Detection Of Endoleaks Research Articles

A systematic review of surveillance after endovascular aortic repair

ObjectiveThe objective of this systematic review and meta-analysis was to evaluate the optimal modality and frequency of surveillance after endovascular aortic repair (EVAR) in adult patients with abdominal aortic aneurysms. MethodsWe searched for studies of post-EVAR surveillance in MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Scopus through May 10, 2016. The outcomes of interest were endoleaks, mortality, limb ischemia, renal complications, late rupture, and aneurysm-related mortality. Outcomes were pooled using a random-effects model and were reported as incidence rate and 95% confidence interval. ResultsOf 1099 candidate references, we included 6 meta-analyses and 52 observational studies. Complication rates were common after EVAR, particularly in the first year. Magnetic resonance imaging had a higher detection rate of endoleaks than computed tomography angiography. Doppler ultrasound had lower diagnostic accuracy, whereas contrast-enhanced ultrasound was likely to be as sensitive as computed tomography angiography. The highest endoleak detection rates were in surveillance approaches that used combined tests. There were no studies that compared different surveillance intervals to determine optimal intervals; however, most studies reported detection rates of patient-important outcomes at 1, 6, 12, 24, 36, 48, and 60 months. Data were insufficient to provide comparative inferences about the best strategy to reduce the risk of patient-important outcomes, such as mortality, limb ischemia, rupture, and renal complications. ConclusionsSeveral tests with reasonable diagnostic accuracy are available for surveillance after EVAR. The available evidence suggests a high complication rate, particularly in the first year, and provides a rationale for surveillance.

Ultrasonography for endoleak detection after endoluminal abdominal aortic aneurysm repair.

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. 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). 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. Any cross-sectional diagnostic study evaluating participants who received EVAR by both ultrasound (with or without contrast) and CT scan assessed at regular intervals. 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. 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. 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.

Contrast-Enhanced Ultrasound in the Follow-Up ofEndoleaks after Endovascular Aortic Repair (EVAR).

Endovascular aortic repair (EVAR) has become established in the treatment of abdominal aortic aneurysms and shows potential benefits such as a low perioperative morbidity and a short hospitalization duration. The follow-up after EVAR primarily consists of lifelong postinterventional imaging of the aneurysm size in order to detect complications such as endoleaks or stent dislocation. Computed tomography angiography, an imaging modality that uses ionizing radiation and that relies on a contrast medium which is dependent on thyroid and renal function, is widely used for follow-up. Meanwhile, contrast-enhanced ultrasound (CEUS) has been established as a viable, fast and cost-effective imaging alternative for the follow-up and the detection of endoleaks after EVAR with the additional benefit of being a real-time non-ionizing radiation examination and having comparable or even superior diagnostic performance. This review describes the use of CEUS for follow-up after EVAR and describes the most common pathologies.

Follow up CT angiography post EVAR: Endoleaks detection, classification and management planning

ObjectiveThe goal of this study was to highlight the role of follow up CT angiography examination in detection and classification of endoleaks and therefore deciding management plans after endovascular abdominal aortic aneurysm repair (EVAR). Patients and MethodsDuring one year duration 37 patients who have been operated were examined 1 and 6months after EVAR as routine follow up. The images obtained were interpreted and reconstructed using dedicated software and work stations. ResultsOut of 37 cases, 14 cases (37.8%) had positive endoleaks and 23 cases (62.2%) were free. Type I endoleak was diagnosed in 4 cases (10.8%) and type II endoleaks was diagnosed in 10 cases (27%) as 7 cases (18.9%) showed leak through lumbar arteries and 3 cases (8.1%) showed leak through the inferior mesenteric arteries. ConclusionCT angiography can accurately detect and classify endoleaks and thus determine line of treatment. Endoleaks are often asymptomatic and may become evident intra operatively or many years after the operation, therefore lifelong imaging supervision is necessary.

