Residual Aneurysm Sac Research Articles

‘Peacock tail’ Clipping Technique for a Giant Middle Cerebral Artery Aneurysm: A Technical Note

Background: Giant middle cerebral artery (MCA) aneurysms are surgically challenging lesions. Because of the complexity and variability of these aneurysms, a customized surgical technique is often needed for each case. In this article, we present a modified clip reconstruction technique of a ruptured complex giant partially thrombosed middle cerebral artery aneurysm. Case description: The aneurysm was exposed using the pterional approach. Following proximal control, the aneurysm sac was decompressed. Then, we applied permanent clips to reconstruct the aneurysm neck. The configuration of the aneurysm mandated a tailored clipping pattern to account for residual aneurysm sac sagging beyond the confinement of the single inflow and the two outflow channels. As a result, clipping in a fanning pattern was done to obliterate the lateral extensions while retaining a smooth curvature of the reconstructed neck. This final clipping pattern mirrored the arrangement of the peacock tail feathers. The 'peacock tail’ clipping technique can be thought of as a variation of the traditional straight tandem clipping, also known as 'picket-fence,' applied to less complicated aneurysm configurations. Conclusion: Giant MCA aneurysms may demand an adaptive clipping technique to account for the unique geometry of each aneurysm. In this paper, we described the 'peacock tail’ clipping technique for clip reconstruction of a giant complex partially thrombosed M2 MCA aneurysm as a modification of the conventional tandem clipping technique.

Axial views of the preoperative contrasted CT Aorta demonstrating the total arch and descending thoracic aorta endovascular repair with ZenithTM Arch and Alpha distal extension modular stents (Cook) finishing above the visceral segment. Note the residual chronic aneurysm sac within the descending thoracic aorta, without the presence of any endoleaks. Due to the stent graft infection there is a dislocation

Axial views of the preoperative contrasted CT Aorta demonstrating the total arch and descending thoracic aorta endovascular repair with ZenithTM Arch and Alpha distal extension modular stents (Cook) finishing above the visceral segment. Note the residual chronic aneurysm sac within the descending thoracic aorta, without the presence of any endoleaks. Due to the stent graft infection there is a dislocation

Outcomes of chimney and fenestrated endografting using Viabahn VBX and atrium iCAST stents.

The Atrium iCAST balloon expandable stent is the traditional choice of stent for chimney and fenestrated endovascular aneurysm repair (ChEVAR and FEVAR respectively). Due to the iCAST's lack of flexibility, the Gore Viabahn balloon-expandable stent (VBX; W. L. Gore & Associates, Inc., Newark, DE, USA) has arisen as a flexible alternative for parallel or branch graft placement during complex EVAR. Our purpose was to analyze patients' outcomes after undergoing ChEVAR or FEVAR using VBX or iCAST stents with the major outcome of assessing stent graft patency. The secondary outcome was residual aneurysm sac behavior. We retrospectively reviewed patients who were treated by ChEVAR or FEVAR with placement of iCAST or VBX stents from July 2012 to August 2018. Patients received follow-up CT scan and/or aortic duplex imaging. We examined 53 cases (70% ChEVAR and 30% FEVAR) with 15.6 months (0-76.5 months) mean follow-up period. Placement of stents included renal (65 iCAST and 38 VBX), superior mesenteric (12 iCAST and 13 VBX), celiac (4 iCAST and 5 VBX), and iliac arteries (1 iCAST and 5 VBX). A total of 143 stents (57% iCAST and 43% VBX) were successfully deployed with 100% initial patency. Follow-up patency was similar for both stent types (100% VBX vs 98.7% iCAST). VBX and iCAST had the same follow-up Type 1a endoleak occurrence (9%). Average aneurysm sac sizes for iCAST decreased more than VBX (9% iCAST and 4% VBX, P=0.21), however, the iCAST group had longer follow-up. Our experience demonstrates that the use of VBX stents for ChEVAR and FEVAR is a safe and effective alternative to iCAST stents with excellent mid-term patency without a negative impact on endoleak frequency.

