Invited commentary

Abstract

The article by Harthun and Lau raises a number of cogent points for vascular specialists who perform the endovascular aneurysm repair (EVAR) procedure. Given the risk profile of aortic aneurysm patients, particularly tobacco abuse, one should not be surprised by the occurrence of pulmonary pathology on routine computed tomography (CT) imaging that includes the base of the lungs. The more common scenario seen today is the incidental pulmonary nodule found on pulmonary CT angiography obtained to rule out pulmonary embolism. These scans include the full lung fields in the examination and similarly report a 10% to 15% overall incidence of incidental pulmonary nodules. The management pathway of the incidental pulmonary nodule discovered on EVAR follow-up CT is the most contentious point of their article. Which of the patient's care providers are responsible for informing the patient of the finding and coordinating subsequent follow-up of the nodule is a discussion beyond the scope of this commentary and has significant medical and legal implications. The provider who orders the examination has the primary responsibility to see that the patient is informed of the diagnosis and that the appropriate follow-up is initiated. The physician interpreting the examination has the responsibility to notify the ordering physician of the presence of the nodule, beyond mentioning it in the dictated report, particularly if it is a new finding compared with previous examinations. The most important point to emphasize is the clear documentation of the communication to the patient and subsequent care providers by the vascular specialist of the finding and the plan of action. Subsequent investigations and management of the pulmonary nodule is beyond the scope of practice today for most vascular specialists. The more appropriate pathway would be for the patient to be referred to a pulmonary specialist. Whether that referral comes directly from the vascular specialist or through the patient's primary care provider would depend on practice patterns in one's own community. Finally, much of this discussion may become moot as most EVAR follow-up transitions to ultrasound-based techniques. This evolution is fueled by the public perception that the radiation exposure secondary to CT scans may lead to malignancies and by the need for our health care system to control costs. Serial postoperative CT imaging for uncomplicated EVAR cases is likely coming to a close and with it the need for vascular specialists to pursue further diagnosis and treatment of incidental nonvascular pathology. The incidence of pulmonary neoplasms discovered by serial computed tomography scanning after endovascular abdominal aortic aneurysm repairJournal of Vascular SurgeryVol. 53Issue 3PreviewSerial computed tomography (CT) scanning is routinely used to follow up endovascular exclusion of abdominal aortic aneurysms (AAAs). Nonvascular diseases can be identified, and these exams include images of the lung bases, which can provide information that leads to the diagnosis of pulmonary neoplasms. This study was conducted to determine the rate and type of pulmonary-based oncologic diseases identified by serial CT scanning of patients with endovascular repair of AAAs. Full-Text PDF Open Archive