were higher in the studies published before 2006 than the estimates obtained from studies published in 2006 or later (P < 0.001); and studies judged as low/unclear quality provided higher estimates in sensitivity. When regression testing was applied to the individual based CE-CDUS studies, none of the items, namely direction of the study design, quality, and age, were identified as a source of heterogeneity.Twenty-two studies provided accuracy data based on number of scans performed (of which four provided data with and without the use of contrast). Analysis of the studies that provided scan based data showed similar results. Summary estimates for CDUS (18 studies) showed 0.72 (95% CI 0.55 to 0.85) for sensitivity and 0.95 (95% CI 0.90 to 0.96) for specificity whereas summary estimates for CE-CDUS (eight studies) were 0.91 (95% CI 0.68 to 0.98) for sensitivity and 0.89 (95% CI 0.71 to 0.96) for specificity. AUTHORS' CONCLUSIONS This review demonstrates that both ultrasound modalities (with or without contrast) showed high specificity. For ruling in endoleaks, CE-CDUS appears superior to CDUS. In an endoleak surveillance programme CE-CDUS can be introduced as a routine diagnostic modality followed by CT scan only when the ultrasound is positive to establish the type of endoleak and the subsequent therapeutic management.
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Affiliation(s)
- Iosief Abraha
- Regional Health Authority of UmbriaHealth Planning ServicePerugiaItaly06124
| | | | - Rita De Florio
- Local Health UnitAzienda SanitariaLocale USL 1, Medicina GeneralePerugiaItaly
| | - Francesco Cozzolino
- Regional Health Authority of UmbriaVia Mario Angeloni 61PerugiaUnbriaItaly06124
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
| | - Piergiorgio Duca
- Ospedale Luigi SaccoL.I.T.A. Polo UniversitarioVia G.B. Grassi, 74MilanoItaly20157
| | - Basso Parente
- Azienda Ospedaliera di PerugiaChirurgia VascolareSant' Andrea delle FrattePerugiaItaly06156
| | - Massimiliano Orso
- Regional Health Authority of UmbriaHealth Planning ServicePerugiaItaly06124
| | - Antonella Germani
- Azienda Unita' Sanitaria Locale Umbria N. 2Servizio Immunotrasfusionalevia ArcamoneFolignoItaly06034
| | - Paolo Eusebi
- Regional Health Authority of UmbriaEpidemiology DepartmentVia Mario Angeloni 61PerugiaUmbriaItaly06124
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Lowe C, Abbas A, Rogers S, Smith L, Ghosh J, McCollum C. Three-dimensional contrast-enhanced ultrasound improves endoleak detection and classification after endovascular aneurysm repair. J Vasc Surg 2017; 65:1453-1459. [DOI: 10.1016/j.jvs.2016.10.082] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 10/08/2016] [Indexed: 11/16/2022]
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Cantisani V, David E, Ferrari D, Fanelli F, Di Marzo L, Catalano C, Benedetto F, Spinelli D, Katsargyris A, Blandino A, Ascenti G, D'Ambrosio F. Color Doppler Ultrasound with Superb Microvascular Imaging Compared to Contrast-enhanced Ultrasound and Computed Tomography Angiography to Identify and Classify Endoleaks in Patients Undergoing EVAR. Ann Vasc Surg 2017; 40:136-145. [DOI: 10.1016/j.avsg.2016.06.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 05/31/2016] [Accepted: 06/22/2016] [Indexed: 12/18/2022]
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Bashshur RL, Krupinski EA, Thrall JH, Bashshur N. The Empirical Foundations of Teleradiology and Related Applications: A Review of the Evidence. Telemed J E Health 2016; 22:868-898. [PMID: 27585301 PMCID: PMC5107673 DOI: 10.1089/tmj.2016.0149] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/10/2016] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Radiology was founded on a technological discovery by Wilhelm Roentgen in 1895. Teleradiology also had its roots in technology dating back to 1947 with the successful transmission of radiographic images through telephone lines. Diagnostic radiology has become the eye of medicine in terms of diagnosing and treating injury and disease. This article documents the empirical foundations of teleradiology. METHODS A selective review of the credible literature during the past decade (2005-2015) was conducted, using robust research design and adequate sample size as criteria for inclusion. FINDINGS The evidence regarding feasibility of teleradiology and related information technology applications has been well documented for several decades. The majority of studies focused on intermediate outcomes, as indicated by comparability between teleradiology and conventional radiology. A consistent trend of concordance between the two modalities was observed in terms of diagnostic accuracy and reliability. Additional benefits include reductions in patient transfer, rehospitalization, and length of stay.
