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Zehtabi F, Gangrade A, Tseng K, Haghniaz R, Abasgholizadeh R, Montazerian H, Khorsandi D, Bahari J, Ahari A, Mohaghegh N, Kouchehbaghi NH, Mandal K, Mecwan M, Rashad A, de Barros NR, Byun Y, Ermis M, Kim HJ, Khademhosseini A. Injectable Shear-Thinning Hydrogels with Sclerosing and Matrix Metalloproteinase Modulatory Properties for the Treatment of Vascular Malformations. ADVANCED FUNCTIONAL MATERIALS 2023; 33:2305880. [PMID: 38558868 PMCID: PMC10977963 DOI: 10.1002/adfm.202305880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Indexed: 04/04/2024]
Abstract
Sac embolization of abdominal aortic aneurysms (AAAs) remains clinically limited by endoleak recurrences. These recurrences are correlated with recanalization due to the presence of endothelial lining and matrix metalloproteinases (MMPs)-mediated aneurysm progression. This study incorporated doxycycline (DOX), a well-known sclerosant and MMPs inhibitor, into a shear-thinning biomaterial (STB)-based vascular embolizing hydrogel. The addition of DOX was expected to improve embolizing efficacy while preventing endoleaks by inhibiting MMP activity and promoting endothelial removal. The results showed that STBs containing 4.5% w/w silicate nanoplatelet and 0.3% w/v of DOX were injectable and had a 2-fold increase in storage modulus compared to those without DOX. STB-DOX hydrogels also reduced clotting time by 33% compared to untreated blood. The burst release of DOX from the hydrogels showed sclerosing effects after 6 h in an ex vivo pig aorta model. Sustained release of DOX from hydrogels on endothelial cells showed MMP inhibition (ca. an order of magnitude larger than control groups) after 7 days. The hydrogels successfully occluded a patient-derived abdominal aneurysm model at physiological blood pressures and flow rates. The sclerosing and MMP inhibition characteristics in the engineered multifunctional STB-DOX hydrogels may provide promising opportunities for the efficient embolization of aneurysms in blood vessels.
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Affiliation(s)
- Fatemeh Zehtabi
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | - Ankit Gangrade
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | - Kaylee Tseng
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
- Department of Chemical Engineering and Materials Science, University of Southern California, Los Angeles, California 90007, United States
| | - Reihaneh Haghniaz
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | - Reza Abasgholizadeh
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | - Hossein Montazerian
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
- Department of Bioengineering, University of California, Los Angeles, Los Angeles, California 90095, United States
- California NanoSystems Institute, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Danial Khorsandi
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | - Jamal Bahari
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | - Amir Ahari
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | - Neda Mohaghegh
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | - Negar Hosseinzadeh Kouchehbaghi
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
- Department of Textile Engineering, Amirkabir University of Technology (Tehran Polytechnic), Hafez Avenue, 1591634311 Tehran, Iran
| | - Kalpana Mandal
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | - Marvin Mecwan
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | - Ahmad Rashad
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | | | - Youngjoo Byun
- College of Pharmacy, Korea University, Sejong 30019, Republic of Korea
| | - Menekse Ermis
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
| | - Han-Jun Kim
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
- College of Pharmacy, Korea University, Sejong 30019, Republic of Korea
- Vellore Institute of Technology (VIT), Vellore, India, 632014
| | - Ali Khademhosseini
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, United States
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Contrella BN, Khaja MS, Majdalany BS, Kim CY, Kalva SP, Beck AW, Browne WF, Clough RE, Ferencik M, Fleischman F, Gunn AJ, Hickey SM, Kandathil A, Kim KM, Monroe EJ, Ochoa Chaar CI, Scheidt MJ, Smolock AR, Steenburg SD, Waite K, Pinchot JW, Steigner ML. ACR Appropriateness Criteria® Thoracoabdominal Aortic Aneurysm or Dissection: Treatment Planning and Follow-Up. J Am Coll Radiol 2023; 20:S265-S284. [PMID: 37236748 DOI: 10.1016/j.jacr.2023.02.007] [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: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
As the incidence of thoracoabdominal aortic pathology (aneurysm and dissection) rises and the complexity of endovascular and surgical treatment options increases, imaging follow-up of patients remains crucial. Patients with thoracoabdominal aortic pathology without intervention should be monitored carefully for changes in aortic size or morphology that could portend rupture or other complication. Patients who are post endovascular or open surgical aortic repair should undergo follow-up imaging to evaluate for complications, endoleak, or recurrent pathology. Considering the quality of diagnostic data, CT angiography and MR angiography are the preferred imaging modalities for follow-up of thoracoabdominal aortic pathology for most patients. The extent of thoracoabdominal aortic pathology and its potential complications involve multiple regions of the body requiring imaging of the chest, abdomen, and pelvis in most patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | | | - Bill S Majdalany
- Panel Chair, University of Vermont Medical Center, Burlington, Vermont
| | - Charles Y Kim
- Panel Chair, Duke University Medical Center, Durham, North Carolina
| | - Sanjeeva P Kalva
- Panel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts
| | - Adam W Beck
- University of Alabama at Birmingham Medical Center, Birmingham, Alabama; Society for Vascular Surgery
| | | | - Rachel E Clough
- St Thomas' Hospital, King's College, School of Biomedical Engineering and Imaging Science, London, United Kingdom; Society for Cardiovascular Magnetic Resonance
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography
| | - Fernando Fleischman
- Keck School of Medicine of USC, Los Angeles, California; American Association for Thoracic Surgery
| | - Andrew J Gunn
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Sean M Hickey
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; American College of Emergency Physicians
| | - Asha Kandathil
- UT Southwestern Medical Center, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging
| | - Karen M Kim
- University of Michigan, Ann Arbor, Michigan; The Society of Thoracic Surgeons
| | | | | | | | - Amanda R Smolock
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Scott D Steenburg
- Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana; Committee on Emergency Radiology-GSER
| | - Kathleen Waite
- Duke University Medical Center, Durham, North Carolina, Primary care physician
| | - Jason W Pinchot
- Specialty Chair, University of Wisconsin, Madison, Wisconsin
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Cruz J, McGillen K, Pryor W, Esslinger D, Shin B. Novel use of contrast-enhanced ultrasound in the pretreatment planning prior to endovascular repair of endoleak after endovascular aortic aneurysm repair in a patient with chronic renal insufficiency: A case report and literature review. J Med Ultrasound 2022; 30:54-58. [PMID: 35465604 PMCID: PMC9030361 DOI: 10.4103/jmu.jmu_173_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/17/2021] [Accepted: 03/02/2021] [Indexed: 11/04/2022] Open
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Williamson PN, Docherty PD, Yazdi SG, Khanafer A, Kabaliuk N, Jermy M. PIV Analysis of Haemodynamics Distal to the Frozen Elephant Trunk Stent Surrogate. Cardiovasc Eng Technol 2021; 12:373-386. [PMID: 33675018 DOI: 10.1007/s13239-021-00521-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/13/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The Frozen Elephant Trunk (FET) stent is a hybrid endovascular device that may be implemented in the event of an aneurysm or aortic dissection of the aortic arch or superior descending aorta. A Type 1B endoleak can lead to intrasaccular flow during systole and has been identified as a known failure of the FET stent graft. The purpose was to develop in-vitro modelling techniques to enable the investigation of the known failure. METHODS A silicone aortic phantom and 3D printed surrogate stent graft were manufactured to investigate the haemodynamics of a Type 1B endoleak. Physiological pulsatile flow dynamics distal to the surrogate stent graft were investigated in-vitro using Particle Image Velocimetry (PIV). RESULTS PIV captured recirculation zones and an endoleak distal to the surrogate stent graft. The endoleak was developed at the peak of systole and sustained until the onset of diastole. The endoleak was asymmetric, indicating a potential variation in the phantom artery wall thickness or stent alignment. Recirculation was identified on the posterior dorsal line during late systole. CONCLUSIONS The identification of the Type 1B endoleak proved that in-vitro modelling can be used to investigate complex compliance changes and wall motions. The recirculation may indicate the potential for long term intimal layer inflammatory issues such as atherosclerosis. These results may aid future remediation techniques or stent design. Further development of the methods used in this experiment may assist with the future testing of stents prior to animal or human trial.
