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Boer GJ, van Engen LAH, van Dam L, van de Luijtgaarden KM, Bokkers RPH, de Vries JPPM, Fioole B. Dynamic Computed Tomography Angiography as Imaging Method for Endoleak Classification after Endovascular Aneurysm Repair: A Case Series and Systematic Review of the Literature. Diagnostics (Basel) 2023; 13:diagnostics13050829. [PMID: 36899973 PMCID: PMC10001404 DOI: 10.3390/diagnostics13050829] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION This study evaluated our experience with dynamic computed tomography angiography (dCTA) as a diagnostic tool after endovascular aortic aneurysm repair (EVAR) with respect to the endoleak classification and the available literature. METHODS We reviewed all patients who underwent dCTA because of suspected endoleaks after the EVAR and classified the endoleaks in these patients based on standard CTA (sCTA) and dCTA. We systematically reviewed all available publications that investigated the diagnostic accuracy of dCTA compared with other imaging techniques. RESULTS In our single-center series, 16 dCTAs were performed in 16 patients. In 11 patients, the undefined endoleaks that appeared on sCTA scans were successfully classified using dCTA. In three patients with a type II endoleak and aneurysm sac growth, inflow arteries were successfully identified using dCTA, and in two patients, aneurysm sac growth was observed without a visible endoleak on both sCTA and dCTA scans. The dCTA revealed four occult endoleaks, all of which were type II endoleaks. The systematic review identified six series comparing dCTA with other imaging methods. All articles reported an excellent outcome regarding the endoleak classification. In published dCTA protocols, the number and timing of phases varied greatly, affecting radiation exposure. Time attenuation curves of the current series show that some phases do not contribute to the endoleak classification and that the use of a test bolus improves the timing of the dCTA. CONCLUSIONS The dCTA is a valuable additional tool that can identify and classify endoleaks more accurately than the sCTA. Published dCTA protocols vary greatly and should be optimized to decrease radiation exposure as long as accuracy can be maintained. The use of a test bolus to improve the timing of the dCTA is recommended, but the optimal number of scanning phases is yet to be determined.
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Affiliation(s)
- Gert Jan Boer
- Department of Vascular Surgery, Maasstad Hospital, 3007 AC Rotterdam, The Netherlands
- Correspondence:
| | | | - Lievay van Dam
- Department of Radiology, Maasstad Hospital, 3007 AC Rotterdam, The Netherlands
| | | | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Jean-Paul P. M. de Vries
- Department of Vascular Surgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, 3007 AC Rotterdam, The Netherlands
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Berczeli M, Chinnadurai P, Legeza P, Peden EK, Bavare CS, Chang SM, Lumsden AB. Dynamic, Time-Resolved CT Angiography After EVAR: A Quantitative Approach to Accurately Characterize Aortic Endoleak Type and Identify Inflow Vessels. J Endovasc Ther 2023; 30:123-131. [PMID: 35068202 DOI: 10.1177/15266028211070970] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE Our purpose was to study the accuracy of dynamic computed tomography angiography (d-CTA) in characterizing endoleak type, inflow vessels as compared with digital subtraction angiography (DSA) using qualitative and quantitative analysis. METHODS Between March 2019 and January 2021, all patients who underwent d-CTA imaging after EVAR were retrospectively reviewed. Two blinded independent reviewers qualitatively reviewed d-CTA and DSA images. Quantitative region of interest (ROI) analysis was performed by measuring time-resolved contrast enhancement within the aorta and endoleak lesion(s) in the aneurysm sac. Differences between time-to-peak enhancement (Δ TTP) across different ROIs were quantified. RESULTS A total of 48 patients underwent d-CTA during the study period, of whom 24 patients had abdominal EVAR and DSA imaging for comparison. Qualitative review of DSA imaging showed type I (n=4), type II (n=16), and type III (n=2) and no endoleak (n=2). In 23 of 24 patients (95.8%), d-CTA findings correlated with DSA findings for endoleak type. One patient had a type III endoleak that was demonstrated only in d-CTA (arising from defect in polymer sealing ring of Ovation stent graft) imaging. In type II endoleak cases, d-CTA identified more inflow vessels than DSA imaging (33 vs 21 vessels, p=0.010). Quantitative analysis showed mean (±SD) Δ TTP values for type I endoleak as 1.8 (±1.8) seconds, type II as 9.6 (±3.5) seconds, and for type III endoleak as 5.6 (±1.3) seconds. CONCLUSION Dynamic CTA can accurately characterize aortic endoleak type, inflow vessels as compared with DSA imaging. Quantitative parameters such as Δ TTP enhancement can help better differentiate endoleak types and provide an objective approach to endoleak diagnosis.