Hybrid Retrograde Endovascular Repair of a Rapidly Expanding Chronic SMA Dissection

A 59-year-old man with a 7-cm superior mesenteric artery (SMA) aneurysm had expanded 2 cm in the past 4 months. He presented 7 years after being lost to follow-up in the early postoperative period after thoracic endovascular aortic repair for type B dissection with dilated chronic aortic and aortic branch dissections: a 12-cm type 3 thoracoabdominal aortic aneurysm, a 59-cm SMA aneurysm, and 4-cm common and internal iliac artery aneurysms. As the patient underwent and recovered from a staged, multimodal, thoracoabdominal aortic and iliac artery repair, the SMA aneurysmal dilation rapidly progressed. Given the previous thoracoabdominal aortic surgery as well as an inflamed, large, residual aortic aneurysm sac and inflamed surrounding tissue, including the large SMA aneurysm itself, a hybrid retrograde endovascular repair was used. This consisted of laparotomy, and SMA true lumen branch exploration with open and retrograde placement of endografts from the SMA thoracoabdominal branch graft repair to the true lumen of the native SMA, followed by patch angioplasty and SMA false lumen embolization. The patient recovered well and was discharged to home after a 1-week hospital admission. Resultant, extensive, aneurysmal dilations may be safely repaired in a multistage, multimodal fashion to use the advantages of a variety of approaches—endovascular, open, and hybrid—while modifying technical challenges and overall risk.

Demystifying Endovascular Treatment of Abdominal Aortic Aneurysms: A Study by CT Angiography at a Tertiary Hospital

Aims & Objectives: The aim of this study is to compare the results of Doppler ultrasound with enhancer (EDP) versus CT angiography in the follow-up of patients with AAA(Abdominal-aortic-aneurysms) treated with EVAR(endovascular treatment), compare our results with the published literature and be able to validate the EDP in our hospital for the follow-up of AAAs treated by EVAR.Material & Methods: Of all patients with AAA treated by EVAR in our P.B.M hospital and to whom controls are being performed, 22 patients were randomly selected. The informed consent of the patients was obtained both for the performance of the control CT angiography and for the realization of the EDP. All of them underwent first a CT angiography and then the EDP. Two radiologists, one with 21 years of experience in EDP and the other radiologist with 3 years of experience in angio-CT, independently analyzed the results of the tests without knowing the results of the other test.Results: The mean diameter of the residual aneurysmal sac measured by EDP was 64.49 ± 15.12 mm (41.5- 104) with a median of 63 mm and measured by angio-CT showed an average diameter of 59.41 ± 17.54 mm (30- 108) with a median of 59 mm. Angio-CT identified a leak in 13.63% of the cases (n=3). The EDP demonstrated leakage in 31.82% of the cases (n=7), all type II; in 85.72% of cases (n=6) they corresponded to hyperdynamic type II leaks (before 100 seconds) and 14.28% of cases (n=1) corresponded to hypodynamic type II leaks (after 100 seconds). The values of sensitivity, specificity, positive and negative predictive value of the EDP were: sensitivity 100%, specificity 79%, positive predictive value 43% and negative predictive value 100%.Conclusion: The EDP is a technique that does not irradiate, it can be used in patients in whom the use of iodinated contaste is contraindicated. It is more specific than angio-CT for detecting low-flow leaks, being able to consider it as the first modality of imaging in the follow-up of patients after EVAR. The EDP allows an economic saving since the angio-CT or angio-MR are more expensive than the realization of an EDP. Our results are in agreement with those published by other authors, but we need a wider series to give greater statistical strength to our results. There is a perfect correlation between the two techniques when assessing the diameter of the residual aneurysmal sac.

Inflammation, Endoleaks, and Aortic Remodeling--The Chicken or the Egg.