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Affiliation(s)
- Petra N Williamson
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8041, New Zealand
| | - Paul D Docherty
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8041, New Zealand. .,Institute of Technical Medicine, Furtwangen University, Campus Villingen-Schwenningen, Jakob-Kienzle Strasse 17, 78054, Villingen-Schwenningen, Germany.
| | - Sina G Yazdi
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8041, New Zealand
| | - Adib Khanafer
- Vascular, Endovascular & Renal Transplant Unit, Christchurch Hospital, Canterbury District Health Board, Riccarton Avenue, Christchurch, 8053, New Zealand.,Christchurch School of Medicine, University of Otago, Dunedin, New Zealand
| | - Natalia Kabaliuk
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8041, New Zealand
| | - Mark Jermy
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8041, New Zealand
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Abstract
Type 2 endoleaks are the most common endoleak type following endovascular aneurysm repair. The natural history of these endoleaks can vary, with some demonstrating a self-limited or indolent course, while others can contribute to aneurysm sac enlargement and rupture. A variety of embolization techniques, including transarterial catheterization and direct sac puncture techniques, have been developed for the treatment of type 2 endoleaks. In this article, the authors review the indications, techniques, and outcomes of current treatment strategies for type 2 endoleaks.
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Affiliation(s)
- James X Chen
- Division of Vascular and Interventional Radiology Specialists of Charlotte Radiology, Charlotte, North Carolina
| | - S William Stavropoulos
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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6
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Dynamic CT perfusion imaging for type 2 endoleak assessment after endograft placement. Med Hypotheses 2020; 139:109701. [DOI: 10.1016/j.mehy.2020.109701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/21/2020] [Accepted: 03/30/2020] [Indexed: 12/12/2022]
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7
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Systematic review and meta-analysis of sex differences in outcomes after endovascular aneurysm repair for infrarenal abdominal aortic aneurysm. J Vasc Surg 2020; 71:283-296.e4. [DOI: 10.1016/j.jvs.2019.06.105] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/04/2019] [Indexed: 12/21/2022]
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Bando Y, Kitase M, Shimohira M, Honda J, Furuta Y, Kasuya A, Imada H, Mizutani M, Shibamoto Y. 2D-shear wave elastography in the prediction of type II endoleaks after endovascular aneurysm repair. MINIM INVASIV THER 2019; 30:21-26. [PMID: 31621439 DOI: 10.1080/13645706.2019.1678174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate the usefulness of 2D-shear wave elastography (2D-SWE) in the prediction of type II endoleaks after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA). MATERIAL AND METHODS Twenty-nine patients underwent EVAR for AAA, and 2D-SWE was performed after EVAR. Follow-up contrast-enhanced CT and ultrasonography were performed to evaluate endoleaks in all patients. The median follow-up period was 12 months (range, 3-12 months). Patients were divided into two groups: one with an endoleak (endoleak group) and another without it (control group). We compared the elasticity index (EI) of intraluminal thrombus (ITL) and fresh thrombus (FT) between the two groups. RESULTS Type II endoleaks were confirmed in five of the 29 patients (endoleak group), and there were no endoleaks in the other 24 (control group). ILT was observed in 21 patients of the control group and in all patients of the endoleak group. There was a difference only in EI of ILT; the mean EI (± standard deviation) of ILT was 89 ± 16 kPA in the control group and 113 ± 25 kPA in the endoleak group (p=.037). CONCLUSIONS High EI of ILT may predict the occurrence of type II endoleaks after EVAR of AAA.
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Affiliation(s)
- Yuya Bando
- Department of Radiology, Konan Kosei Hospital, Aichi, Japan
| | - Masanori Kitase
- Department of Radiology, Kariya Toyota General Hospital, Aichi, Japan
| | - Masashi Shimohira
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Junichi Honda
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yoshiteru Furuta
- Department of Radiology, Kariya Toyota General Hospital, Aichi, Japan
| | - Akihiro Kasuya
- Central Division of Radiology, Kariya Toyota General Hospital, Aichi, Japan
| | - Hidenao Imada
- Central Division of Radiology, Kariya Toyota General Hospital, Aichi, Japan
| | - Masaru Mizutani
- Department of Radiology, Kariya Toyota General Hospital, Aichi, Japan
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Velocities of type II endoleaks on Doppler ultrasonography predict outcome. J Vasc Surg 2019; 71:1719-1725. [PMID: 31619352 DOI: 10.1016/j.jvs.2019.07.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 07/18/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We sought to determine whether flow velocities measured using Doppler ultrasonography after endovascular aortic aneurysm repair (EVAR) can predict for resolution of type II endoleaks without intervention. We also assessed the relationship of the flow velocities to sac growth and the need for intervention. We hypothesized that hemodynamic properties suggesting low flow velocity would predict for resolution of type II endoleaks. METHODS The data from 23 patients with type II endoleaks identified on Doppler ultrasonography after EVAR from January 2014 to December 2017 were retrospectively analyzed. The 23 patients with type II endoleaks were split into two groups. Group 1 included the 13 patients with resolved endoleaks or shrinking sac size and group 2, the 10 patients with an increasing sac size or those requiring intervention to seal the endoleak because of an increased sac size. We analyzed the velocities of the endoleak nidus. RESULTS Doppler ultrasound velocities were significantly lower in patients with resolved type II endoleaks and those with a shrinking aneurysm sac size compared with those demonstrating an increase in aneurysm sac size (42.6 ± 25.2 cm/s vs 219.5 ± 84.1 cm/s; P < .0001). Of the 10 patients in group 2, nine had required intervention with either translumbar embolization or transarterial embolization, with only two experiencing complete resolution of the type II endoleak, despite the intervention. All patients in group 2 had had ≥1 duplex ultrasound scan with endoleak nidus velocities >100 cm/s. In contrast, no patient in group 1 had had any duplex ultrasound scan with endoleak nidus velocities >100 cm/s. CONCLUSIONS The Doppler ultrasound velocities of type II endoleaks might be able to predict for spontaneous resolution of type II endoleaks or increased sac growth. Type II endoleaks on Doppler ultrasonography with endoleak nidus velocities >100 cm/s can persistent, even with attempted treatment.
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10
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Uemura H, Tanaka H, Mitsuno M, Yamamura M, Ryomoto M, Sekiya N, Sato A, Ueda D, Miyamoto Y. Usefulness of Abdominal Duplex Ultrasound for Detecting Endoleaks after Endovascular Aneurysm Repair. Ann Vasc Dis 2019; 12:30-35. [PMID: 30931054 PMCID: PMC6434359 DOI: 10.3400/avd.oa.18-00108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: The usefulness of abdominal duplex ultrasound (DUS) for the detection of endoleaks after endovascular aneurysm repair (EVAR) was evaluated. Materials and Methods: Among 286 patients who underwent EVAR between September 2007 and July 2017, 241 patients were followed up using abdominal DUS. Endoleaks were detected in 74 patients (31%), who were divided into enlarged and nonenlarged sac groups. Endoleak velocities and widths were measured using abdominal DUS every 6 months after EVAR and were compared between the 2 groups. Results: The aneurysm diameter in the nonenlarged sac group was 54.4±8.7 mm in the final follow-up. None of the patients in the nonenlarged sac group were subjected to reintervention, whereas all patients in the enlarged sac group were subjected to reintervention. The aneurysm diameter in the enlarged sac group was 62.8±8.8 mm at the time of reintervention, and the maximum endoleak flow velocities and endoleak widths were significantly higher in the enlarged sac group than in the nonenlarged sac group (p<0.05). The cutoff values on receiver operating characteristics curves for endoleak velocity and width were 83.4 cm/s and 4.0 mm, respectively. Conclusion: Follow-ups using abdominal DUS are useful after EVAR. Endoleak velocity and width measurements are important, and reintervention may be needed when these measurements exceed their cutoff values.
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Affiliation(s)
- Hisashi Uemura
- Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroe Tanaka
- Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Masataka Mitsuno
- Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Mitsuhiro Yamamura
- Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Masaaki Ryomoto
- Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Naosumi Sekiya
- Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Ayaka Sato
- Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Daisuke Ueda
- Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yuji Miyamoto
- Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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Lange C, Sommerfeld M, Namsolleck P, Kintscher U, Unger T, Kaschina E. AT
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R (Angiotensin AT2 Receptor) Agonist, Compound 21, Prevents Abdominal Aortic Aneurysm Progression in the Rat. Hypertension 2018; 72:e20-e29. [DOI: 10.1161/hypertensionaha.118.11168] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Christoph Lange
- From the Charité—Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Pharmacology, Center for Cardiovascular Research, Germany (C.L., M.S., U.K., E.K.)
| | - Manuela Sommerfeld
- From the Charité—Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Pharmacology, Center for Cardiovascular Research, Germany (C.L., M.S., U.K., E.K.)
| | - Pawel Namsolleck
- CARIM School for Cardiovascular Diseases, Maastricht University, The Netherlands (P.N., T.U.)
| | - Ulrich Kintscher
- From the Charité—Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Pharmacology, Center for Cardiovascular Research, Germany (C.L., M.S., U.K., E.K.)