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Affiliation(s)
- Marton Berczeli
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Ponraj Chinnadurai
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA.,Advanced Therapies, Siemens Medical Solutions USA Inc, Malvern, PA, USA
| | - Peter Legeza
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Eric K Peden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Charudatta S Bavare
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Su Min Chang
- Department of Cardiology, Houston Methodist Hospital, Houston, TX, USA
| | - Alan B Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
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Berczeli M, Chinnadurai P, Osztrogonácz P, Peden EK, Bavare CS, Sótonyi P, Chang SM, Lumsden AB. Dynamic CT angiography is more accurate in diagnosing endoleaks than standard triphasic CT angiography and enables targeted embolization. Ann Vasc Surg 2022; 88:318-326. [PMID: 35817381 DOI: 10.1016/j.avsg.2022.06.014] [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: 04/14/2022] [Revised: 06/09/2022] [Accepted: 06/12/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE The primary objective was to compare the accuracy of dynamic CT angiography (d-CTA) with standardized triphasic contrast enhanced CT angiography (t-CTA) in diagnosing endoleak type after endovascular aortic repair (EVAR) using digital subtraction angiography (DSA) as reference standard. The secondary objective was to study the impact of d-CTA on image-fusion guided endoleak embolization. MATERIALS AND METHODS Retrospective review of patients who underwent d-CTA imaging after EVAR between March 2019 and July 2021 was performed. De-identified images were independently reviewed by two-two blinded readers to document endoleak type and target vessels. Impact of d-CTA-guided embolization was evaluated by number of planning angiograms, radiation exposure and accuracy of target vessel overlay. RESULTS During the study period, 52 patients underwent d-CTA, 19 had all three modalities available for analysis. DSA imaging confirmed 4(21.0%) type-I, 14(73.7%) type-II and 1(5.3%) type-III endoleak. Findings from d-CTA matched with DSA in 19/19 cases (100%), whereas t-CTA matched in 14/19 cases (73.7%). In type-II endoleaks, number of target vessels identified by d-CTA, t-CTA and DSA were 23, 17 and 16 respectively. Mean dose-length product from d-CTA and t-CTA was 1445±551 and 1612±530 mGy*cm (p=0.26). Nine patients underwent d-CTA-guided type-II endoleak embolization, using a median of 1(range:1-4) planning angiogram before embolization utilizing 21.6(±8.7)% of total procedural radiation dose. Target vessel overlay was accurate in 9/9(100%) cases. CONCLUSION Dynamic, time-resolved CTA is more accurate compared to standardized triphasic contrast enhanced CTA in diagnosing endoleak type after EVAR. In type-II endoleak, d-CTA better identified target vessels and enabled safe, targeted embolization.
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Affiliation(s)
- Marton Berczeli
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX; Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary.