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Affiliation(s)
| | | | - James H. Thrall
- Department of Radiology, Massachusetts General Hospital, Harvard, Boston, Massachusetts
| | - Noura Bashshur
- University of Michigan Health System, Ann Arbor, Michigan
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Three-dimensional Ultrasound in the Management of Abdominal Aortic Aneurysms: A Topical Review. Eur J Vasc Endovasc Surg 2016; 52:466-474. [DOI: 10.1016/j.ejvs.2016.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 06/16/2016] [Indexed: 11/24/2022]
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Cantador AA, Siqueira DED, Jacobsen OB, Baracat J, Pereira IMR, Menezes FH, Guillaumon AT. Duplex ultrasound and computed tomography angiography in the follow-up of endovascular abdominal aortic aneurysm repair: a comparative study. Radiol Bras 2016; 49:229-233. [PMID: 27777476 PMCID: PMC5073389 DOI: 10.1590/0100-3984.2014.0139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective To compare duplex ultrasound and computed tomography (CT) angiography in
terms of their performance in detecting endoleaks, as well as in determining
the diameter of the aneurysm sac, in the postoperative follow-up of
endovascular abdominal aortic aneurysm repair. Materials and Methods This was a prospective study involving 30 patients who had undergone
endovascular repair of infrarenal aortoiliac aneurysms. Duplex ultrasound
and CT angiography were performed simultaneously by independent
radiologists. Measurements of the aneurysm sac diameter were assessed, and
the presence or absence of endoleaks was determined. Results The average diameter of the aneurysm sac, as determined by duplex ultrasound
and CT angiography was 6.09 ± 1.95 and 6.27 ± 2.16 cm,
respectively. Pearson's correlation coefficient showing a statistically
significant correlation (R = 0.88; p <
0.01). Comparing the duplex ultrasound and CT angiography results regarding
the detection of endoleaks, we found that the former had a negative
predictive value of 92.59% and a specificity of 96.15%. Conclusion Our results show that there is little variation between the two methods
evaluated, and that the choice between the two would have no significant
effect on clinical management. Duplex ultrasound could replace CT
angiography in the postoperative follow-up of endovascular aneurysm repair
of the infrarenal aorta, because it is a low-cost procedure without the
potential clinical complications related to the use of iodinated contrast
and exposure to radiation.
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Affiliation(s)
| | - Daniel Emílio Dalledone Siqueira
- Graduate Student in the Department of Vascular Diseases, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil
| | | | - Jamal Baracat
- PhD, Assistant Professor in the Department of Radiology, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil
| | - Ines Minniti Rodrigues Pereira
- PhD, Assistant Professor in the Department of Radiology, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil
| | - Fábio Hüsemann Menezes
- PhD, Assistant Professor in the Department of Vascular Diseases, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil
| | - Ana Terezinha Guillaumon
- PhD, Associate Professor, Head of the Department of Vascular Diseases, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil
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Scaife M, Giannakopoulos T, Al-Khoury GE, Chaer RA, Avgerinos ED. Contemporary Applications of Ultrasound in Abdominal Aortic Aneurysm Management. Front Surg 2016; 3:29. [PMID: 27303669 PMCID: PMC4882338 DOI: 10.3389/fsurg.2016.00029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 05/09/2016] [Indexed: 11/17/2022] Open
Abstract
Ultrasound (US) is a well-established screening tool for detection of abdominal aortic aneurysms (AAAs) and is currently recommended not only for those with a relevant family history but also for all men and high-risk women older than 65 years of age. The advent of minimally invasive endovascular techniques in the treatment of AAAs [endovascular aneurysm repair (EVAR)] has increased the need for repeat imaging, especially in the postoperative period. Nevertheless, preoperative planning, intraoperative execution, and postoperative surveillance all mandate accurate imaging. While computed tomographic angiography and angiography have dominated the field, repeatedly exposing patients to the deleterious effects of cumulative radiation and intravenous nephrotoxic contrast, US technology has significantly evolved over the past decade. In addition to standard color duplex US, 2D, 3D, or 4D contrast-enhanced US modalities are revolutionizing AAA management and postoperative surveillance. This technology can accurately measure AAA diameter and volume, and most importantly, it can detect endoleaks post-EVAR with high sensitivity and specificity. 4D contrast-enhanced US can even provide hemodynamic information about the branch vessels following fenestrated EVARs. The need for experienced US operators and accredited vascular labs is mandatory to guarantee the reliability of the results. This review article presents a comprehensive overview of the literature on the state-of-art US imaging in AAA management, including post-EVAR follow-up, techniques, and diagnostic accuracy.