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany (U.K.)
| | - Thomas Unger
- CARIM School for Cardiovascular Diseases, Maastricht University, The Netherlands (P.N., T.U.)
| | - Elena Kaschina
- From the Charité—Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Pharmacology, Center for Cardiovascular Research, Germany (C.L., M.S., U.K., E.K.)
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12
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Ultee KHJ, Büttner S, Huurman R, Bastos Gonçalves F, Hoeks SE, Bramer WM, Schermerhorn ML, Verhagen HJM. Editor's Choice - Systematic Review and Meta-Analysis of the Outcome of Treatment for Type II Endoleak Following Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2018; 56:794-807. [PMID: 30104089 DOI: 10.1016/j.ejvs.2018.06.009] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 06/06/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The efficacy and need for secondary interventions for type II endoleaks following endovascular abdominal aortic aneurysm repair (EVAR) remain controversial. This systematic review aimed at investigating the clinical outcomes of different type II endoleak treatments in patients with a persistent type II endoleak after EVAR. DATA SOURCES Embase, Medline via Ovid, Web of Science Core Collection, the Cochrane CENTRAL, and Google Scholar. REVIEW METHODS This systematic review was performed in accordance with the PRISMA Statement. Outcomes of interest were technical and clinical success, change in sac diameter, complications, need for additional interventions, abdominal aortic aneurysm (AAA) rupture, and (AAA related) mortality. Meta-analyses were performed with random effects models. RESULTS A total of 59 studies were included, with a cumulative cohort of 1073 patients with persistent type II endoleak. Peri-operative complications following treatment of type II endoleaks occurred in 3.8% of patients (95% CI 2.7-5.2%), and AAA related mortality was 1.8% (95% CI 1.1-2.7%). Overall technical success was 87.9% (95% CI 83.1-92.1%), while clinical success was 68.4% (95% CI 61.2-75.1%). Among studies detailing sac dynamics, decrease or stable sac, with or without resolution, was achieved in 78.4% (95% CI 70.2-85.6%). Changes in sac diameter following type II endoleak treatment were documented in 157 patients to at least 24 months. Within this group an actual decrease in sac diameter was reported in only 27 of 40 patients. CONCLUSION There is little evidence supporting the efficacy of secondary intervention for type II endoleaks after EVAR. Although generally safe, the lack of evidence supporting the efficacy of type II endoleak treatment leads to difficulty in assessing its merits.
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Affiliation(s)
- Klaas H J Ultee
- Department of Vascular Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Stefan Büttner
- Department of Vascular Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Roy Huurman
- Department of Vascular Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Frederico Bastos Gonçalves
- Department of Vascular Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands; Hospital de Santa Marta, CHLC & NOVA Medical School, Lisbon, Portugal
| | - Sanne E Hoeks
- Department of Anaesthetics, Erasmus University Medical Centre, The Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre and Harvard Medical School, Boston, MA, USA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.
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13
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Gifford JN, Cheong HW, Teoh WC. Late-onset type I endoleak characterized by contrast enhanced ultrasound after endovascular repair of aortic aneurysm. JOURNAL OF CLINICAL ULTRASOUND : JCU 2018; 46:424-429. [PMID: 29105814 DOI: 10.1002/jcu.22556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/03/2017] [Accepted: 10/14/2017] [Indexed: 06/07/2023]
Abstract
We report in the case of a patient with an intra-abdominal aortic aneurysm treated with endovascular aneurysm repair (EVAR) who developed renal impairment during the period of follow up. The repair was complicated with an early-onset type II endoleak which later evolved into a late-onset type I endoleak. It was treated with proximal extension of stent graft, with treatment success and follow-up documented on contrast enhanced ultrasound (CEUS). This case illustrates the usefulness of CEUS in post-EVAR surveillance and emphasizes the need for life-long monitoring as late-onset complications are not uncommon.
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Affiliation(s)
| | - Hsueh Wen Cheong
- Department of Radiology, Changi General Hospital, Singapore, Singapore
| | - Wey Chyi Teoh
- Department of Radiology, Changi General Hospital, Singapore, Singapore
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14
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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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Hallett RL, Ullery BW, Fleischmann D. Abdominal aortic aneurysms: pre- and post-procedural imaging. Abdom Radiol (NY) 2018; 43:1044-1066. [PMID: 29460048 DOI: 10.1007/s00261-018-1520-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abdominal aortic aneurysm (AAA) is a relatively common, potentially life-threatening disorder. Rupture of AAA is potentially catastrophic with high mortality. Intervention for AAA is indicated when the aneurysm reaches 5.0-5.5 cm or more, when symptomatic, or when increasing in size > 10 mm/year. AAA can be accurately assessed by cross-sectional imaging including computed tomography angiography and magnetic resonance angiography. Current options for intervention in AAA patients include open surgery and endovascular aneurysm repair (EVAR), with EVAR becoming more prevalent over time. Cross-sectional imaging plays a crucial role in AAA surveillance, pre-procedural assessment, and post-EVAR management. This paper will discuss the current role of imaging in the assessment of AAA patients prior to intervention, in evaluation of procedural complications, and in long-term follow-up of EVAR patients.
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Affiliation(s)
- Richard L Hallett
- Department of Radiology, Cardiovascular Imaging Section, Stanford University Hospital and Clinics, 300 Pasteur Drive, Grant Building, S-072, Stanford, CA, 94305, USA.
- St. Vincent Heart Center of Indiana, Indianapolis, IN, USA.
- Northwest Radiology Network, Indianapolis, IN, USA.
| | - Brant W Ullery
- Department of Cardiovascular Surgery, Providence Heart and Vascular Institute, Portland, OR, USA
| | - Dominik Fleischmann
- Department of Radiology, Cardiovascular Imaging Section, Stanford University Hospital and Clinics, 300 Pasteur Drive, Grant Building, S-072, Stanford, CA, 94305, USA
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Monastiriotis S, Lau I, Loh S, Ferretti J, Tassiopoulos A, Labropoulos N. Evolution of type II endoleaks based on different ultrasound-identified patterns. J Vasc Surg 2018; 67:1074-1081. [DOI: 10.1016/j.jvs.2017.08.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/13/2017] [Indexed: 11/16/2022]
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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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Prevalence and risk factors of type II endoleaks after endovascular aneurysm repair: A meta-analysis. PLoS One 2017; 12:e0170600. [PMID: 28182753 PMCID: PMC5300210 DOI: 10.1371/journal.pone.0170600] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 01/07/2017] [Indexed: 02/05/2023] Open
Abstract
Objectives This systematic review and meta-analysis aims to determine the current evidence on risk factors for type II endoleaks after endovascular aneurysm repair (EVAR). Materials and methods A systematic literature search was carried out for studies that evaluated the association of demographic, co-morbidity, and other patient-determined factors with the onset of type II endoleaks. Pooled prevalence of type II endoleaks after EVAR was updated. Results Among the 504 studies screened, 45 studies with a total of 36,588 participants were included in this review. The pooled prevalence of type II endoleaks after EVAR was 22% [95% confidence interval (CI), 19%–25%]. The main factors consistently associated with type II endoleaks included age [pooled odds ratio (OR), 0.37; 95% CI, 0.31–0.43; P<0.001], smoking (pooled OR, 0.71; 95% CI, 0.55–0.92; P<0.001), patent inferior mesenteric artery (pooled OR, 1.98; 95% CI, 1.06–3.71; P = 0.012), maximum aneurysm diameter (pooled OR, 0.23; 95% CI, 0.17–0.30; P<0.001), and number of patent lumbar arteries (pooled OR, 3.07; 95% CI, 2.81–3.33; P<0.001). Sex, diabetes, hypertension, anticoagulants, antiplatelet, hyperlipidemia, chronic renal insufficiency, types of graft material, and chronic obstructive pulmonary diseases (COPD) did not show any association with the onset of type II endoleaks. Conclusions Clinicians can use the identified risk factors to detect and manage patients at risk of developing type II endoleaks after EVAR. However, further studies are needed to analyze a number of potential risk factors.