Experimental feasibility of dual contrast agent based spectral photon-counting computed tomografy for detection of endoleaks following EVAR

Experimental feasibility of dual contrast agent based spectral photon-counting computed tomografy for detection of endoleaks following EVAR

Three-dimensional contrast-enhanced ultrasound improves endoleak detection and classification after endovascular aneurysm repair

BackgroundThree-dimensional contrast-enhanced ultrasound (3D-CEUS) is a novel technology allowing surgeons to view duplex ultrasound images in three dimensions with ultrasound contrast highlighting blood flow in endoleaks after endovascular aneurysm repair (EVAR). It potentially reduces the need for computed tomography angiography (CTA) and catheter angiography. This study compares 3D-CEUS with both CTA and the final vascular multidisciplinary team (MDT) diagnosis using all available imaging. Interoperator variability for detection of endoleak and the influence of 3D-CEUS on patient management were studied. MethodsA consecutive 100 patients undergoing CTA for EVAR surveillance were invited to undergo standard CEUS and 3D-CEUS on the same day, with 3D-CEUS reported independently by two blinded vascular scientists. Presence and type of endoleak were compared between CTA, standard CEUS, 3D-CEUS, and the final diagnostic decision made in the vascular MDT meeting. Interoperator reliability of 3D-CEUS was analyzed using the κ statistic. ResultsThe 100 paired CTA, CEUS, and 3D-CEUS studies were analyzed. Compared with CTA, the sensitivity, specificity, positive predictive value, and negative predictive value of 3D-CEUS to endoleak were 96%, 91%, 90%, and 96%, respectively. Compared with the MDT decision with access to all imaging modalities, the sensitivity, specificity, positive predictive value, and negative predictive value of 3D-CEUS were 96%, 100%, 100%, and 96%. The κ statistic for interoperator agreement was 0.89. Conclusions3D-CEUS was more sensitive and accurate than CTA for endoleak detection and classification after EVAR. 3D-CEUS is now our initial investigation of choice in cases of sac expansion during duplex ultrasound follow-up or if there is diagnostic uncertainty on standard duplex ultrasound or CTA.

Endovascular abdominal aortic aneurysm sealing: A systematic review of early outcomes.

Objectives There has been a clear move towards endovascular repair of abdominal aortic aneurysms owing to better peri-operative outcomes compared with open surgical repair. However, follow-up has continued to reveal relatively high rates of endoleaks and re-interventions. Improvements in endovascular stent-grafts aim to decrease these complications. This systematic review aims to determine the early outcomes of abdominal aortic aneurysm sealing. Methods Standard PRISMA guidelines were followed. A literature search was performed with the aim to extract any publication related to the endovascular aneurysm sealing device. Results The total number of patients in this systematic review of 11 studies is 684, with a mean age of 73.2 years, and 587 (88.0%) males. The majority were undergoing elective procedures ( n = 606, 91.0%), the remainder as emergencies ( n = 30, 4.5% as ruptures, n = 30, 4.5% as symptomatic). Technical success rate including emergency cases was 99.1%. Thirty-day mortality rate was 2.6% ( n = 17) including all cases, and 1.0% ( n = 6) including elective cases only. Thirty -day endoleak detection rate was 4.7% ( n = 31) including all cases, and 4.8% ( n = 29) including elective cases only. Thirty-day aneurysm-related re-intervention rate was 5.7% ( n = 38) including all cases, and 4.6% ( n = 28) including elective cases only. There was no conversion to open surgery within 30 days post-op in the elective cases. There were three delayed conversions to open surgery within 30 days and one report of stent migration causing rupture in the emergency setting. Conclusions This novel endovascular aneurysm-sealing device for abdominal aortic aneurysm repair has shown respectable early outcomes. Good technical success rates, in both elective and emergency settings, low rates of all-type endoleaks and low re-intervention rates have all been demonstrated. It is proving to be a safe alternative to open and endovascular aneurysm repair; however, longer term follow-up results are needed to assess the safety and effectiveness of the device in the long term.