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Affiliation(s)
- Mark Scaife
- Division of Vascular Surgery, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | | | - Georges E Al-Khoury
- Division of Vascular Surgery, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
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Partovi S, Kaspar M, Aschwanden M, Lopresti C, Madan S, Uthoff H, Imfeld S, Staub D. Contrast-enhanced ultrasound after endovascular aortic repair-current status and future perspectives. Cardiovasc Diagn Ther 2015; 5:454-63. [PMID: 26673398 DOI: 10.3978/j.issn.2223-3652.2015.09.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
An increasing number of patients with abdominal aortic aneurysms (AAAs) are undergoing endovascular aortic repair (EVAR) instead of open surgery. These patients require lifelong surveillance, and the follow-up imaging modality of choice has been traditionally computed tomography angiography (CTA). Repetitive CTA imaging is associated with cumulative radiation exposure and requires the administration of multiple doses of nephrotoxic contrast agents. Contrast-enhanced ultrasound (CEUS) has emerged as an alternative strategy in the follow-up of patients with EVAR and demonstrates high sensitivity and specificity for detection of endoleaks. In fact, a series of studies have shown that CEUS is at least performing equal to computed tomography for the detection and classification of endoleaks. This article summarizes current evidence of CEUS after EVAR and demonstrates its usefulness via various patient cases.
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Affiliation(s)
- Sasan Partovi
- 1 Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA ; 2 Department of Angiology, University Hospital Basel, Basel, Switzerland ; 3 Department of Medicine, Louis Stokes Cleveland VA Medical Center, 4 Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mathias Kaspar
- 1 Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA ; 2 Department of Angiology, University Hospital Basel, Basel, Switzerland ; 3 Department of Medicine, Louis Stokes Cleveland VA Medical Center, 4 Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Markus Aschwanden
- 1 Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA ; 2 Department of Angiology, University Hospital Basel, Basel, Switzerland ; 3 Department of Medicine, Louis Stokes Cleveland VA Medical Center, 4 Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Charles Lopresti
- 1 Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA ; 2 Department of Angiology, University Hospital Basel, Basel, Switzerland ; 3 Department of Medicine, Louis Stokes Cleveland VA Medical Center, 4 Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Shivanshu Madan
- 1 Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA ; 2 Department of Angiology, University Hospital Basel, Basel, Switzerland ; 3 Department of Medicine, Louis Stokes Cleveland VA Medical Center, 4 Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Heiko Uthoff
- 1 Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA ; 2 Department of Angiology, University Hospital Basel, Basel, Switzerland ; 3 Department of Medicine, Louis Stokes Cleveland VA Medical Center, 4 Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Stephan Imfeld
- 1 Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA ; 2 Department of Angiology, University Hospital Basel, Basel, Switzerland ; 3 Department of Medicine, Louis Stokes Cleveland VA Medical Center, 4 Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Daniel Staub
- 1 Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA ; 2 Department of Angiology, University Hospital Basel, Basel, Switzerland ; 3 Department of Medicine, Louis Stokes Cleveland VA Medical Center, 4 Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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Karthikesalingam A, Attallah O, Ma X, Bahia SS, Thompson L, Vidal-Diez A, Choke EC, Bown MJ, Sayers RD, Thompson MM, Holt PJ. An Artificial Neural Network Stratifies the Risks of Reintervention and Mortality after Endovascular Aneurysm Repair; a Retrospective Observational study. PLoS One 2015; 10:e0129024. [PMID: 26176943 PMCID: PMC4503678 DOI: 10.1371/journal.pone.0129024] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/03/2015] [Indexed: 12/16/2022] Open
Abstract