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Nolz R, Ulrika A, Furtner J, Woitek R, Unterhumer S, Wibmer A, Prusa A, Loewe C, Schoder M. Type 2 Endoleaks: The Diagnostic Performance of Non-Specialized Readers on Arterial and Venous Phase Multi-Slice CT Angiography. PLoS One 2016; 11:e0149725. [PMID: 26930490 PMCID: PMC4773111 DOI: 10.1371/journal.pone.0149725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 02/04/2016] [Indexed: 11/25/2022] Open
Abstract
Purpose To define the diagnostic precision of non-specialized readers in the detection of type 2 endoleaks (T2EL) in arterial versus venous phase acquisitions, and to evaluate an approach for radiation dose reduction. Methods The pre-discharge and final follow-up multi-slice CT angiographies of 167 patients were retrospectively analyzed. Image data were separated into an arterial and a venous phase reading set. Two radiology residents assessed the reading sets for the presence of a T2EL, feeding vessels, and aneurysm sac size. Findings were compared with a standard of reference established by two experts in interventional radiology. The effective dose was calculated. Results Overall, experts detected 131 T2ELs, and 331 feeding vessels in 334 examinations. Persistent T2ELs causing aneurysm sac growth > 5 mm were detected in 20 patients. Radiation in arterial and venous phases contributed to a mean of 58.6% and 39.0% of the total effective dose. Findings of reader 1 and 2 showed comparable sensitivities in arterial sets of 80.9 versus 85.5 (p = 0.09), and in venous sets of 73.3 versus 79.4 (p = 0.15), respectively. Reader 1 and 2 achieved a significant higher detection rate of feeding vessels with arterial compared to venous set (p = 0.04, p < 0.01). Both readers correctly identified T2ELs with growing aneurysm sac in all cases, independent of the acquisition phase. Conclusion Arterial acquisitions enable non-specialized readers an accurate detection of T2ELs, and a significant better identification of feeding vessels. Based on our results, it seems reasonable to eliminate venous phase acquisitions.
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Affiliation(s)
- Richard Nolz
- Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Vienna, Austria
- * E-mail:
| | - Asenbaum Ulrika
- Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Division of General Radiology, Vienna, Austria
| | - Julia Furtner
- Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Vienna, Austria
| | - Ramona Woitek
- Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Division of General Radiology, Vienna, Austria
| | - Sylvia Unterhumer
- Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Vienna, Austria
| | - Andreas Wibmer
- Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Vienna, Austria
| | - Alexander Prusa
- Medical University of Vienna, Department of Surgery, Division of Vascular Surgery, Vienna, Austria
| | - Christian Loewe
- Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Vienna, Austria
| | - Maria Schoder
- Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Vienna, Austria
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Abstract
The management of endoleaks remains an inherent challenge to endovascular aneurysm repair (EVAR), particularly as evolving techniques and devices have allowed treatment of increasingly complex aneurysm anatomy. Endovascular techniques are the favored modality for endoleak repair and include techniques to bridge the endoleak defector and embolize the endoleak nidus and inflow/outflow vessels. Conversion to surgical repair remains the definitive option in cases where less invasive methods have failed or are precluded. In this article, the authors review evidence on the indications, approach, and outcomes of current techniques for endoleak management.
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Affiliation(s)
- James Chen
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - S William Stavropoulos
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Cantisani V, Grazhdani H, Clevert DA, Iezzi R, Aiani L, Martegani A, Fanelli F, Di Marzo L, Wlderk A, Cirelli C, Catalano C, Di Leo N, Di Segni M, Malpassini F, D’Ambrosio F. EVAR: Benefits of CEUS for monitoring stent-graft status. Eur J Radiol 2015. [DOI: 10.1016/j.ejrad.2015.07.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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22
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Couchet G, Pereira B, Carrieres C, Maumias T, Ribal JP, Ben Ahmed S, Rosset E. Predictive Factors for Type II Endoleaks after Treatment of Abdominal Aortic Aneurysm by Conventional Endovascular Aneurysm Repair. Ann Vasc Surg 2015; 29:1673-9. [PMID: 26303269 DOI: 10.1016/j.avsg.2015.07.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 06/06/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to identify the predictive factors for the development of type II endoleaks (EL-II) after endovascular aneurysm repair (EVAR). METHODS We assessed the preoperative and postoperative computed tomography data of 308 patients who underwent EVAR between 2000 and 2012 and in 84 of whom primary or secondary EL-II occurred. The data analyzed were: demographics, number and diameter of lumbar arteries (LAs), inferior mesenteric artery (IMA), median sacral artery (MSA), accessory renal arteries (ARas), maximum diameter of infrarenal abdominal aortic aneurysm, diameter and length of proximal aortic neck. Statistical analysis was performed using Stata software (version 12). Categorical parameters were compared between groups using chi-squared or Fisher's exact tests as appropriate. Continuous variables were analyzed using Student's t-test or Mann-Whitney test as appropriate (normality studied by the Shapiro-Wilk and homoscedasticity verified using the Fisher-Snedecor test). RESULTS Of the 308 patients included (mean age, 73.8 ± 8.74 years), 284 (92%) were men, 61 (20%) were smokers, 113 (37%) had chronic obstructive pulmonary disease, 215 (70%) were taking antiplatelet. Respectively, 13, 51, 60, 103, 28, 40, 2, and 7 patients had 1, 2, 3, 4, 5, 6, 7, and 8 patent LAs. Before surgery, 221 IMAs and 136 MSA were patent. The sources of EL-II were: LA (n = 51), IMA (n = 22), MSA (n = 1), IMA and LA (n = 8), IMA and ARa (n = 1), and unknown (n = 1). Logistic regression models adjusting for clinically relevant covariables (age, American Society of Anesthesiologists, smoking status, dyslipidemia, and diuretics) were proposed to study morphologic EL-II predictive factors, first in the entire population, and then in the more specific population for whom IMA was patent. Risk factors of occurrence EL-II were: permeability of the IMA (70 patients [83%] vs. 155 [69%], P = 0.01), IMA diameter (3.49 mm vs. 2.71 mm, P < 0.001), number of LAs patent higher than or equal to 4 (P < 0.001), the mean LA diameter greater than 2.4 mm (P < 0.001), and MSA diameter (2.28 mm vs. 1.94 mm; P < 0.01). CONCLUSIONS Our results show the major role of the number and diameter of the patent aortic branches in the development of EL-II. As they can result in complications increasing the morbidity and mortality after EVAR, it is relevant to identify the risk factors of their occurrence.
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Affiliation(s)
- Geoffroy Couchet
- Department of Vascular Surgery, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Caroline Carrieres
- Department of Vascular Surgery, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Thibaut Maumias
- Department of Vascular Surgery, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Pierre Ribal
- Department of Vascular Surgery, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Sabrina Ben Ahmed
- Department of Vascular Surgery, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Eugenio Rosset
- Department of Vascular Surgery, CHU Clermont-Ferrand, Clermont-Ferrand, France.
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23
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Miranda Jr. F. Endovascular abdominal aortic aneurysm repair: type 2 endoleaks and risk of rupture. J Vasc Bras 2014. [DOI: 10.1590/1677-5449.1304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Essentials of endovascular abdominal aortic aneurysm repair imaging: postprocedure surveillance and complications. AJR Am J Roentgenol 2014; 203:W358-72. [PMID: 25247965 DOI: 10.2214/ajr.13.11736] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Lifelong postprocedural imaging surveillance is necessary after endovascular abdominal aortic aneurysm repair (EVAR) to assess for complications of endograft placement, as well as device failure and continued aneurysm growth. Refinement of the surveillance CT technique and development of ultrasound and MRI protocols are important to limit radiation exposure. CONCLUSION A comprehensive understanding of EVAR surveillance is necessary to identify life-threatening complications and to aid in secondary treatment planning.