Shalaby and colleagues1have taken a fresh look at inflammationandaortic aneurysmsbyexamining thecontinued remodeling of the residual aneurysmal sac after endovascular repair of infrarenal aortic aneurysms (endovascular aneurysm repair [EVAR]). Two long-term pitfalls for EVAR areendoleaksandcontinuedexpansionof the residual sac.The rate of type II endoleaks may be as low as 15%2 or as high as 27%.3Type II endoleaksusually involve continued flowwithin the aneurysm sac. Approximately 60% resolve within 6 months, but persistence of a type II endoleak after the first 6 months is associatedwith higher rates (55%) of aneurysm sac enlargement.2 The search for risk factors for type II endoleaks and sac expansion have primarily focused on anatomical factors (after all, it is a plumbingproblem): thenumber of patent lumbars, the sizeof the inferiormesenteric artery, theburden of laminated thrombus in the aneurysm, or the technical complexities of the endovascular procedure. Inflammation in the arterialwall has long been suspected as a causative factor for thedevelopment and expansionof an infrarenal aortic aneurysm, which is the most common type of sporadic, nonsyndromic aneurysm. An abundance of inflammatory cells can be found in the aneurysm wall, as well as increases in proteolytic activity and matrix protein degradation.4 This article1 suggests that increased systemic inflammationmay play a role in the failure of sac shrinkage and the development of endoleaks. In a retrospective group of 79 patients undergoingEVAR, 65%had some type of inflammatory condition (eg, allergic rhinitis, osteoarthritis, gout, or rheumatoid arthritis). The “inflammatory” group showed comparable long-termsurvival, experiencedmorepostoperativecomplications (no surprise), and had a significantly higher rate of type II endoleaks, as well as less sac shrinkage in the longterm. Their observations support the intuitive idea that excessive systemic inflammation leads to a failure of aorticwall fibrosis and contraction, resulting in retarded sac shrinkage. Why should this cause more endoleaks, primarily an anatomic problem? Instead of the conventional wisdom that endoleaks cause a failure of sac shrinkage, perhaps the reverse is true: does failure of sac shrinkage foster endoleaks? Themain caveat to their conclusions is that their classification of systemic inflammatory diseasewas based on a diagnosis proffered by others and lacked independent confirmation or, even better, some objective measurements of inflammation.Without confirmatorydata, itwouldbehard to understandhowallergic rhinitisandrheumatoidarthritismight confer a similar derangement of the systemic inflammatory state. This points to a key therapeutic question: what aspect(s) of systemic inflammationmightbeassociatedwith failure of aortic remodeling and which pathways are involved? Some directions for further study may be found in disorders in transforminggrowth factor–βsignalingandtheSMADgenes, bothofwhich share clinical associationswith aneurysmal diseases and osteoarthritis.4,5

PP-356 A Rare Cause of Pulmonary Hypertension: Distal Pulmonary Artery Stenosis Due To Takayasu Arteritis

A B S T R A C T S maximum diameter of 7.5 cm and patent lumen being 4.85 cms. Eccentric thrombus is seen in the arch. Fusiform aneurysm of infrarenal aorta and bilateral common iliac arteries (Rt > Left).In April 2011 Patient underwent subclavian carotid shunt with 8 mm ring graft under GA. Patient underwent aortic arch aneurysm repair with 24 mm Dacron graft under TCA and antegrade axillary artery perfusion after 2 days. An elephant trunk of about 5 cms was constructed at the time of surgery. MDCT Aortogram 11/12/2012 Residual aneurysm sac arising from the distal arch and proximal descending thoracic aorta has increased in diameter from 67 mm to 82 mmSI dimension of the aneurysm in 98 mm,and it projects inferiorly into the aortopulmonary window. Infra renal abdominal aorta shows fusiform dilatation to 45 mm,increased from 37 mm in previous scanImpression: Increasing size of aortic arch residual aneurysm sac.Increasing size of fusiform infrarenal abdominal aortic aneurysm. Underwent Aortic arch and proximal thoracic aneurysm stenting with a valiant thoracic stent graft 32*200 mm on 21/12/2012. Uneventful post op period. Follow up MDCT Aortogram in Dec 2012,Feb 2013,March and June showed residual aneurysm thrombus noted remains status quo.Stent graft noted in situ.No evidence or stent occlusion or thombus within the graft.