Evaluation the Aortic Aneurysm Remodeling After a Successful Stentgraft Implantation

SummaryBackgroundRoutine imaging follow-up after endovascular treatment of abdominal aortic aneurysms (EVAR) is mainly aimed at detection of endoleaks. The aim of the study was to assess changes in the size of the abdominal aortic aneurysm sack using CT angiography (CTA) after successful treatment using endovascular stent graft implantation.Material/MethodsA retrospective analysis of CTA results included 102 patients aged 54–88, who had no postoperative complications. Patients underwent CTA before EVAR and after the treatment (mean time between studies, 7.6 months). The largest cross-sectional area of the aneurysm sac was measured using a curved multiplanar reconstruction. A change of the aneurysm cross-sectional over 10% was considered significant.ResultsThe average cross-sectional area decreased after EVAR by 3% and this change was not statistically significant. Regression of the cross-sectional area was observed in 18.6% of patients, progression was in 23.5%, and no change was seen in 57.8%. Cross-sectional areas before and after EVAR were significantly correlated (r=0.75, p<0.0001). There was no correlation between the cross-sectional area change after EVAR and patients’ age or the time between the treatment and the follow-up CTA. Cross-sectional area before the treatment predicted changes in the aneurysm size after EVAR (p=0.0045).ConclusionsRemodeling of abdominal aortic aneurysms after EVAR is not uniform. The change of aneurysm size depends on the initial aneurysm size but not on the time from EVAR. The size of the aneurysm after EVAR should not be considered as a measure of the treatment efficacy.

Three-Dimensional Contrast-Enhanced Ultrasound Improves the Detection and Classification of Endoleaks Following Endovascular Aneurysm Repair

Three-Dimensional Contrast-Enhanced Ultrasound Improves the Detection and Classification of Endoleaks Following Endovascular Aneurysm Repair

Comparison of portable ultrasound system and high end ultrasound system in detection of endoleaks.

To compare the value of a portable ultrasound system and a high end ultrasound system in detection of endoleaks after EVAR. In this retrospective study, a cohort of 25 patients underwent both standard examination using a portable ultrasound system (Philips VISIQ) and a second examination using a high end ultrasound system (Philips EPIQ 7). The examination included B-mode and color Doppler in detection of endoleaks. Additional the maximum diameter of the aneurysm was measured in two planes (right-left and ventral-dorsal). The gold standard was contrast-enhanced ultrasound (CEUS) in detection of endoleaks. 25 patients were included in the study. Patients were predominantly male (n = 23) with an average age of 73,30±7.82 years (range 54-85). Diameters of the treated aneurysms were in the right-left plane 5,32±1.88 cm and ventral-dorsal 4,99±1.78 cm using the high end system. Diameters of the treated aneurysms were in the right-left plane 5,30±1.82 cm and ventral-dorsal 4,87±1.74 cm using portable ultrasound system. In 80% of the cases CEUS could detect an endoleak. Whereas the high end system could detect in B-mode 40% and color Doppler 45% of the cases an endoleak. The portable system could detect in B-mode 30% and in color Doppler 35% of the cases an endoleak. On both systems in B-mode a false positive endoleak was found on the same patient. All high flow endoleaks, which needed intervention, could be detected on all systems. The high end ultrasound system does not seem to have an additional advantage in the measurement of the aneurysm diameter. Due to a higher resolution, more endoleaks could be detected in B-mode and color Doppler by using the high end system. The presence of small endoleaks could only be detected by using contrast enhanced ultrasound on an high end ultrasound system. High flow endoleaks could be reliable seen on both systems.