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Khaja MS, Park AW, Swee W, Evans AJ, Fritz Angle J, Turba UC, Sabri SS, Matsumoto AH. Treatment of Type II Endoleak Using Onyx With Long-Term Imaging Follow-Up. Cardiovasc Intervent Radiol 2013; 37:613-22. [DOI: 10.1007/s00270-013-0706-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 06/22/2013] [Indexed: 10/26/2022]
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Nolz R, Teufelsbauer H, Asenbaum U, Beitzke D, Funovics M, Wibmer A, Plank C, Prusa AM, Lammer J, Schoder M. Type II endoleaks after endovascular repair of abdominal aortic aneurysms: fate of the aneurysm sac and neck changes during long-term follow-up. J Endovasc Ther 2012; 19:193-9. [PMID: 22545884 DOI: 10.1583/11-3803.1] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE To evaluate the frequency of type II endoleaks after endovascular aneurysm repair (EVAR) and to compare sac diameter and neck changes in patients with type II endoleak to endoleak-free patients with at least 3-year imaging follow-up. METHODS Among 407 consecutive EVAR patients, 109 patients (101 men; mean age 72.1 years, range 55-86) had at least 3-year computed tomography (CT) data and no type I or III endoleak. In this cohort, 49 patients presented with a type II endoleak at some time and 60 patients had no endoleak. Patients with type II endoleaks were further divided into subgroups based on the vessel origin and the perfusion status (persistent or transient). The course of the perfusion status of type II endoleaks and changes in the aneurysm sac diameters, neck diameters, and renal to stent-graft distances (RSD) were evaluated in the defined groups. Reintervention and death rates were also reported. RESULTS The mean follow-up was 68.1 ± 23.8 months. Compared to the no endoleak group, overall sac diameter increased significantly in the type II endoleak group (p = 0.007), but vessel origin did not have any influence. With regard to the perfusion status of type II endoleaks, aneurysm sac changes were significantly higher (p = 0.002) in the persistent endoleak group. During the study period, the increase in the proximal neck diameter was significantly higher in the no endoleak group compared to the type II endoleak group (p = 0.025). No significant difference was found in RSD changes between the defined groups. Reinterventions were performed in 20 (18.3%) patients (13 for type II endoleak); 2 (1.8%) patients without type II endoleak died of ruptured aneurysm. CONCLUSION Persistent type II endoleaks led to significant aneurysm sac enlargement, but without increased mortality or rupture rates.
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Affiliation(s)
- Richard Nolz
- Department of Radiology, Division of Cardiovascular and Interventional Radiology, Medical University of Vienna, Austria.
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27
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van den Berg JC. Commentary: Type II endoleaks: still the crux of EVAR? J Endovasc Ther 2012; 19:209-12. [PMID: 22545886 DOI: 10.1583/11-3653c.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Jos C van den Berg
- Service of Interventional Radiology, Ospedale Regionale di Lugano sede Civico, Lugano, Switzerland.
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28
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Georgakarakos E, Georgiadis GS, Ioannou CV, Kapoulas KC, Trellopoulos G, Lazarides M. Aneurysm sac shrinkage after endovascular treatment of the aorta: Beyond sac pressure and endoleaks. Vasc Med 2012; 17:168-73. [DOI: 10.1177/1358863x11431293] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The isolation of the aneurysm sac from systemic pressure and its consequent shrinkage are considered criteria of success after endovascular repair (EVAR). However, the process of shrinkage does not solely depend on the intrasac pressure, the predictive role of which remains ambiguous. This brief review summarizes the additional pathophysiological mechanisms that regulate the biomechanical properties of the aneurysm wall and may interfere with the process of aneurysm sac shrinkage.
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Affiliation(s)
- Efstratios Georgakarakos
- Department of Vascular Surgery, ‘Demokritus’ University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, ‘Demokritus’ University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Christos V Ioannou
- Department of Vascular Surgery, University of Crete Medical School, University Hospital of Heraklion, Heraklion, Greece
| | - Konstantinos C Kapoulas
- Department of Vascular Surgery, ‘Demokritus’ University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - George Trellopoulos
- First Surgical Clinic, General Hospital ‘G. Papanikolaou’, Exohi, Thessaloniki, Greece
| | - Miltos Lazarides
- Department of Vascular Surgery, ‘Demokritus’ University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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Sucandy I, Kim H, Sullivan TR. Endovascular management of the patent inferior mesenteric artery in two cases of uncontrolled type II endoleak after endovascular aneurysm repair. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2011; 3:387-90. [PMID: 22171248 PMCID: PMC3234148 DOI: 10.4297/najms.2011.3387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Context: Endovascular aneurysm repair (EVAR) has well documented advantages over traditional open repair and has been widely adopted as the alternative treatment modality for abdominal aortic aneurysm. However, endoleaks specifically type II can be a significant problem with this technique leading to aortic sac expansion and potential rupture. A large number of type II endoleaks are caused by persistent inferior mesenteric artery (IMA) retrograde bleeding. Various methods to try to manage this complication have been previously described. IMA embolization via the marginal artery of Drummond, however, has not been adequately popularized as an alternative less invasive approach to the treatment of type II endoleak. Case Report: Two men, ages 77 and 81, underwent uneventful EVAR for 5.5 and 5.0 cm infrarenal abdominal aortic aneurysms, respectively, using Zenith Cook® bifurcated stent grafts. Computed tomography angiography at 1 and 6 months postoperatively demonstrated small type II endoleaks in both cases which were followed clinically. Subsequent follow-up tomography scan at 12 months revealed persistent type II endoleaks related to retrograde filling from the IMA with significant enlargement of the aneurysm sacs. Both patients underwent successful IMA coil embolization via the marginal artery of Drummond. Conclusions: Percutaneous IMA embolization using standard endovascular techniques to access the marginal artery of Drummond is an alternative, and in our opinion, preferred technique for controlling type II endoleaks caused by a persistently patent IMA.
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Affiliation(s)
- Iswanto Sucandy
- Department of Surgery, Abington Memorial Hospital, Abington, Pennsylvania, USA
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Cho DM, Park KM, Yang SS, Kim NR, Woo SY, Kim YW, Park KB, Park HS, Do YS, Kim DI. Natural History of Type II Endoleaks after Endovascular Aneurysm Repair in Abdominal Aortic Aneurysm. Vasc Specialist Int 2011. [DOI: 10.5758/kjves.2011.27.4.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Dong Min Cho
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keun Myoung Park
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin Seok Yang
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Na Ri Kim
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin Young Woo
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Wook Kim
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Bo Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Suk Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Soo Do
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Ik Kim
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Franz RW, Nguyen TV. A unique case of a type II endoleak after EVAR caused by patent inferior mesenteric and accessory renal arteries. Vasc Endovascular Surg 2011; 45:651-3. [PMID: 21757496 DOI: 10.1177/1538574411414305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Type II endoleaks have been viewed as the Achilles' heel of endovascular repair of abdominal aortic aneurysms. This report describes a unique etiology to this common challenge and our approach to endovascular repair.
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Affiliation(s)
- Randall W Franz
- The Vascular and Vein Center at Grant Medical Center, 285 East State Street, Suite 260, Columbus, OH 43215, USA.
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Marchiori A, von Ristow A, Guimaraes M, Schönholz C, Uflacker R. Predictive Factors for the Development of Type II Endoleaks. J Endovasc Ther 2011; 18:299-305. [DOI: 10.1583/10-3116.1] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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33
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Aracil Sanus E, Vila i Coll R, Leal J, Fontcuberta J, Riera Vázquez R, Merino Mairal O. Guía de seguimiento no invasivo del tratamiento endovascular del aneurisma de aorta abdominal. ANGIOLOGIA 2011. [DOI: 10.1016/j.angio.2011.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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34
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Beeman BR, Murtha K, Doerr K, McAfee-Bennett S, Dougherty MJ, Calligaro KD. Duplex ultrasound factors predicting persistent type II endoleak and increasing AAA sac diameter after EVAR. J Vasc Surg 2010; 52:1147-52. [DOI: 10.1016/j.jvs.2010.06.099] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 06/02/2010] [Accepted: 06/06/2010] [Indexed: 11/24/2022]
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35
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Louwers LM, Seder CW, Bove PG. A novel treatment approach to a type II endoleak at endograft implantation using components of an endosensor monitoring device. Vasc Endovascular Surg 2010; 44:568-71. [PMID: 20675313 DOI: 10.1177/1538574410375128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE There continues to be debate regarding optimal management of type II endoleaks following endovascular abdominal aortic aneurysm repair. CASE REPORT We present an intraoperative treatment approach to type II endoleaks using components of the EndoSure Intrasac Pressure Monitor System. Our technique can easily be reproduced with commercially available guidewires and catheters. We also present a literature review that identifies type II endoleak characteristics associated with a high rate of persistence (high-risk endoleaks) and could benefit from early treatment. CONCLUSIONS If a high-risk type II endoleak is identified intraoperatively, those patients may benefit from our model of an early intervention strategy. Early definitive treatment of the endoleaks could result in lower morbidity and reintervention rates.