Background Lifelong surveillance after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) is considered mandatory to detect potentially life-threatening endograft complications. A minority of patients require reintervention but cannot be predictively identified by existing methods. This study aimed to improve the prediction of endograft complications and mortality, through the application of machine-learning techniques. Methods Patients undergoing EVAR at 2 centres were studied from 2004-2010. Pre-operative aneurysm morphology was quantified and endograft complications were recorded up to 5 years following surgery. An artificial neural networks (ANN) approach was used to predict whether patients would be at low- or high-risk of endograft complications (aortic/limb) or mortality. Centre 1 data were used for training and centre 2 data for validation. ANN performance was assessed by Kaplan-Meier analysis to compare the incidence of aortic complications, limb complications, and mortality; in patients predicted to be low-risk, versus those predicted to be high-risk. Results 761 patients aged 75 +/- 7 years underwent EVAR. Mean follow-up was 36+/- 20 months. An ANN was created from morphological features including angulation/length/areas/diameters/volume/tortuosity of the aneurysm neck/sac/iliac segments. ANN models predicted endograft complications and mortality with excellent discrimination between a low-risk and high-risk group. In external validation, the 5-year rates of freedom from aortic complications, limb complications and mortality were 95.9% vs 67.9%; 99.3% vs 92.0%; and 87.9% vs 79.3% respectively (p<0.001) Conclusion This study presents ANN models that stratify the 5-year risk of endograft complications or mortality using routinely available pre-operative data.
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Affiliation(s)
- Alan Karthikesalingam
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
| | - Omneya Attallah
- College of Engineering and Applied Science, Aston University, Birmingham, B4 7ET, United Kingdom
- Department of Electronics and Communications Engineering, Arab Academy for Science and Technology and Maritime Transport, Alexandria, Egypt
| | - Xianghong Ma
- College of Engineering and Applied Science, Aston University, Birmingham, B4 7ET, United Kingdom
| | - Sandeep Singh Bahia
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
- * E-mail:
| | - Luke Thompson
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
| | - Alberto Vidal-Diez
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
- Department of Community Health Sciences, St George’s University of London, London, SW17 0QT, United Kingdom
| | - Edward C. Choke
- Vascular Surgery Group, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, United Kingdom
| | - Matt J. Bown
- Vascular Surgery Group, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, United Kingdom
| | - Robert D. Sayers
- Vascular Surgery Group, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, United Kingdom
| | - Matt M. Thompson
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
| | - Peter J. Holt
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
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Sun L, Zhou H, Gu L, Jiang C, Liu Y, Xu Q. Effects of surgical procedures on the occurrence and development of postoperative portal vein thrombosis in patients with cirrhosis complicated by portal hypertension. Int J Surg 2015; 16:31-35. [PMID: 25701619 DOI: 10.1016/j.ijsu.2015.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 01/26/2015] [Accepted: 02/12/2015] [Indexed: 01/06/2023]
Abstract
OBJECTIVE We have compared the influences of three surgical strategies on the occurrence and development of portal vein thrombosis (PVT) in patients with liver cirrhosis complicated by portal hypertension (PHT) in this study. METHODS Total 116 patients who respectively underwent pericardial devascularization (PCDV) with splenectomy (PDS group: n = 50), selective PCDV (SPD group: n = 28) and splenorenal shunt (SRS) combined with PCDV (combined group: n = 38) were investigated in this study. The incidence of PVT before and after operation was monitored. The incidence of Grade II-IV PVT was used to assess the severity of PVT. The liver function was assessed according to the Child-Pugh classification. RESULTS The incidence and severity of PVT and live function were similar among the three groups before operation (P > 0.05). The incidence of PVT was significantly increased after surgery in each group (P < 0.001), but recovered to the baseline level at six months in combined group (P = 0.629). Besides, the severity of PVT was significantly aggravated in PDS (P < 0.001) and SPD (P = 0.026) groups after operation, but not in combined group (P = 0.525). Patients in combined group showed significantly lower incidence and severity of PVT than those in the other two groups at each follow-up time point (P < 0.05). In addition, the liver function in the combined group was significantly improved compared with the other two groups. CONCLUSIONS SRS combined with PCDV is superior to PCDV with splenectomy and selective PCDV for PHT in liver cirrhotic patients in inhibiting the occurrence and development of postoperative PVT and improving liver function.