Statins Promote Residual Aneurysm Sac Regression Following Endovascular Aortic Aneurysm Repair

Regression of the residual sac is indicative of successful endovascular aortic aneurysm (EVAR) repair. Using color duplex ultrasound (CDU), we monitored the residual aneurysm sac following EVAR and correlated sac behavior with perioperative risk factors. Of 145 patients with EVAR, 106 (73.1%) patients between January 01, 2003, and July 01, 2010, had at least 2 consecutive postoperative scans and thus were eligible for inclusion. Mean (± standard deviation [SD]) CDU scans per person was 4.6 (± 1.4). All were conducted by the same technologist using a standard protocol on the same machine. Aneurysm sac change in centimeters and percentage terms was calculated. The presence or absence of an endoleak was also recorded. Change in aneurysm sac size was correlated with preoperative risk factors. Mean sac size change at 1 month was a decrease of 0.24 cm, equating to a percentage change of 4.3%. At 7 months, the decrease was 0.59 cm (9.8%), at 12 months, 0.73 cm (12.4%), at 18 months 0.92 cm (15.8%), and at 36 months 1.0 cm (16.6%). Both univariate and multivariate analyses demonstrated that statin therapy (P = .002) was the only risk factor variable positively associated with aneurysm regression while the presence of an endoleak was inversely related to sac reduction (P = .01). Maximum aneurysmal sac reduction seems to occur in the first year following endograft implantation. Statin therapy appears to be associated with an increased likelihood of sac regression following EVAR. Further investigation of the role of statins in the biology of abdominal aortic aneurysmal disease is warranted.

Idiopathic Lenticulostriate Artery Pseudoaneurysm Protruding into the Lateral Ventricle: A Case Report

We report a rare case of an idiopathic pseudoaneurysm causing intraventricular hemorrhage (IVH). A 28-year-old man presented with sudden onset of severe headache. He underwent external ventricular drainage for an isolated IVH in the right lateral ventricle. Digital subtraction angiography (DSA) revealed that the aneurysm (7.5×4.5 mm) arose from the distal part of the medial lenticulostriate artery. Following removal of the external ventricular drainage catheter, the aneurysm decreased in size (4.0×2.3 mm). However, follow-up DSA revealed a slightly enlarged aneurysm (4.2×3.2 mm) with morphologic change. The aneurysm was clipped via the interhemispheric transcallosal approach, but postoperative DSA revealed a residual aneurysm sac beside the clips. Given the risk of rebleeding, a second operation was planned for complete resection of the aneurysm. After revised craniotomy and careful dissection of the caudate nucleus, the aneurysm sac was completely resected. Histopathological examination revealed that the aneurysm was a pseudoaneurysm. The patient recovered without any neurological sequel and was discharged.To the best of our knowledge, this is the first reported case of an idiopathic lenticulostriate artery pseudoaneurysm protruding into the right lateral ventricle and causing an IVH that was successfully treated with microsurgical resection.

O-027 In-hospital mortality and short-term clinical outcome in octo- and non-agenarian patients with aneurysmal subarachnoid hemorrhage treated endovascularly at a tertiary referral medical center

PurposeTo determine the in-hospital mortality and short-term clinical outcome in a cohort of octo- and non-agenarian patients with aneurysmal subarachnoid hemorrhage (SAH) treated endovascularly at a tertiary referral medical center.MethodsWe...

Y-Configuration Stent Placement (Crossing and Kissing) for Endovascular Treatment of Wide-Neck Cerebral Aneurysms Located at 4 Different Bifurcation Sites