| | - Ponraj Chinnadurai
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX; Siemens Medical Solutions USA Inc., Malvern, PA
| | - Peter Osztrogonácz
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX; Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Eric K Peden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX
| | - Charudatta S Bavare
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX
| | - Péter Sótonyi
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Su Min Chang
- Department of Cardiology, Houston Methodist Hospital, Houston, TX
| | - Alan B Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX
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Basha MAA, Salem AF, Azmy TM, Shehata SM. The added value of CT virtual angioscopy to MDCT angiography in the evaluation of aortic diseases. Abdom Radiol (NY) 2020; 45:2576-2584. [PMID: 32564211 DOI: 10.1007/s00261-020-02607-2] [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: 10/24/2022]
Abstract
PURPOSE Incorporation of virtual angioscopy (VA) in the diagnostic work-up of aortic diseases could improve the clinical value and efficiency of multidetector computed tomography angiography (MDCTA). We aim to evaluate the clinical usefulness of virtual aortic navigation by CT angiography in various aortic diseases as a complement to standard MDCTA. MATERIALS AND METHODS We retrospectively selected 211 patients who performed MDCTA for suspected or operated aortic diseases. VA endoluminal images of the aorta were obtained by a fly-through technique. Two senior vascular radiologists independently evaluated all MDCTA images. After 1 month, the same two radiologists independently reviewed the MDCTA images combined with CTVA images. The respective accuracy of CTVA in delineating aortic abnormalities was compared to that of MDCTA using Fisher's exact test. The Fleiss kappa (κ) statistic was used to assess the inter-reader agreement (IRA). RESULTS We detected 229 abnormalities in 203 patients on MDCTA and 231 abnormalities in 205 patients on CTVA. CTVA provided significant additional findings in 63.8% (146/229) of all abnormalities diagnosed by MDCTA (p < 0.001, odd ratio [OR] = 42). Although CTVA diagnosed two abnormalities overlooked by MDCTA, the value was statistically insignificant (p = 0.787, OR = 1.3). Regarding postoperative abnormalities, the CTVA added significant additional findings over MDCTA (p = 0.006, OR = 87.4). The overall IRA for the performance of CTVA was good (κ = 0.699). CONCLUSIONS CTVA yields extra findings and improves diagnostic efficiency of MDCTA, especially in postoperative patients.
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Pisana F, Haubenreisser H, Henzler T, Schönberg S, Kachelrieß M. Singular value-guided similarity filter improves detection of vessels in low-dose dynamic CT angiography: application to DIEP flap studies. ACTA ACUST UNITED AC 2018; 63:165003. [DOI: 10.1088/1361-6560/aad477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Lu CY, Diao YK, Guo YQ, Zhang XH, Bai HL, Li ZL. Can multiphase dynamic CT angiography provide a better assessment of aortic dissection compared with the standard triphasic protocol? Acta Radiol 2018; 59:58-64. [PMID: 28440669 DOI: 10.1177/0284185117704236] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Acute aortic dissection (AD) is a life-threatening medical emergency. It has been debated whether the multiphase dynamic computed tomography angiography (CTA) protocol is superior to the standard triphasic protocol for revealing the characteristics of AD. Purpose To examine two multiphase dynamic protocols, Dynamic four-dimensional (4D) CTA using the shuttle mode and Flash 4D CTA using the high-pitch mode for the assessment of AD and to compare them with the standard triphasic protocol. Material and Methods A total of 54 consecutive patients were randomly and equally assigned to three groups and scanned with a second-generation DSCT scanner. Groups A, B, and C were assessed with the Dynamic 4D CTA in the shuttle mode, the Flash 4D CTA in the high-pitch mode, and the standard triphasic acquisition protocol, respectively. Image quality of all patients was evaluated. The effective radiation dose (ED) was recorded. Results In 54 patients, CTA images could display the true and false lumens, the intimal flap, the entry tear, and branch vessel involvement in the AD. Compared with group C, additional diagnostic information was obtained in groups A and B, including the dynamic enhancement delay between the true and false lumens (A = 18, B = 18); the presence of membrane oscillation (A = 8, B = 14); dynamic ejection of the contrast material from the true lumen into the false lumen (A = 6, B = 7); and the dynamic obstruction of the left renal artery (B = 2). The ED in these three groups was significantly different ( P < 0.05). Conclusion Compared to the standard triphasic protocol, the multiphase dynamic CTA protocol is feasible and is able to reveal additional diagnostic information. Therefore, we recommend using the high-pitch, dual-source multiphase dynamic CTA to assess ADs.