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Affiliation(s)
- Longci Sun
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Hong Zhou
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Lei Gu
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Chunhui Jiang
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Ye Liu
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Qing Xu
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China.
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Sorrentino K, Shah PS, Bendick P. Ultrasonographic Surveillance of Abdominal Aortic Endovascular Aneurysm Stent Graft Repair in a Dedicated Vascular Laboratory. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2015. [DOI: 10.1177/8756479314563162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surveillance following abdominal aortic endovascular aneurysm repair (EVAR) is imperative to confirm graft patency, analyze residual sac size (RSS), and evaluate for complications. This retrospective study evaluated ultrasonographic (US) surveillance after EVAR compared to computed tomography (CT). US was done by 1 of 11 experienced registered technologists. US was ordered for surveillance more frequently than CT, with a ratio of 4:1. Compared to CT, US endoleak evaluations were 74% sensitive and 76% specific with a 63% positive predictive value and 84% negative predictive value. However, 11 CT scans were likely false negatives, and 1 CT was a false positive. For true positives that stated endoleak type, there was a 93% agreement between the type on US and CT. US had a 75% accuracy for RSS (95% CI, −1.02 to 1.16). These data support the use of US along with clinical symptoms as a first-line surveillance program after EVAR and are widely applicable to the majority of vascular laboratories that employ multiple registered vascular technologists. The adaptation of increased US surveillance would decrease the number of CT scans, thereby significantly reducing cost and radiation/contrast exposure to patients.
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Affiliation(s)
| | - Parth S. Shah
- Hartford HealthCare Medical Group, Hartford, CT, USA
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Sidloff D, Gokani V, Stather P, Choke E, Bown M, Sayers R. Editor's Choice – Type II Endoleak: Conservative Management Is a Safe Strategy. Eur J Vasc Endovasc Surg 2014; 48:391-9. [DOI: 10.1016/j.ejvs.2014.06.035] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 06/03/2014] [Indexed: 10/25/2022]
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Tse DML, Tapping CR, Patel R, Morgan R, Bratby MJ, Anthony S, Uberoi R. Surveillance After Endovascular Abdominal Aortic Aneurysm Repair. Cardiovasc Intervent Radiol 2014; 37:875-88. [DOI: 10.1007/s00270-014-0916-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 04/03/2014] [Indexed: 02/05/2023]
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Surveillance Computed Tomographic Arteriogram Does Not Change Management before 3 Years in Patients Who Have a Normal Post-EVAR Study. Ann Vasc Surg 2014; 28:831-6. [DOI: 10.1016/j.avsg.2013.09.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/13/2013] [Accepted: 09/29/2013] [Indexed: 11/19/2022]
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3D Contrast Enhanced Ultrasound for Detecting Endoleak Following Endovascular Aneurysm Repair (EVAR). Eur J Vasc Endovasc Surg 2014; 47:487-92. [DOI: 10.1016/j.ejvs.2014.02.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 02/03/2014] [Indexed: 10/25/2022]
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Kaczynski J, Jaber B, Woolgar J. Rupture of the infrarenal abdominal aortic aneurysm (AAA) following an endovascular aneurysm repair (EVAR) due to an isolated type II endoleak. BMJ Case Rep 2014; 2014:bcr-2013-202964. [PMID: 24443343 DOI: 10.1136/bcr-2013-202964] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present a case of an elderly man with the persisting type II endoleak following endovascular aneurysm repair. In a view of the multiple comorbidities, the patient was denied an open elective repair. However, when presented with a ruptured aneurismal sac, he underwent an emergency open abdominal aortic aneurysm repair. Overall, the patient has made a good postoperative recovery.