The Y-stent technique, including crossing-Y and kissing-Y, is a promising therapeutic option for some complex bifurcation aneurysms. Here, its efficacy and safety are evaluated on the basis of 11 bifurcation aneurysms. A retrospective review was conducted for all patients who underwent endovascular treatment of aneurysms in our department between January 2009 and June 2011 to identify and analyze cases with bifurcation aneurysms reconstructed by using Y-stents. Eleven patients (4 ruptured and 7 unruptured aneurysms) were identified (4 men, 7 women) with a mean age of 60.4 years. Nine aneurysms (2 AcomAs, 3 MCA-Bifs, 1 PcomA, 3 BA apexes) were treated by using the crossing-Y technique, and 2 (both BA apexes) were treated with the kissing-Y technique, achieving complete occlusion in 6 aneurysms, residual neck in 4, and partial occlusion in 1. Perioperatively, a single thromboembolic event occurred in 1 case without neurologic deficit, which required a salvaging second stent implantation. Means of 9.9 months of angiographic and 13.7 months of clinical follow-up were available. As a result, 9 (81.8) aneurysms were completely occluded, 1 with a residual neck remained stable, and 1 residual aneurysm sac was recanalized, which was retreated and achieved a complete occlusion. All patients were independent with an mRS score of 0-1 at discharge and follow-up. In selected patients, the reconstruction of bifurcation aneurysms by using the Y-stent can be successfully achieved with satisfactory midterm results.

Sonographic Evaluation of Aortic Endografts

The selective use of endovascular devices to repair abdominal aortic aneurysms was introduced in the early 1990s. Although placement of an aortic endograft offers patients a less morbid alternative to surgical repair, this procedure is not without complications. Persistent perfusion of the residual aneurysmal sac via endoleaks may place the patient at risk for aneurysmal enlargement and subsequent rupture. Historically, serial computed tomographic angiography has been used as the primary modality for assessment of aortic endografts. In recent years, sonography has been shown to provide a valued tool for ongoing surveillance of aortic endografts and identification of endoleaks, increasing aneurysmal size, hemodynamic disorders, and graft migration and/or kinking. Standardization of the sonographic evaluation yields accurate information vital to the long-term patency of these conduits.

Clinical Practice Guidelines for Endovascular Abdominal Aortic Aneurysm Repair: Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association

From the Department of Radiology, Division of Vascular Imaging and Intervention (T.G.W., S.P.K., K.Y., S.W.), Massachusetts General Hospital, Boston, Massachusetts; Department of Medical Imaging (S.K.), Scarborough General Hospital, Toronto, Ontario, Canada; Department of Interventional Radiology (P.D.), West Allis Memorial Hospital, Milwaukee, Wisconsin; Department of Radiology, Division of Interventional Radiology (B.J.D.), University of Maryland Medical Center, Baltimore, Maryland; Department of Radiology (S.C.R.), University of California San Diego Medical Center, San Diego, California; and Department of Radiology (J.F.C.), Geisinger Health System, Danville, Pennsylvania. Received May 4, 2010; final revision received May 24, 2010; accepted July 11, 2010. Address corre-

Technique for repair of suprarenal and thoracoabdominal aortic aneurysms

Suprarenal and thoracoabdominal aortic aneurysms represent significant surgical challenges. For patients with associated aortic dissections, current endovascular technology has not been matured to address branch reconstructions that derive from separate lumens, making open surgical reconstruction the only proven method for repair. The required exposures of the thoracoabdominal aorta are expansive, and the extent of aortic replacement mandates efficient technique. Furthermore, a well-orchestrated team of surgeons, nurses, anesthesiologists, and perfusionists are all integral to achieving good outcomes and keeping operative courses tightly managed. Techniques to address extensive aneurysms of the thoracoabdominal aorta are reviewed in detail here, and videos are provided on The Journal website to show relevant anatomical features.

Combined Endovascular and Microsurgical Procedures as Complementary Approaches in the Treatment of a Single Intracranial Aneurysm

Both endovascular coil embolization and microsurgical clipping are now firmly established as treatment options for the management of cerebral aneurysms. Moreover, they are sometimes used as complementary approaches each other. This study retrospectively analyzed our experience with endovascular and microsurgical procedures as complementary approaches in treating a single aneurysm. Nineteen patients with intracranial aneurysm were managed with both endovascular and microsurgical treatments. All of the aneurysms were located in the anterior circulation. Eighteen patients presented with SAH, and 14 aneurysms had diameters of less than 10 mm, and five had diameters of 10-25 mm. Thirteen of the 19 patients were initially treated with endovascular coil embolization, followed by microsurgical management. Of the 13 patients, 9 patients had intraprocedural complications during coil embolization (intraprocedural rupture, coil protrusion, coil migration), rebleeding with regrowth of aneurysm in two patients, residual sac in one patient, and coil compaction in one patient. Six patients who had undergone microsurgical clipping were followed by coil embolization because of a residual aneurysm sac in four patients, and regrowth in two patients. In intracranial aneurysms involving procedural endovascular complications or incomplete coil embolization and failed microsurgical clipping, because of anatomical and/or technical difficulties, the combined and complementary therapy with endovascular coiling and microsurgical clipping are valuable in providing the best outcome.