A Systematic Review of Ultrasound or Magnetic Resonance Imaging Compared With Computed Tomography for Endoleak Detection and Aneurysm Diameter Measurement After Endovascular Aneurysm Repair

Purpose: To analyze the literature comparing ultrasound [duplex (DUS) or contrast-enhanced (CEUS)] or magnetic resonance imaging (MRI) with computed tomography angiography (CTA) for endoleak detection and aneurysm diameter measurement after endovascular aneurysm repair (EVAR). Methods: A systematic review identified 31 studies that included 3853 EVAR patients who had paired scans (DUS or CEUS vs CTA or MRI vs CTA) within a 1-month interval for identification of endoleaks during EVAR surveillance. The primary outcome was the number of patients with an endoleak detected by one test but undetected by another test. Results are presented for all endoleaks and for types I and III endoleaks only. Aneurysm diameter measurements between CTA and ultrasound were examined using meta-analysis. Results: Endoleaks were seen in 25.6% (985/3853) of patients after EVAR. Fifteen studies compared DUS with CTA for the detection of all endoleak types. CTA had a significantly higher proportion of additional endoleaks detected (214/2346 vs 77/2346 for DUS). Of 19 studies comparing CEUS with CTA for the detection of all endoleak types, CEUS was more sensitive (138/1694) vs CTA (51/1694). MRI detected 42 additional endoleaks that were undetected by CTA during the paired scans, whereas CTA detected 2 additional endoleaks that MRI did not show. CTA had a similar proportion of additional types I and III endoleaks undetected by CEUS or MRI. Of 9 studies comparing ultrasound vs CTA for post-EVAR aneurysm diameter measurement, the aneurysm diameter measured by CTA was greater than ultrasound (mean difference −1.70 mm, 95% confidence interval −2.45 to −0.96, p<0.001). Conclusion: This study demonstrated that CEUS and MRI are more accurate than CTA for the detection of post-EVAR endoleaks, but they are no better than CTA for detecting types I and III endoleaks specifically. Aneurysm diameter differences between CTA and ultrasound should be considered when evaluating the change in aneurysm diameter postoperatively.

Duplex ultrasound and computed tomography angiography in the follow-up of endovascular abdominal aortic aneurysm repair: a comparative study.

ObjectiveTo compare duplex ultrasound and computed tomography (CT) angiography in terms of their performance in detecting endoleaks, as well as in determining the diameter of the aneurysm sac, in the postoperative follow-up of endovascular abdominal aortic aneurysm repair.Materials and MethodsThis was a prospective study involving 30 patients who had undergone endovascular repair of infrarenal aortoiliac aneurysms. Duplex ultrasound and CT angiography were performed simultaneously by independent radiologists. Measurements of the aneurysm sac diameter were assessed, and the presence or absence of endoleaks was determined.ResultsThe average diameter of the aneurysm sac, as determined by duplex ultrasound and CT angiography was 6.09 ± 1.95 and 6.27 ± 2.16 cm, respectively. Pearson's correlation coefficient showing a statistically significant correlation (R = 0.88; p < 0.01). Comparing the duplex ultrasound and CT angiography results regarding the detection of endoleaks, we found that the former had a negative predictive value of 92.59% and a specificity of 96.15%.ConclusionOur results show that there is little variation between the two methods evaluated, and that the choice between the two would have no significant effect on clinical management. Duplex ultrasound could replace CT angiography in the postoperative follow-up of endovascular aneurysm repair of the infrarenal aorta, because it is a low-cost procedure without the potential clinical complications related to the use of iodinated contrast and exposure to radiation.

Endoleak detection using single-acquisition split-bolus dual-energy computer tomography (DECT)