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Affiliation(s)
- Jakub Kaczynski
- General Surgery Department, Dumfries and Galloway Royal Infirmary, Dumfries, UK
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Ambulatory percutaneous endovascular abdominal aortic aneurysm repair. J Vasc Surg 2014; 59:58-64. [DOI: 10.1016/j.jvs.2013.06.076] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 06/24/2013] [Accepted: 06/26/2013] [Indexed: 12/17/2022]
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Vallabhaneni R, Farber MA, Schneider F, Ricco JB. Debate: Whether young, good-risk patients should be treated with endovascular abdominal aortic aneurysm repair. J Vasc Surg 2013; 58:1709-15. [DOI: 10.1016/j.jvs.2013.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Vallabhaneni R, Farber M. Part One: For the Motion. Young Patients with Good Risk Factors Should be Treated with EVAR. Eur J Vasc Endovasc Surg 2013; 46:614-7. [DOI: 10.1016/j.ejvs.2013.09.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lynch B, Nelson J, Kavanagh EG, Walsh SR, McGloughlin TM. A Review of Methods for Determining the Long Term Behavior of Endovascular Devices. Cardiovasc Eng Technol 2013. [DOI: 10.1007/s13239-013-0168-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Bobadilla JL, Suwanabol PA, Reeder SB, Pozniak MA, Bley TA, Tefera G. Clinical implications of non-contrast-enhanced computed tomography for follow-up after endovascular abdominal aortic aneurysm repair. Ann Vasc Surg 2013; 27:1042-8. [PMID: 23711975 DOI: 10.1016/j.avsg.2012.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 10/03/2012] [Accepted: 10/09/2012] [Indexed: 10/26/2022]
Abstract
BACKGROUND There is growing concern over the long-term radiation exposure from serial computed tomographic (CT) scan follow-up after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). Screening for endoleaks with non-contrast-enhanced volumetric CT has been shown to significantly reduce radiation doses. We evaluated the use of NCT as the primary method of follow-up after EVAR of AAAs. METHODS Our institutional post-EVAR CT protocol consisted of contrast-enhanced CT angiography (CTA) 1 month after repair, followed by NCT at 3 or 6 and 12 months, and annually thereafter. At each follow-up scan, immediate 3-dimensional volume analysis was performed. If the volume change was <2%, NCT follow-up was continued. If the volume increased by ≥2% on nonenhanced images, contrast-enhanced CT was performed immediately to identify potential endoleaks. All images were reviewed by an experienced cardiovascular radiologist. End points included identification of endoleak, reintervention, and rupture. RESULTS Over a 7-year period, 126 patients were followed. Serial CTA was performed in 59 patients, while 67 patients were followed with the NCT protocol. The mean follow-up was 2.07 years. There were no differences in age, sex, or initial aneurysm volume or size. There were 35 total endoleaks identified. Twenty of these were early endoleaks (<30 days post-EVAR). The remaining 15 leaks were late in nature (10 in the contrast group and 5 in the noncontrast group; P=0.17). NCT aneurysm sac volume changes prompted contrasted studies in all 5 late leaks. The mean volume change was 11.2 cm3, an average change of 5.88%. These findings were not significantly different than the late leaks found by routine contrast studies (8.9 cm3; 4.98% [P=0.58]). There were no delayed ruptures or emergent reinterventions in the NCT group. CONCLUSIONS Serial NCT appears to be safe and effective as the sole means of follow-up after EVAR for AAAs. AAA volume increases of ≥2% should prompt further contrast-enhanced CT imaging. Changes of <2% can be safely followed with serial NCT. This protocol requires dedicated cardiovascular radiologist involvement, and patients should be retained in the radiology suite until real-time image evaluation can be completed.
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Affiliation(s)
- Joseph Louis Bobadilla
- Department of Surgery, Division of Vascular Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI
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Dindyal S, Kyriakides C. Duplex ultrasound with the implementation of contrast enhancement in selected cases is satisfactory for EVAR surveillance. J Endovasc Ther 2012; 19:844-6; author reply 846. [PMID: 23210887 DOI: 10.1583/jevt-12-4060l.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Dindyal S, Kyriakides C. Re: Use of colour duplex ultrasound as a first line surveillance to following EVAR is associated with a reduction in cost without compromising accuracy. Eur J Vasc Endovasc Surg 2012; 44:522. [PMID: 23020964 DOI: 10.1016/j.ejvs.2012.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 08/21/2012] [Indexed: 11/24/2022]
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