Technical challenges to surgical clipping of aneurysmal regrowth with coil herniation following endovascular treatment – a case report

In recent years, technical developments have made endovascular procedures attractive therapeutic options and enabled the endovascular surgeon to redefine the management of cerebral aneurysms. However, as the number of aneurysms undergoing endovascular therapy has grown, so has the number of patients with incompletely treated aneurysms who are presenting for further management. In cases of failure of endovascular treatment caused by either incomplete occlusion or regrowth of the aneurysm, a complementary treatment is often necessary. Surgical treatment of these patients is challenging. We present a case of a ruptured posterior cerebral artery aneurysm treated initially with endovascular coiling that left behind significant residual aneurysmal sac. Regrowth of the aneurysm documented on follow-up was treated surgically. At surgery, the coil was found to have herniated through the aneurysmal sac into the subarachnoid space, and the aneurysm was successfully clipped without removing the coils. We review the regrowth of aneurysms following endovascular therapy and potential problems and challenges of surgically managing these lesions.

Aortoesophageal fistula secondary to stent-graft repair of the thoracic aorta after previous surgical coarctation repair

Clinical Summary A 31-year-old woman was admitted to a peripheral hospital with an episode of massive hematemesis. She had undergone a patchtechnique coarctation repair at age 3 years and required balloon dilatation for recoarctation at age 14 years. Annual cardiologic follow-up detected, at age 26 years, a pseudoaneurysm at the coarctation site with dimensions of 2.4 1.9 cm. The pseudoaneurysm size remained stable, but 8 months before the hematemesis, TEVAR was recommended to avert any risk of rupture and a Jomed 48 20-mm covered stent (Abbott Vascular Ltd, Kent, United Kingdom) was deployed at the coarctation site pseudoaneurysm. Post-TEVAR imaging suggested satisfactory exclusion. After the hematemesis, she underwent esophagogastroduodenoscopy, which showed a 1.5-cm bluish polypoid lesion 26 cm from the incisura. Biopsy revealed blood clot only. She was discharged but readmitted 4 weeks later with a further massive hematemesis. A repeat esophagogastroduodenoscopy revealed that the lesion had enlarged 3-fold. This finding, together with the history of coarctation surgery, prompted a computed tomographic (CT) scan (Figure 1), which demonstrated a perigraft hematoma suggestive of AEF. After transfer to our center, aortography confirmed peri–stent-graft extravasation, further supporting a diagnosis of AEF. Another covered stent (38 12 mm, Jostent; Abbott Vascular Ltd) was deployed and the hematemesis abated. However, a postprocedure angiogram demonstrated persistent filling of the pseudoaneurysm. The incomplete pseudoaneurysm exclusion and the perceived risk of further complications prompted surgical referral. Echocardiography demonstrated moderate bicuspid aortic valve stenosis. Surgery was performed via a transsternal thoracotomy in the left fourth intercostal space and comprised mechanical aortic valve replacement, retrocardiac ascending–descending aortic conduit insertion, and an interposition graft between the conduit and the left subclavian artery. The aortic arch was staple-ligated between the left common carotid artery and the left subclavian artery. The descending aorta was stapled below the stent site. The aortic pseudoaneurysm was opened and the previously placed stents were removed. Inspection revealed a section of necrotic and partially absent aortic wall with erosion of the longitudinal esophageal muscle but no mucosal breach. It was assumed that stent deployment had perforated or disintegrated the aortic wall leading to an AEF. The aortic remnant was left open, a feeding enterostomy and decompression gastrostomy performed, and the chest closed with drainage. Recovery was uneventful, with a contrast swallow examination showing no abnormalities. At 12 months, the patient remains free of symptoms, and CT scan (Figure 2) demonstrates resolution of perigraft hematoma and satisfactory anatomic reconfiguration.