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Abularrage CJ, Crawford RS, Conrad MF, Lee H, Kwolek CJ, Brewster DC, Cambria RP, Lamuraglia GM. Preoperative variables predict persistent type 2 endoleak after endovascular aneurysm repair. J Vasc Surg 2010; 52:19-24. [PMID: 20478685 DOI: 10.1016/j.jvs.2010.02.023] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Revised: 02/03/2010] [Accepted: 02/07/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Persistent type 2 endoleaks (PT2, present >or=6 months) after endovascular aneurysm repair (EVAR) are associated with adverse outcomes. This study evaluated the preoperative risk factors and natural history of PT2 in order to define a population at high risk. METHODS From January 1999 to December 2007, 595 of 832 EVAR patients had long-term computed tomography follow-up and comprised the study cohort. Preoperative anatomic and clinical variables were correlated with PT2 using Cox regression. Composite hazard ratios (HRs) were constructed with clusters of high-risk preoperative variables. Primary end points, including spontaneous resolution, sac enlargement >5 mm, and freedom from reintervention, were evaluated using Kaplan-Meier analysis. RESULTS There were 136 PT2 patients (23%) with a median follow-up of 34.8 months (range, 6.4-121.2 months). Positive predictive factors included patent inferior mesenteric artery (IMA; HR, 4.00; 95% confidence interval [CI], 1.62-9.90; P = .003), increasing number of patent lumbar arteries (HR, 1.24; 95% CI, 1.10-1.41; P = .0006), increasing age (HR, 1.04; 95% CI, 1.01-1.06; P = .005), and increasing luminal diameter on CT-contrast opacified lumen (HR, 1.03; 95% CI, 1.02-1.05; P = .0001). During follow-up, spontaneous PT2 resolution occurred in 34 patients (25%), sac diameter remained stable in 63 (46%), and rupture occurred in 2 (1.5%). Kaplan-Meier analysis estimated that 35.2% +/- 5.6% (95% CI, 23.8%-46.2%) of PT2 resolve spontaneously at 5 years after the index procedure. Freedom from sac enlargement >5 mm was 54.6% +/- 7.2% (95% CI, 40.6%-69.4%) at 5 years. Fifty-nine reinterventions were performed in 39 patients with PT2. Freedom from reintervention was 67.3% +/- 5.0% (95% CI, 57.0%-77.0%) at 5 years. The combination of a patent IMA and one risk factor of more than six patent lumbar arteries, maximum luminal diameter >30 mm, or age >70 years increased the odds of PT2 approximately ninefold. The combination of a patent IMA and any two risk factors increased the odds of PT2 approximately 18-fold. CONCLUSIONS Several readily identifiable preoperative variables are associated with PT2 whose natural history was benign in but 35% of patients. On the basis of the composite high-risk HRs, there is accordingly a cohort of patients in whom perioperative interventions to preclude PT2 should be considered.
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Affiliation(s)
- Christopher J Abularrage
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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37
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Beeman BR, Doctor LM, Doerr K, McAfee-Bennett S, Dougherty MJ, Calligaro KD. Duplex ultrasound imaging alone is sufficient for midterm endovascular aneurysm repair surveillance: A cost analysis study and prospective comparison with computed tomography scan. J Vasc Surg 2009; 50:1019-24. [DOI: 10.1016/j.jvs.2009.06.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2009] [Revised: 06/04/2009] [Accepted: 06/06/2009] [Indexed: 10/20/2022]
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Lawrence-Brown MMMD, Sun Z, Semmens JB, Liffman K, Sutalo ID, Hartley DB. Type II endoleaks: when is intervention indicated and what is the index of suspicion for types I or III? J Endovasc Ther 2009; 16 Suppl 1:I106-18. [PMID: 19317572 DOI: 10.1583/08-2585.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
One of the principal reasons for failure of endovascular aneurysm repair (EVAR) is the occurrence of endoleaks, which regardless of size or type can transmit systemic pressure to the aneurysm sac. There is little debate that type I endoleaks (poor proximal or distal sealing) are associated with continued risk of aneurysm rupture and require treatment. Similarly, with type III endoleak, there is agreement that the defect in the device needs to be addressed; however, what to do with type II endoleaks and their effect on long-term outcome are not so clear. Aneurysm sac change is a primary parameter for determining the presence of an endoleak and assessing its impact. While diameter measurement has been the most commonly used method for determining sac changes, volume measurement has now been proven superior for monitoring structural changes in the 3-dimensional sac. Determining the source of an endoleak and the direction of flow are necessary for proper classification; however, while computed tomographic angiography has high sensitivity and specificity for detecting endoleaks, it is limited in its ability to show the direction of flow. Contrast-enhanced duplex ultrasound, on the other hand, is better able to quantify flow and characterize endoleaks. Flow is evidence of pressure, and increasing intrasac pressure increases wall tension, thus inducing progressive aneurysm expansion until rupture. Hence, determining intrasac pressure is becoming a vital component of endoleak assessment. All endoleaks can create systemic pressure inside the aneurysm sac, and there are a variety of intrasac pressure transducers being evaluated to assess this effect. A clinical pathway for patients with suspected type II endoleaks is based on a combination of imaging and pressure measurements. Imaging alone requires at least two interval examinations to determine the trend, while pressure measurements give immediate reassurance or an indication to intervene. Although still under development, pressure measurement is destined for general use and will provide a scientific basis for the management of type II endoleaks.
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Bargellini I, Cioni R, Napoli V, Petruzzi P, Vignali C, Cicorelli A, Sardella S, Ferrari M, Bartolozzi C. Ultrasonographic Surveillance With Selective CTA After Endovascular Repair of Abdominal Aortic Aneurysm. J Endovasc Ther 2009; 16:93-104. [DOI: 10.1583/08-2508.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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40
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Hiramoto JS, Howell B, Reilly LM, Chuter TA. Effect of Systemic Blood Pressure on Aneurysm Size in the Presence of a Type II Endoleak. Vascular 2008; 16:321-5. [DOI: 10.2310/6670.2008.00082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The objective of this study was to determine whether hypertension is a risk factor for aneurysm enlargement in patients with an untreated type II endoleak after endovascular abdominal aortic aneurysm repair (EVAR). Between January 2000 and December 2005, 296 patients underwent elective EVAR using a bifurcated Zenith stent graft. Forty-nine (17%) patients had a type II endoleak triaged to observation. Patient clinical data and data on endoleak status, aneurysm size, and endoleak intervention were collected prospectively. Aneurysm size remained the same or decreased in 39 of 49 (80%) patients. In the remaining 10 (20%) patients with aneurysm enlargement, 7 required intervention. There was no difference in initial aneurysm size, patient age, gender, or comorbidities between patients with enlarging aneurysms and those with stable or regressing aneurysms. However, patients with enlarging aneurysms had a mean systolic blood pressure (SBP) of 144 ± 14 mm Hg compared with 136 ± 13 mm Hg for patients with stable or regressing aneurysms ( p = .08). Multivariate regression analysis demonstrated increased SBP to be an independent predictor of aneurysm enlargement ( p = .05). Patients with systolic hypertension and an untreated type II endoleak are more likely to demonstrate aneurysm enlargement after EVAR. Aggressive blood pressure control may be an important adjunct in the management of patients with type II endoleak after EVAR.
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Affiliation(s)
- Jade S. Hiramoto
- *Department of Surgery, Division of Vascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Benjamin Howell
- *Department of Surgery, Division of Vascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Linda M. Reilly
- *Department of Surgery, Division of Vascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Timothy A.M. Chuter
- *Department of Surgery, Division of Vascular Surgery, University of California, San Francisco, San Francisco, CA
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41
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Kleinstreuer C, Li Z, Farber MA. Fluid-Structure Interaction Analyses of Stented Abdominal Aortic Aneurysms. Annu Rev Biomed Eng 2007; 9:169-204. [PMID: 17362195 DOI: 10.1146/annurev.bioeng.9.060906.151853] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Rupture of abdominal aortic aneurysms (AAAs) alone is the thirteenth leading cause of death in the United States. Thus, reliable AAA-rupture risk prediction is an important advancement. If repair becomes necessary, the minimally invasive technique of inserting a stent-graft (SG), commonly referred to as endovascular aneurysm repair (EVAR), is a viable option in many cases. However, postoperative complications, such as endoleaks and/or SG migration, may occur. Computational fluid-structure interaction simulations provide physical insight into the hemodynamics coupled with multi-wall mechanics' function as an assessment tool for optimal SG placement and improved device design.