ObjectivesTo assess a single-phase, dual-energy computed tomography (DECT) with a split-bolus technique and reconstruction of virtual non-enhanced images for the detection of endoleaks after endovascular aneurysm repair (EVAR).MethodsFifty patients referred for routine follow-up post-EVAR CT and a history of at least one post-EVAR follow-up CT examination using our standard biphasic (arterial and venous phase) routine protocol (which was used as the reference standard) were included in this prospective trial. An in-patient comparison and an analysis of the split-bolus protocol and the previously used double-phase protocol were performed with regard to differences in diagnostic accuracy, radiation dose, and image quality.ResultsThe analysis showed a significant reduction of radiation dose of up to 42 %, using the single-acquisition split-bolus protocol, while maintaining a comparable diagnostic accuracy (primary endoleak detection rate of 96 %). Image quality between the two protocols was comparable and only slightly inferior for the split-bolus scan (2.5 vs. 2.4).ConclusionsUsing the single-acquisition, split-bolus approach allows for a significant dose reduction while maintaining high image quality, resulting in effective endoleak identification.Key Points• A single-acquisition, split-bolus approach allows for a significant dose reduction.• Endoleak development is the most common complication after endovascular aortic repair (EVAR).• CT angiography is the imaging modality of choice for aortic aneurysm evaluation.

Clinical outcomes for endovascular repair of abdominal aortic aneurysm with the Seal stent graft

Since 2007, the availability of the Seal (S & G Biotech Inc, Seong-nam, Gyeonggi-do, Korea) stent graft for endovascular aneurysm repair (EVAR) has improved short-term outcomes in Korea. However, midterm outcome data are lacking. This retrospective study evaluated the midterm outcomes of 126 patients who underwent EVAR using the Seal stent graft between 2007 and2010. Data regarding use of the Seal stent graft for EVAR were collected from 16 Korean centers, and were analyzed retrospectively using Kaplan-Meier and Cox univariate and multivariate analyses. The mean patient age was 71± 8years (median, 70; range, 49-87 years). Patients who were treated using a bifurcated graft (113; 90%) were generally symptomatic (56; 44%, which included 13 ruptured abdominal aortic aneurysms [10%]) and male (105; 83%). The primary technical success rate was 99%. Four patients (3%) died within 30days, 5 patients (4%) died after 30days, and 12 patients (9%) were lost to follow-up. The survival rates were 97%± 2% (1month), 97%± 2% (3months), 96%± 2% (6months), 96%± 2% (1year), 94%± 3% (3years), and 81%± 10% (5years). During a mean follow-up of 55± 22months (median, 40; range, 0.03-91.2 months), 18 reinterventions were performed for 16 patients (13%). The freedom from reintervention rates were 96%± 2% (1month), 96%± 2% (3months), 94%± 2% (6months), 89%±3% (1year), 84%± 4% (3years), and 57%± 17% (5years). The mean aneurysm diameter significantly decreased from 69.6 to 46.6mm during the follow-up (P< .0001). A proximal neck of less than 15mm, different simultaneous endoleaks, and insufficient bilateral coverage of the iliac aneurysm were associated with significantly higher rates of increased or unchanged aneurysm diameters (all P< .0001). Significantly higher rates of clinical failure were observed in patients who were less than 70years old (P= .04), had a neck length of less than 15mm(P= .02), and had a neck diameter of greater than 28mm(P= .02). Most Seal stent grafts were implanted successfully (even in cases with a physical status of grade IV or higher or a ruptured abdominal aortic aneurysm), had an appropriate reintervention rate, and were stable during the midterm follow-up. However, there was a high rate of type I endoleak, which may be related to the early device model that we used. Therefore, long-term radiologic follow-up is recommended for the early detection of stent graft migration or endoleaks.

A special issue and a new look for Ultrasound.

