Prospective Comparison of Cone Beam Computed Tomography with Routine or Selective Predismissal Computed Tomography Angiography to Detect Technical Problems During Fenestrated-Branched Endovascular Aortic Repair

Abstract

Introduction: To compare two imaging strategies using cone beam computed tomography (CBCT) with rotational angiography and routine or selective predismissal computed tomography angiography (CTA) for technical assessment of fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR). Methods: One hundred and seventy consecutive patients (119 male, mean age 74±8 years old) treated by F-BEVAR were enrolled in a prospective non-randomized study (2016-2018). Technical assessment in the first 85 patients (Group 1) consisted of intraoperative CBCT with rotational angiography and routine predismissal CTA. The subsequent 85 patients (Group 2) had CBCT with rotational angiography and selective predismissal CTA, which was obtained only if clinically indicated. Imaging surveillance in both groups included CTA at 30-days, 6-months and annually thereafter. End-points analyzed as intention-to-treat included effective dose (ED, mSv) and contrast volume for CBCT and predismissal CTA, presence of findings warranting immediate revision (stent kink/compression, type I/III endoleak, dissection/thrombus), and mortality, major adverse events (MAEs) and reinterventions at 30-days. Results: Patients in both groups had similar clinical and anatomical characteristics, stent design and procedural variables. Patients in Groups 1 and 2 had similar technical success (97% vs. 95%, P=.66), endoleak detection (53% vs. 59%, P=.53) and rate of positive findings by CBCT with rotational angiography (21% vs. 27%, P=.37). Immediate revisions (Table) were indicated for stent kink/compression in 20 patients (12%), type I/III endoleak in 19 patients (11%) and vessel dissection/thrombosis in two patients (1%). Predismissal CTA was obtained in 83 patients (97%) assigned to Group 1 and in 24 patients (28%) assigned to Group 2 (P< .0001), and identified new findings in three (4%) and two (2%) patients, respectively (P>.99). Patients in Group 1 had higher ED (+20mSv, P=.0007) and contrast volume (+102ml, P< .0001) compared to patients in Group 2 (Figure). At 30-days, CTA revealed new findings in none of Group 1 and in two (2%) patients in Group 2 (P=.49). There were no differences in mortality (1% vs. 1%, P=.97), MAEs (32% vs. 23%, P=.21) and reinterventions (9% vs. 4%, P=.13) at 30-days between patients in Group 1 and 2, respectively. Conclusion: CBCT with rotational angiography is sufficient to detect technical problems requiring immediate revisions. Mortality, morbidity and rate of early reinterventions were similar in patients who had CBCT with routine or selective predismissal CTA, indicating that routine predismissal CTAs can be safely eliminated from F-BEVAR protocols without deleterious effect on early outcomes.TablePositive findings by CBCT, predismissal and 30-day CTAFigureEffective Dose and Contrast Volume.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: GSO has received consulting fees and grants from Cook Medical, W. L. Gore, and GE Healthcare (all paid to Mayo Clinic with no personal income). PO is employed by GE Healthcare