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Affiliation(s)
- Chun-yan Lu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
| | - Yi-ke Diao
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
| | - Ying-qiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
| | - Xiao-hui Zhang
- Department of Healthcare Imaging & Therapy Division, Siemens Ltd. China, Nanhui, Shanghai, PR China
| | - Hong-li Bai
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
| | - Zhen-lin Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
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Lehmkuhl L, Andres C, Lücke C, Hoffmann J, Foldyna B, Grothoff M, Nitzsche S, Schmidt A, Ulrich M, Scheinert D, Gutberlet M. Dynamic CT Angiography after Abdominal Aortic Endovascular Aneurysm Repair: Influence of Enhancement Patterns and Optimal Bolus Timing on Endoleak Detection. Radiology 2013; 268:890-9. [DOI: 10.1148/radiol.13120197] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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CT Dynamics: The Shift from Morphology to Function. CURRENT RADIOLOGY REPORTS 2013. [DOI: 10.1007/s40134-012-0004-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Meinel FG, Nikolaou K, Weidenhagen R, Hellbach K, Helck A, Bamberg F, Reiser MF, Sommer WH. Time-resolved CT angiography in aortic dissection. Eur J Radiol 2012; 81:3254-61. [DOI: 10.1016/j.ejrad.2012.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 02/26/2012] [Accepted: 03/05/2012] [Indexed: 11/24/2022]
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CT Angiography of the Aorta and Aortic Diseases. CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9156-2] [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]
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Dynamic CT Angiography after Abdominal Aortic Endovascular Aneurysm Repair: Differences in Contrast Agent Dynamics in the Aorta and Endoleaks—Preliminary Results. J Vasc Interv Radiol 2012; 23:744-50. [DOI: 10.1016/j.jvir.2012.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Revised: 02/17/2012] [Accepted: 02/17/2012] [Indexed: 11/21/2022] Open
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Sommer WH, Becker CR, Haack M, Rubin GD, Weidenhagen R, Schwarz F, Nikolaou K, Reiser MF, Johnson TR, Clevert DA. Time-resolved CT Angiography for the Detection and Classification of Endoleaks. Radiology 2012; 263:917-26. [DOI: 10.1148/radiol.12111217] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Helck A, Bamberg F, Sommer W, Wessely M, Becker C, Clevert D, Notohamiprodjo M, Reiser M, Nikolaou K. Optimized contrast volume for dynamic CT angiography in renal transplant patients using a multiphase CT protocol. Eur J Radiol 2011; 80:692-8. [DOI: 10.1016/j.ejrad.2010.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 10/06/2010] [Accepted: 10/08/2010] [Indexed: 10/18/2022]
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Optimizing multidetector CT for visualization of splenic vascular injury. Validation by splenic arteriography in blunt abdominal trauma patients. Emerg Radiol 2011; 18:307-12. [PMID: 21614477 DOI: 10.1007/s10140-011-0961-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 05/12/2011] [Indexed: 10/18/2022]
Abstract
Nonoperative management of blunt splenic injury is the treatment of choice in hemodynamically stable patients. Detection of vascular injury by multidetector CT (MDCT) is the most significant factor predicting the need for endovascular treatment. This study evaluated the timing of the appearance of vascular lesions during angiography. Images from 20 patients embolized for pseudoaneurysms (PSA) were evaluated. Angiograms were reviewed for phase and timing of PSA. Admission MDCT was reviewed for injury grade and PSA. Initial MDCT evaluation indicated grade III and IV splenic injuries in 9 and 11 patients, respectively. PSA was seen on MDCT in 14/20 (70%) patients. Time from opacification of the aorta to vascular injury was 1.32 s for arterial phase injuries compared with 2.05 s for postcapillary injuries (P=0.097). Angiography demonstrated 15 vascular injuries during the arterial and 5 in the venous phase. Of injuries seen during arterial phase angiography, 10/15 (66%) were identified on MDCT. Of the five injuries that exhibited postcapillary-phase findings, 4/5 (80%) demonstrated PSA (P=0.5). Vascular lesions are a better indicator of subsequent clinical deterioration than splenic injury grade. PSAs are more frequently seen in postcapillary vascular injuries than arterial phase lesions with the current timing of MDCT. In a subset of patients in whom splenic injury grades III and IV warrant angiography, PSAs are not initially demonstrated on MDCT. Therefore, alteration of MDCT timing parameters to better correlate with arterial phase angiography may improve initial diagnosis of vascular injury.
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