Welcome to this special issue on non-hepatic applications of contrast-enhanced ultrasound. The benefits of CEUS imaging in organs such as the heart and liver, for which it was originally licensed, are now well established, but new applications continue to be explored. This special issue brings together a collection of articles showing that CEUS can be a very useful additional imaging tool for assessing vascularity in the kidneys, spleen and testes as well as in the detection of endoleaks in post EVAR follow-up and DVT. Professor Paul Sidhu introduces this special issue overleaf in a guest editorial, charting the development of CEUS and highlighting new areas where it is being shown to be most useful. CEUS may become a practical alternative to contrast CT in many circumstances, avoiding the use of nephrotoxic contrast agents and exposure to radiation. You will have noticed by the time you reach this point, that Ultrasound has had something of a makeover. In collaboration with our publisher, SAGE Publications, we have redesigned the internal layout and cover to be more consistent with the recently rebranded BMUS website. The new internal format is also more consistent with industry standards for journals and helps to make content more discoverable through search engines. I do hope that you like the new look front cover. This will now be the same for each issue and will not show short titles for the content. We will also bid a fond farewell to the hand of a previous editor that has been a feature of the front cover for the last six years! As editor, I would like to think that the quality and content ofUltrasound has continued to improve. So I am delighted to be able to tell you that Ultrasound has been selected for inclusion in a new area of Web of Science called the Emerging Sources Citation Index. According to owners Thompson Reuters, this new index will extend Web of Science to include high-quality, peer-reviewed publications of regional importance and in emerging fields. The content will be visible in Web of Science, where it is searchable, discoverable and citable. I hope this development will give a new incentive to authors to send their work to Ultrasound for publication. For those of you who attended the excellent BMUS Annual Scientific Meeting in Cardiff in December, it probably now feels like a distant memory. However, I would like to encourage those who presented their work there as a lecture or poster to consider writing it up as an article for Ultrasound. Publishing your work in the journal ensures that a much wider audience can learn from your efforts, you will have a permanent record and your work will now be discoverable in Web of Science. If you need a little extra incentive, two of the articles that won journal prizes in 2015 started out as ASM presentations. For 2015, there were two joint winners and one runner up for the postgraduate paper prize. The winners were: Dr Neeraj Purohit for his article entitled ‘‘Ultrasound of lower limb sports injuries’’; and Katie Johnson for her article ‘‘Temporomandibular joint effusion and its relationship with perceived disability assessed using musculoskeletal ultrasound and a patient-reported disability index’’. The runner-up was Dr Anu Obaro for his article entitled ‘‘Benign liver lesions: grey-scale and contrast-enhanced ultrasound appearances’’. In addition, the inaugural Paul Allan prize for the best paper published in Ultrasound in 2015 was awarded to Dr Iain Willits for his article entitled ‘‘What proportions of focal liver lesions detected by unenhanced ultrasound are inconclusive?’’ I do hope that you find this special issue a useful educational resource and I look forward to seeing some article submissions from you! You can find author instructions and all you need to know on the journal website at: http://ult.sagepub.com.

