Abstract
Introduction Iodinated contrast media completion angiography (ICM-A) may underestimate the presence of type II endoleak (ELII) after endovascular aortic repair (EVAR), particularly if they are at low flow. Contrast-enhanced ultrasound (CEUS) has been proposed as the gold standard in ELII detection during EVAR follow-up. Intraprocedural carbon dioxide (CO2) angiography has been shown to be useful in this setting; however no comparative studies including these three techniques are currently available. Our aim was to investigate the accuracy of a new automated CO2 angiographic (CO2-A) system in the detection of ELII, by comparing it with ICM-A and CEUS. Methods A series of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) were enrolled and submitted to ICM-A and CO2-A during the procedure. The iodinated contrast media were delivered through an automatic injector connected to a pigtail catheter in the suprarenal aorta. CO2 was delivered through a recently available automatic injector connected to a 10 F sheath positioned in the external iliac artery. All patients were blindly evaluated by CEUS within postoperative day 1. The ICM-A and CO2-A ability to detect ELII was compared with that of CEUS through Cohen's concordance Index (K). Results Twenty-one patients were enrolled in the study. One (5%), seven (33%), and four (19%) ELII were detected by ICM-A, CO2-A, and CEUS, respectively. The only ELII detected by ICM-A was also detected by CO2-A and CEUS. Three cases of ELII detected by CO2-A were not detected by CEUS. All ELII detected by CEUS were visualized by CO2-A. CEUS and ICM-A showed a poor agreement (Cohen's K: 0.35) while CEUS and CO2-A showed a substantial agreement (Cohen's K: 0.65) for ELII detection. Conclusion CO2-A is safe and effective method for ELII detection in EVAR, with a significantly higher agreement with CEUS if compared with ICM-A. This trial is registered with 155/2015/U/Oss.
Highlights
Iodinated contrast media completion angiography (ICM-A) may underestimate the presence of type II endoleak (ELII) after endovascular aortic repair (EVAR), if they are at low flow
The use of carbon dioxide (CO2) digital subtraction angiography (CO2-A) has been studied extensively [5,6,7,8,9,10] as an alternative contrast media in order to minimize the use of iodinated contrast medium (ICM) during EVAR, especially in patients with severe renal insufficiency
Contrast-enhanced ultrasound (CEUS) has high sensitivity and specificity for endoleaks, if they are at low flow, and has been proposed as the gold standard during EVAR follow-up [13,14,15]
Summary
Endovascular abdominal aortic repair (EVAR) has become widely accepted as a treatment of choice for abdominal aortic aneurysm repair, due to its minor invasiveness and lower short-term morbidity and mortality, if compared with open repair (OR) [1, 2]. Some studies have shown that CO2-A has good sensitivity and specificity for the evaluation of type I and III endoleaks but it is not a reliable method to detect type II endoleaks (ELII) [7, 12]. As a matter of fact, the presence of endoleaks after endovascular aortic repair (EVAR) can be investigated with different methods. Contrast-enhanced ultrasound (CEUS) has high sensitivity and specificity for endoleaks, if they are at low flow, and has been proposed as the gold standard during EVAR follow-up [13,14,15]. The aim of our study is to investigate the accuracy of a new automated CO2 angiographic system in the detection of endoleaks with particular attention to type II endoleak, by comparing it with ICM-A and CEUS
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