Benefits of Completion 3D Angiography Associated with Contrast Enhanced Ultrasound to Assess Technical Success after EVAR.

OBJECTIVES: This study evaluated a new strategy to assess technical success after standard and complex endovascular aortic repair (EVAR), combining completion contrast enhanced cone beam computed tomography (ceCBCT) and post-operative contrast enhanced ultrasound (CEUS). METHODS: Patients treated with bifurcated or fenestrated and branched endografts in the hybrid room during the study period were included. From December 2012 to July 2013, a completion angiogram (CA) was performed at the end of the procedure, and computed tomography angiography (CTA) before discharge (group 1). From October 2013 to April 2014, a completion ceCBCT was performed, followed by CEUS during the 30 day post-operative period (group 2). The rate of peri-operative events (type I or III endoleaks, kinks, occlusion of target vessels), need for additional procedures or early secondary procedures, total radiation exposure (mSv), and total volume of contrast medium injected were compared. RESULTS: Seventy-nine patients were included in group 1 and 54 in group 2. Peri-operative event rates were respectively 8.9% (n = 7) and 33.3% (n = 18) (p = .001). Additional procedures were performed in seven patients (8.9%) in group 1 versus 17 (31.5%) in group 2 (p = .001). Two early secondary procedures were performed in group 2 (3.7%), and three (3.8%) in group 1 (p = .978). Median radiation exposure due to CBCT was 7 Gy cm(2) (5.25-8) (36%, 27%, and 9% of the total procedure exposure, respectively for bifurcated, fenestrated, and branched endografts). CEUS did not diagnose endoleaks or any adverse events not diagnosed by ceCBCT. Overall radiation and volume of contrast injected during the patient hospital stay in groups 1 and 2 were 34 (25.8-47.3) and 11 (5-20.5) mSv, and 184 (150-240) and 91 (70-132.8) mL respectively (reduction of 68% and 50%, p < .001). CONCLUSIONS: Completion ceCBCT is achievable in routine practice to assess technical success after EVAR. Strategies to evaluate technical success combining ceCBCT and CEUS can reduce total in hospital radiation exposure and contrast medium volume injection.

[Contribution of angioplasty of a fibromuscular angiodysplasic renal artery during early-onset gestational hypertension]. / Efficacité de l'angioplastie d'artère rénale fibrodysplasique dans un contexte d'hypertension artérielle gravidique précoce.

This clinical case illustrates the management difficulties encountered during gestational hypertension and its impact on maternal and foetal outcome. Typically, preeclampsia occurs at the end of the second trimester. If blood pressure remains high early during pregnancy, a secondary cause of hypertension such as renal artery fibromuscular dysplasia should be explored. A renal vascular etiology can be safely ruled out with a duplex ultrasound. In this particular case of renal vascular hypertension in a patient with a single kidney, angioplasty appeared to be the sole solution and was efficient.

Single-centre prospective comparison between contrast-enhanced ultrasound and computed tomography angiography after EVAR.

AIM: To evaluate contrast-enhanced ultrasound (CEUS) as an effective alternative to CT-angiography (CTA) for endoleak detection and aneurismal sac diameter measurement in the follow-up after endovascular abdominal aortic aneurysm repair (EVAR). METHODS: From January 2006 to December 2010, 395 patients underwent EVAR follow-up with both CTA and CEUS. The diameter of the aneurismal sac and the presence of endoleaks were evaluated in all the 395 paired examinations. RESULTS: Bland-Altman plots showed a good agreement in aneurismal sac diameter evaluation between the two imaging modalities. The mean diameter was 54.93 mm (standard deviation (SD) ±12.57) with CEUS and 56.01 mm (SD ± 13.23) with CTA. The mean difference in aneurismal sac diameter was -1.08 mm ± 3.3543 (95% confidence interval (CI), -0.75 to -1.41), in favour of CTA. The number of observed agreement in endoleak detection was 359/395 (90.89%). The two modalities detected the same type I and type III endoleaks. McNemar's χ(2) test confirmed that CTA and CEUS are equivalent in endoleak detection. CONCLUSIONS: CEUS demonstrated to be as accurate as CTA in endoleak detection and abdominal aortic aneurysm diameter measurements during EVAR follow-up, without carrying the risks of radiation exposure or nephrotoxicity. Even if it cannot be proposed as the sole imaging modality during follow-up, our analysis suggests that it should have a major role.

[Follow up of endovascular abdominal aortic anevrysm repair with contrast ultrasound]. / Intérêt de l'échographie de contraste dans la surveillance des endoprothèses aortiques.

Endovascular aortic aneurysm repair (EVAR) is a widely accepted treatment for anatomically fitted abdominal aortic aneurysms. The increasing use of this procedure has prompted the need for close surveillance and reliable post-operative imaging. The current tool for assessing EVAR technical success is to perform computed tomography angiography (CTA) in order to exclude endoleaks and to confirm the exclusion of the aneurysm sac. Contrast enhanced ultrasound with low mechanical index is a promising method for follow-up of patients after EVAR. It seems to allow better identification and characterization of endoleaks than unenhanced ultrasound and even than CTA for very low flow endoleaks.