Invited commentary

The accompanying study by Roselli et al1Roselli E.E. Arko 3rd, F.R. Thompson M.M. Valiant Mona LSA Trial InvestigatorsResults of the Valiant Mona LSA early feasibility study for descending thoracic aneurysms.J Vasc Surg. 2015; 62: 1465-1472Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar is noteworthy for a couple of reasons: this first-in-man study of “safety and efficacy” was performed (mainly) in the United States through participation in the United States Food and Drug Administration's newly developed Innovation Pathway, and the study device provides a much needed all-endovascular option for the treatment of aneurysms involving the proximal descending thoracic aorta. As described in Roselli et al, the cuff-based side branch of the Valiant Mona LSA stent graft (Medtronic, Minneapolis, Minn) preserves flow to the subclavian artery in an attempt to minimize the risk of stroke, paraplegia, and left hand ischemia. The results of this study confirm the feasibility of the approach. All of the stent grafts and their branches were implanted as intended. The case for safety, efficacy, and durability is less clear. As reported in Table III, six patients (67%) sustained “procedure-related” serious adverse events, and strokes occurred in three (33%), all of which were symptomatic and visible on computed tomography. The high stroke rate is reminiscent of early experience with a two-branch system of arch repair (Cook Medical, Bloomington, Ind). As evidenced by later results with the Cook device, increasing familiarity with key parts of the procedure, decreasing instrumentation of the ascending aorta and arch, and the development of a lower-profile device all help to reduce the stroke rate in procedures of this type.2Haulon S. Greenberg R.K. Spear R. Eagleton M. Abraham C. Lioupis C. et al.Global experience with an inner branched arch endograft.J Thorac Cardiovasc Surg. 2014; 148: 1709-1716Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar Five patients (56%) in the current study had an endoleak at some point. The authors suggest that “new endoleaks developed” in the postoperative period. I hope not, because a loss of aneurysm exclusion (new endoleak) would call into question the stability of the device and the durability of the repair. More likely, the endoleaks were present from the time of stent graft implantation. After all, intraoperative angiography is not the most sensitive method of endoleak detection. The current short-term data give little indication of long-term device performance. Nevertheless, I expect that long-term follow-up will confirm the durability of the repair, partly because most of the components of the Valiant Mona LSA device have withstood long-term clinical use in other Medtronic products and partly because the combination of a self-expanding branch with a cuff-bearing stent graft has worked well in the thoracoabdominal aorta3Reilly L.M. Rapp J.H. Grenon S.M. Hiramoto J.H. Sobel J. Chuter T.A. Efficacy and durability of endovascular thoracoabdominal aortic aneurysm repair using the caudally directed cuff technique.J Vasc Surg. 2012; 56: 53-64Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar and the aortic arch.2Haulon S. Greenberg R.K. Spear R. Eagleton M. Abraham C. Lioupis C. et al.Global experience with an inner branched arch endograft.J Thorac Cardiovasc Surg. 2014; 148: 1709-1716Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar If the device proves to be as durable as I predict, and increasing operator experience achieves the hoped for reduction in stroke rate, the Valiant Mona LSA stent graft has a promising future. It might play a role not only in the repair of aneurysms involving the distal aortic arch and descending thoracic aorta but also in type B dissections and aneurysms of the proximal aortic arch. Results of the Valiant Mona LSA early feasibility study for descending thoracic aneurysmsJournal of Vascular SurgeryVol. 62Issue 6PreviewStent graft coverage of the left subclavian artery (LSA) may be required to achieve an adequate landing zone in up to 40% of descending thoracic aneurysms (DTAs). The Valiant Mona LSA Thoracic Stent Graft System (Medtronic, Santa Rosa, Calif) consists of a main stent graft and a branch stent graft designed to maintain LSA patency while diverting circulation through the encroaching aneurysm. Participating in the United States Food and Drug Administration's new Innovation Pathway, this first-in-human, early feasibility study evaluates early clinical experience of the Valiant Mona LSA Stent Graft System in patients with DTAs where the proximal landing zone necessitates LSA coverage. Full-Text PDF Open Archive

Predictors and outcomes of endoleaks in the Veterans Affairs Open Versus Endovascular Repair (OVER) Trial of Abdominal Aortic Aneurysms

The Veterans Affairs Open Versus Endovascular Repair (OVER) Trial of Abdominal Aortic Aneurysms study was a randomized controlled trial comparing open vs endovascular repair (EVAR) in standard-risk patients with infrarenal aortic aneurysms. The analysis reported here identifies characteristics, risk factors, and long-term outcome of endoleaks in patients treated with EVAR in the OVER cohort. The OVER trial enrolled 881 patients, of whom 439 received successful EVAR. Logistic regression analysis was used to identify predictors for endoleaks and secondary interventions. Kaplan-Meier survival analysis, longitudinal plots, and generalized linear mixed models methods were used to describe time to endoleak detection, resolution, or death. During a mean follow-up of 6.2 ± 2.4 years, 135 patients (30.5%) developed 187 endoleaks. Four patients with EVAR went on to rupture; these four patients did not all have an endoleak. Mortality between patients who did and did not develop endoleaks was not significantly different. The 187 endoleaks included 12% type I, 76% type II, 3% type III, 3% type IV, and 6% indeterminate. Patient demographics and vascular risk factors were not associated with endoleak development. The presence of endoleaks resulted in an increase in aneurysm diameter over time (P < .0001). Fifty-three percent of endoleaks resolved spontaneously, and 31.9% received secondary interventions. The initial aneurysm size independently predicted a need for secondary interventions (P < .0003). Delayed type II endoleaks (detected >1 year after EVAR) were associated with aneurysm enlargement compared with the early counterpart. There was no difference in aneurysm size or length of survival between type II and other types of endoleak. We present one of the most comprehensive and longest follow-up analyses of patients treated with aortic endografts. Endoleaks were common and negatively affected aneurysm diameter reduction. Delayed type II endoleaks were associated with late aneurysm diameter enlargement. Endoleaks and aneurysm diameter enlargement were not associated with excess mortality compared with those without these features.