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Affiliation(s)
- C Kleinstreuer
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, North Carolina 27695, USA.
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42
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Dias NV, Ivancev K, Resch TA, Malina M, Sonesson B. Endoleaks after endovascular aneurysm repair lead to nonuniform intra-aneurysm sac pressure. J Vasc Surg 2007; 46:197-203. [PMID: 17664097 DOI: 10.1016/j.jvs.2007.04.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Accepted: 04/03/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This was a study of intra-aneurysm sac pressures in patients who presented with endoleaks after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA). METHODS Twenty-five patients (18 men, 7 women) with endoleaks, age (IQR 68 to 80), underwent 31 direct intra-aneurysm sac pressure measurements, DISP at 16 months after EVAR (IQR, 14 to 26 months). Diameter of AAA was 59 mm (IQR, 52 to 67 mm). Six patients underwent DISP twice. Tip-pressure sensors were used through direct translumbar puncture of the AAA except in three patients (transabdominal puncture in 2; endoluminal in 1). Mean pressure index (MPI) was calculated between simultaneously registered intra-aneurysm sac and systemic pressures. Values presented are medians with interquartile range (IQR). RESULTS Type I endoleaks (n = 1) showed MPI of 93% in the nidus and 62% in the thrombus. Type II endoleaks were associated with lower MPIs in the thrombus (35%; IQR 24% to 38%) when AAAs shrank (n = 4) compared with when the AAAs remained unchanged (n = 11; MPI, 78%; IQR, 47% to 85%) or expanded (n = 6; MPI, 74%; IQR, 58% to 87%; P = .019). The nidus of type II endoleaks (MPI, 79%; IQR, 70% to 90%) had higher pressure than the thrombus (45%, IQR, 34% to 85%; P = .047; n = 7). Successful embolization of type II endoleaks led to AAA shrinkage (n = 3; MPI reduction, 13% to 31%) or diameter stability (n = 3; unchanged MPIs, 37% to 44%). Type III endoleaks (n = 3) had MPIs in the thrombus of 33% to 70%. CONCLUSIONS Endoleaks after EVAR pressurize the AAA sac nonuniformly, with higher, near-systemic, pressure in the endoleak nidus compared with the thrombus. Nevertheless, type II endoleaks in shrinking AAAs have lower intra-sac pressure than expanding or stable aneurysms, and successful endoleak embolization reduces pressure.
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Affiliation(s)
- Nuno V Dias
- Department of Vascular Diseases Malmö-Lund and Endovascular Centre, Malmö University Hospital, Lund University, Malmö, Sweden.
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43
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Stavropoulos SW, Charagundla SR. Imaging Techniques for Detection and Management of Endoleaks after Endovascular Aortic Aneurysm Repair1. Radiology 2007; 243:641-55. [PMID: 17517926 DOI: 10.1148/radiol.2433051649] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endovascular aortic aneurysm repair (EVAR) is evolving into a viable alternative to open surgical repair for many patients with abdominal and thoracic aortic aneurysms. Endoleak development is a complication of EVAR and represents one of the limitations of this procedure. Endoleaks represent blood flow outside the stent-graft lumen but within the aneurysm sac. Lifelong imaging surveillance of patients after EVAR is critical to detect endoleaks for the patient's benefit and to determine the long-term performance of the stent-graft. Although computed tomographic angiography is the most commonly used examination for imaging surveillance, magnetic resonance angiography, ultrasonography, and digital subtraction angiography all have a role in endoleak detection and management. This review will focus on imaging techniques used for endoleak detection and the role imaging surveillance plays in the overall care of the post-EVAR patient.
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Affiliation(s)
- S William Stavropoulos
- Department of Radiology, Division of Interventional Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA.
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44
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Mansueto G, Cenzi D, Scuro A, Gottin L, Griso A, Gumbs AA, Mucelli RP. Treatment of type II endoleak with a transcatheter transcaval approach: Results at 1-year follow-up. J Vasc Surg 2007; 45:1120-7. [PMID: 17543674 DOI: 10.1016/j.jvs.2007.01.063] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2006] [Accepted: 01/25/2007] [Indexed: 11/27/2022]
Abstract
PURPOSE This study assessed the feasibility and mid-term outcomes in the treatment of type II endoleak using transcatheter transcaval embolization (TTE). METHODS During an 8-month period, 12 patients underwent TTE. After direct transcaval puncture of the aneurysm sac, embolization was performed by injecting thrombin and placing coils. Systemic and intrasac pressures were recorded throughout the entire procedure. Computed tomography (CT) scans were performed at 24 hours, 30 days, 6 months, and 1 year after TTE to evaluate endoleaks and changes in sac diameter. Technical success was defined as the feasibility of the procedure; clinical success was defined as no evidence of leaks during the follow-up evaluation. RESULTS TTE was feasible in 11 of 12 patients (technical success 92%). The mean systemic pressure was 117 mm Hg. The mean intrasac pressure before embolization was 75 mm Hg (range, 39 to 125 mm Hg), 16.5 mm Hg (range, 7 to 40 mm Hg) in 10 patients after embolization, and it increased in one patient. CT scans at 24 hours showed stable contrast medium inside the sac in 10 patients. Only minor complications were observed during follow-up. At the 1-year follow-up, no recurrence of leaks was noted, and sac diameter was reduced in 10 of 11 patients. As a result, TTE clinical success was obtained in 10 (83%) of 12 patients. CONCLUSION TTE appears to be a feasible technique for the complete exclusion of type II endoleaks. Technical and clinical successes are comparable with other treatment strategies, and TTE should be considered an alternative to direct translumbar puncture of the aneurysm sac.
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Affiliation(s)
- Giancarlo Mansueto
- Department of Morphological and Biomedical Sciences-Radiology Institute, Intensive Care Unit, University Hospital GB Rossi, Verona, Italy.
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45
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San Norberto-García E, del Blanco-Alonso I, Ibáñez-Maraña M, Cenizo-Revuelta N, Brizuela-Sanz J, Mengíbar-Fuentes L, Gutiérrez-Alonso V, González-Fajardo J, del Río-Solá M, Carrera-Díaz S, Vaquero-Puerta C. Valor diagnóstico de la ecografía Doppler color en el control clínico de la reparación endovascular de los aneurismas de aorta abdominal. ANGIOLOGIA 2007. [DOI: 10.1016/s0003-3170(07)75024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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46
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Li Z, Kleinstreuer C. Computational analysis of type II endoleaks in a stented abdominal aortic aneurysm model. J Biomech 2005; 39:2573-82. [PMID: 16221475 DOI: 10.1016/j.jbiomech.2005.09.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2005] [Accepted: 09/01/2005] [Indexed: 11/25/2022]
Abstract
Insertion of a stent-graft into an aneurysm to form a new (synthetic) blood vessel and prevent the weakened artery wall from rupture is an attractive surgical intervention when compared to traditional open surgery. However, focusing on a stented abdominal aortic aneurysm (AAA), post-operative complications such as endoleaks may occur. An endoleak is the net influx of blood during the cardiac cycle into the cavity (or sac) formed by the stent-graft and the AAA wall. A natural endoleak source may stem from one or two secondary branches leading to and from the aneurysm, labeled types IIa and IIb endoleaks. Employing experimentally validated fluid-structure interaction solvers, the transient 3-D lumen and cavity blood flows, wall movements, pressure variations, maximum wall stresses and migration forces were computed for types IIa and IIb endoleaks. Simulation results indicate that the sac pressure caused by these endoleaks depends largely on the inlet branch pressure, where the branch inlet pressure increases, the sac pressure may reach the systemic level and AAA-rupture is possible. The maximum wall stress is typically located near the anterior-distal side in this model, while the maximum stent-graft stress occurs near the bifurcating point, in both cases, due to local stress concentrations. The time-varying leakage rate depends on the pressure difference between AAA sac and inlet branch. In contrast, the stent-graft migration force is reduced by type II endoleaks because it greatly depends on the pressure difference between the stent-graft and the aneurysm cavity.