Ultrasound Surveillance of Endovascular Aneurysm Repair: A Safe Modality versus Computed Tomography

Routine ultrasound surveillance is adequate and safe for monitoring endovascular aneurysm repairs (EVARs). A retrospective chart review including 160 endograft patients was performed from August 2000 to September 2005. All ultrasound examinations (n = 359) were performed by a board-certified vascular surgery group's accredited laboratory. Registered vascular technologists utilized the same equipment consisting of Siemens Antares high-definition ultrasonography with tissue harmonics and color flow Doppler. An identical protocol was followed by each technologist: scan body and both limbs of the endograft and distal iliac vessels, measure anterior-posterior aneurysm sac size, and detect intrasac pulsatility and color flow. Statistical analysis utilized Pearson's correlation coefficient and the paired t-test. Forty-one endoleaks were discovered out of the 359 exams (11.4%). There were type I (7, 17%), type II (26, 63%), and combined type I with type II (8, 20%) endoleaks. Correlation with computed tomography (CT) was obtained in 35 of these cases. CT discovered three endoleaks that were not seen with ultrasound. However, these particular ultrasound exams were inadequate due to additional factors (bowel gas, body habitus, hernia), which prompted CT investigation and, hence, endoleak discovery. Of the 41 endoleaks found on ultrasound, only 14 were seen on CT. Specifically, 26 type II endoleaks were seen with ultrasound versus only nine during CT. Additional factors addressed included comparison between ultrasound and CT of residual aneurysm sac measurements and conditions limiting ultrasound examination. Although criticized in the past, color flow ultrasonography is a safe and effective modality for surveillance of aortic endografts. Utilizing ultrasound to analyze abdominal aortic aneurysm (AAA) sac dimensions and endoleak detection is statistically sound for screening AAA status post-EVAR.

Future of Endograft Surveillance

Frequent and sustained surveillance continues to be mandated for all patients who undergo endovascular repair of the aneurysmal aorta in order to minimize the small but attendant risk of aneurysm rupture. The primary motivation for surveillance includes evaluation of residual aneurysm sac size and presence of endoleak, as well as potential adverse device specific events, such as endograft migration, module disconnection, or component fatigue and failure. The current standard of care and future surveillance modalities after endovascular repair of both abdominal aortic and thoracic aortic aneurysms will be reviewed.

Intracranial Aneurysms Treated With Guglielmi Detachable Coils

To compare the utility of contrast-enhanced MR Angiography (CE-MRA) with digital subtraction angiography (DSA) after endovascular treatment of intracranial aneurysms with Guglielmi detachable coils. From April 1999 to August 2002, 106 patients with 107 aneurysms treated by endovascular coiling using Guglielmi detachable coils underwent simultaneous DSA and CE-MRA at follow-up (mean: 12.9 range: 5 to 27 months). DSA was performed as the standard reference. MR angiographic images were analyzed independently by 2 senior radiologists (J.-Y.G., S.C.) and DSA by a third radiologist (X.L.). Findings were assigned to 1 of 3 categories: complete obliteration (class 1), residual neck (class 2) and residual aneurysm (class 3). DSA at follow-up demonstrated 65 (60.6%) complete obliterations (group 1), 21 (19.7%) residual necks (group 2) and 21 (19.7%) residual aneurysms (group 3). One patient (0.9%) experienced aneurysm rebleed during the follow-up period. Among 101 assessable imaging comparisons, interobserver agreement was determined to be very good for CE-MRA (kappa=0.96) with only 4 discrepancies between both examiners. Comparison between CE-MRA and DSA showed an excellent agreement between techniques (kappa=0.93). Of the 21 with residual necks described on DSA, 20 were seen on CE-MRA. CE-MRA detected all 19 residual aneurysms. CE-MRA after selective embolization of intracranial aneurysm is useful and comparable to DSA in the assessment of aneurysmal recanalization either as residual neck or aneurysmal sac.