Interest of fusion imaging and modern navigation tools with hybrid rooms in endovascular aortic procedures

Because of the emergence of hybrid operating rooms, cone-beam CT scans (CBCT) allow new intraoperative imaging to be produced. Image fusion (3D preoperative CT scan overlaid onto 2D live fluoroscopy image) is the most popular application and makes it possible to navigate throughout the aorta and its branches without having to make use of an additional injection, and allows a reduction to be achieved in the quantity of contrast medium and irradiation required during complex procedures. Planning-oriented software available in hybrid rooms makes it possible to adjust to the patient and the nature of the procedure, the information that is relevant during the operation. CBCT can also be used as a diagnostic tool at the end of a procedure for the detection of endoleaks and could replace routine CT scans made during the first month following the procedure, indirectly contributing again to a reduction of X-ray and contrast agent doses.

Contrast-enhanced ultrasound after endovascular aortic repair-current status and future perspectives.

An increasing number of patients with abdominal aortic aneurysms (AAAs) are undergoing endovascular aortic repair (EVAR) instead of open surgery. These patients require lifelong surveillance, and the follow-up imaging modality of choice has been traditionally computed tomography angiography (CTA). Repetitive CTA imaging is associated with cumulative radiation exposure and requires the administration of multiple doses of nephrotoxic contrast agents. Contrast-enhanced ultrasound (CEUS) has emerged as an alternative strategy in the follow-up of patients with EVAR and demonstrates high sensitivity and specificity for detection of endoleaks. In fact, a series of studies have shown that CEUS is at least performing equal to computed tomography for the detection and classification of endoleaks. This article summarizes current evidence of CEUS after EVAR and demonstrates its usefulness via various patient cases.

Length of abdominal aortic aneurysm and incidence of endoleaks type II after endovascular repair.

To evaluate the predicting factors for the development of endoleak type II, its frequency and influencing factors after elective endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAA). Data were prospectively collected in a unicenter observational study (tertiary center of [endo-] vascular surgery) and retrospectively evaluated in patients who had undergone elective EVAR of AAA. Vascular (lumbar arteries (LA) and inferior mesenteric artery, aneurysm) and general patient (habits, medication, basic diseases) as well as procedural characteristics, were analyzed for their association with the development of endoleak type II. Pre and postinterventional computed tomography (CT) scans were evaluated for aneurysm anatomy, in particular, postinterventional growth or shrinkage as well detection of an endoleak of each type. The study cohort included 82 patients (mean age, 72 (52-87) years; 77 men, 93.9%) throughout 36 months. The median follow-up period was 29.5 months (range, 1-57). Overall, 51 endoleaks type II (62.2%) were identified at any time during the postinterventional follow-up period. In the Cox regression, AAA length was the only significant predictor (P = 0.024; hazard ratio (HR), 1.07; 95% confidence interval (CI), 1.01-1.14). Thirteen patients (15.8%) underwent at least one secondary intervention. Aneurysm growth was observed in four patients because of an endoleak type II (4.9%). No AAA rupture occurred in association with an isolated endoleak type II. The preoperative AAA length (correlating with the number of LA) can be considered a risk factor for postinterventional occurrence of endoleak type II prompting to greater attention and possible preemptive therapy.