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Affiliation(s)
- Z Li
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC 27695-7910, USA
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47
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Wright IA, Gordon MK, Buckenham TM. SPECTRAL DOPPLER CHARACTERIZATION OF ENDOLEAKS FOLLOWING ENDOLUMINAL ABDOMINAL AORTIC ANEURYSM REPAIR. ANZ J Surg 2005; 75:118-23. [PMID: 15777387 DOI: 10.1111/j.1445-2197.2005.03313.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Colour Doppler ultrasound of endoluminal abdominal aortic aneurysm repair is becoming an established imaging technique in identifying endoleak. Management and treatment of endoleak is determined in part by the exact nature of the endoleak, namely its type and whether it has single or multiple vessel inflow and outflow. To date, spectral Doppler waveform analysis has provided some information about the propensity for spontaneous seal of isolated type II endoleaks, rather than assisting in their classification. METHODS We present a collection of three case reports outlining the directionality/phasicity of the Doppler waveform profile associated with endoleaks whose type and subtype (uni- /or multi-conduital) were angiographically determined. RESULTS In all three cases uniconduital type II endoleak demonstrated a to-and-fro waveform on Doppler ultrasound imaging. CONCLUSIONS To-and-fro Doppler waveforms may be associated with uniconduital type II endoleaks. If upon investigation of further cases this is found to be the case, this waveform classification may facilitate determination of the subtype (uni- or multi-conduital) of endoleak, thus identifying those cases which may be more amenable to percutaneous repair.
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Affiliation(s)
- Isabel A Wright
- Department of Surgery, Christchurch Public Hospital, Christchurch, New Zealand.
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48
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Bargellini I, Napoli V, Petruzzi P, Cioni R, Vignali C, Sardella SG, Ferrari M, Bartolozzi C. Type II lumbar endoleaks: Hemodynamic differentiation by contrast-enhanced ultrasound scanning and influence on aneurysm enlargement after endovascular aneurysm repair. J Vasc Surg 2005; 41:10-8. [PMID: 15696037 DOI: 10.1016/j.jvs.2004.10.037] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The objective of this study was to differentiate type II lumbar endoleaks on the basis of dynamic features identified by contrast-enhanced ultrasound scanning (CUS) and to evaluate the role of this differentiation in detecting abdominal aortic aneurysm (AAA) enlargement > or =1 mL/mo. METHODS Eighteen male patients (mean age, 71.8 years) with type II lumbar endoleak suspected at CUS underwent computed tomography angiography (CTA) and digital subtraction angiography (DSA). On CTA, AAA volumes and endoleak visualization and volume were assessed. At CUS, performed after a bolus of 1.5 to 2.4 mL of a second generation blood pool contrast agent, the following parameters were evaluated: presence of contrast material within the aneurysmal sac (endoleak), delay of endoleak detection (wash-in) and disappearance (washout) from the beginning of contrast injection, visualization of inflow and outflow vessels, and presence of cavity filling. Statistical analysis was performed regarding endoleak features at CUS, endoleak detection at CTA, and rate of AAA enlargement. RESULTS DSA confirmed all the endoleaks. Mean +/- standard deviation wash-in and washout times were 121.9 +/- 132.6 and 337.2 +/- 193.7 seconds, respectively; a significant relation was observed between these two parameters (P < .01, analysis of variance). By Youden plots, endoleaks were classified as hyperdynamic when wash-in was <100 seconds (n = 10, 55.5%) and/or washout was <520 seconds (n = 13, 72.2%). A slower washout was associated with nonvisualized outflow (66.7%) and/or inflow arteries (66.7%) ( P < .05). Eight endoleaks (44.4%) were missed at CTA; it occurred in hypodynamic endoleaks, absence of detectable inflow or outflow vessels, and absence of cavity filling at CUS (P < .05). Overall mean AAA volume increase rate was 1.1 +/- 1.7 mL/mo. By multiple logistic regression model, the washout time > or = 520 seconds was the only independent predictor of AAA volume increase > or = 1 mL/mo (8 patients, 44.4%). CONCLUSION Type II lumbar endoleaks show different hemodynamic features at CUS, which might influence the rate of aneurysm enlargement, addressing the need for treatment.
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Affiliation(s)
- Irene Bargellini
- Division of Diagnostic and Interventional Radiology, University of Pisa, Via Roma 67, 56127 Pisa, Italy.
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49
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Heikkinen MA, Arko FR, Zarins CK. What is the significance of endoleaks and endotension. Surg Clin North Am 2004; 84:1337-52, vii. [PMID: 15364558 DOI: 10.1016/j.suc.2004.04.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endovascular repair has been used over a decade as a treatment of abdominal aortic aneurysm, and has become a widely accepted treatment method with a low rate of perioperative complications. Endoleak, perigraft blood flow outside endograft but within aneurysmsac, has been intensively studied during the last 10 years of endovascular aneurysm repair (EVR). The natural history of aneurysms with endoleak and the true clinical significance of various types of endoleaks remains unclear. Type I/III endoleak has been found to be associated with aneurysm rupture, while the risk of rupture of aneurysms with type II endoleak and endotension appears very small. In endotension, the aneurysm sac remains pressurized, even if there is no evidence of an endoleak. Currently,it is accepted that type I/III endoleaks should be corrected, preferably by endovascular means, due to the risk of rupture. If endovascular repair is not possible, then open conversion should be considered. The risk of conversion should be weighed against the risk of aneurysm rupture. Treatment of type II endoleaks and endotension is more controversial. In those with aneurysm enlargement,secondary interventions are often performed.
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Affiliation(s)
- Maarit A Heikkinen
- Stanford University Medical Center, 300 Pasteur Drive, H3600, Stanford, CA 94305-5642, USA
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Napoli V, Bargellini I, Sardella SG, Petruzzi P, Cioni R, Vignali C, Ferrari M, Bartolozzi C. Abdominal Aortic Aneurysm: Contrast-enhanced US for Missed Endoleaks after Endoluminal Repair. Radiology 2004; 233:217-25. [PMID: 15454621 DOI: 10.1148/radiol.2331031767] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate contrast material-enhanced ultrasonography (US) for depiction of endoleaks after endovascular abdominal aortic aneurysm repair (or endovascular aneurysm repair [EVAR]) in patients with aneurysm enlargement and no evidence of endoleak. MATERIALS AND METHODS From November 1998 to February 2003, 112 patients underwent EVAR. At follow-up, duplex US and biphasic multi-detector row computed tomographic (CT) angiography were performed. In 10 patients (group A), evident aneurysm enlargement was observed, with no evidence of complications, at both CT angiography and duplex US. Group A patients, 10 men (mean age, 69.6 years +/- 10 [standard deviation]), underwent US after intravenous bolus injection of a second-generation contrast agent, with continuous low-mechanical index (0.01-0.04) real-time tissue harmonic imaging. Group B patients, 10 men (mean age, 71.3 years +/- 8.2) with aneurysm shrinkage and no evidence of complications, and group C patients, 10 men (mean age, 73.2 years +/- 6) with CT angiographic evidence of endoleak, underwent contrast-enhanced US. Digital subtraction angiography (DSA) was performed in groups A and C. Endoleak detection and characterization were assessed with imaging modalities used in groups A-C; at contrast-enhanced US, time of detection of endoleak, persistence of sac enhancement, and morphology of enhancement were evaluated. RESULTS In group A, contrast-enhanced US depicted one type I, six type II, one type III, and two undefined endoleaks that were not detected at CT angiography. All leakages were characterized by slow and delayed echo enhancement detected at longer than 150 seconds after contrast agent administration. DSA results confirmed findings in all patients; percutaneous treatment was performed. In group B, contrast-enhanced US did not show echo enhancement; in group C, results with this modality confirmed findings at CT angiography and DSA. CONCLUSION Contrast-enhanced US depicts endoleaks after EVAR, particularly when depiction fails with other imaging modalities.
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MESH Headings
- Aged
- Aged, 80 and over
- Angiography
- Angiography, Digital Subtraction
- Angioplasty
- Aorta, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/surgery
- Blood Vessel Prosthesis
- Contrast Media
- Female
- Follow-Up Studies
- Humans
- Male
- Middle Aged
- Phospholipids
- Postoperative Complications/diagnostic imaging
- Prosthesis Design
- Stents
- Sulfur Hexafluoride
- Tomography, Spiral Computed
- Ultrasonography, Doppler, Color
- Ultrasonography, Doppler, Duplex
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Affiliation(s)
- Vinicio Napoli
- Department of Oncology, Transplants and Advanced Technologies in Medicine, Division of Diagnostic and Interventional Radiology and Department of Vascular Surgery, University of Pisa, Via Roma 67, 56126 Pisa, Italy
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