Can we replace computed tomography angiography by contrast-enhanced ultrasound in the surveillance of patients submitted to aortoiliac aneurysm repair?

Objectives This study was designed for evaluation of CEUS (contrast-enhanced ultrasound) for the detection of endoleaks after EVAR (endovascular aortic aneurysms repair) as an alternative to CTA (computed tomography angiography), the gold standard in post-EVAR surveillance. Methods Post-EVAR surveillance of patients who underwent CEUS and CTA was retrospectively analyzed to compare the accuracy of CEUS compared to CTA. For that, the following parameters were analyzed: the largest aneurysm diameter, type of endoleaks, and the time elapsed after EVAR using both surveillance tests. Results The study involved 110 pairs of exams in patients with infrarenal aortoiliac or isolated iliac artery aneurysm, covering predominantly a male population (89%). The time elapsed after EVAR using CEUS or CTA exams were statistically similar, ranging from one to 58 months (mean 12.2) and one to 65 months (mean 9.7), respectively ( p = 0.124). CEUS sensitivity was 75.5%, specificity 96.7%, false positives were 24.5%, and false negatives were 3.3%. The accuracy between the two exams was 87.3%. A secondary analysis, comparing CTA with CEUS as a reference standard, revealed CEUS sensitivity of 24.5%, higher than CTA for detecting endoleaks, with a concordance rate of true positive results of 75.5%. Among the endoleaks detected solely by CEUS (12 cases), one case was type Ia and eleven were type II, while those detected only by CTA (2 cases), one was type Ia and one type II. Additionally, a type II endoleak associated with type Ib, identified by CEUS, was seen as type II for CTA only. There was no difference between the pre-EVAR and the post-EVAR diameters of aortoiliac aneurysm ( p = 0.058), both for CEUS and CTA. Computed tomography angiography, on the other hand, showed significant aneurysm diameter reduction compared to CEUS for isolated iliac artery aneurysms ( p < 0.001). Conclusion Contrast-enhanced ultrasound was more effective than CTA in identifying and characterizing endoleaks in patients undergoing EVAR, especially type II endoleaks. The advantages include efficacy and, particularly, safety, and must be considered in EVAR surveillance protocols so that its use becomes widespread. We understand that CEUS, as a surveillance exam, considerably reduces risks to patients compared to CTA.

Woven EndoBridge (WEB) Width at the Aneurysm Neck Level Affects Early Angiographic Aneurysm Occlusion

Purpose Endovascular therapy with the Woven EndoBridge (WEB) device is a safe treatment approach, whereby neoendothelialization at the neck area is a crucial element for aneurysm occlusion. We hypothesized that WEB sizing at the aneurysmal neck level has an impact on early aneurysm occlusion. Methods Patients with short-term follow-up digital subtraction angiography following WEB treatment of unruptured aneurysms were included. Aneurysms were categorized according to the Bicêtre Occlusion Scale Score (BOSS) as adequately (BOSS 0, 0′, 1) or partially occluded (BOSS 2, 3, 1 + 3). The WEB device dimensions, including the average aneurysm diameter (AADi) and the average neck diameter (ANDi) as well as baseline patient characteristics were documented. Results In this study 75 patients with 76 aneurysms were included and 65 aneurysms showed adequate occlusion at short-term follow-up (86%). In univariable logistic regression analysis, smaller differences in WEB size to ANDi (D-ANDi) were significantly associated with adequate aneurysm occlusion (odds ratio, OR = 0.41, 95% confidence interval, CI 0.23–0.71, p = 0.002). Receiver operating characteristic (ROC) curve analyses displayed higher discriminative power for the D‑ANDi (AUC = 0.77, 95% CI 0.66–0.86, cut-off ≤2.9 mm) compared to the difference in WEB size to the average aneurysm diameter (D-AADi, AUC = 0.65, 95% CI 0.53–0.75, cut-off ≤1.0 mm). Conclusion Smaller differences between the WEB width and ANDi were associated with adequate early aneurysm occlusion and might thus have a higher impact on the results than the traditional device sizing considering the mean aneurysm diameter. D‑ANDi ≤2.9 mm served as an optimal cut-off to classify occlusion after WEB treatment at the short-term follow-up. Further external validation is warranted.

Linear plication and external wrapping in ascending aortic aneurysm in well-selected patients: Surgical technique

An aortic aneurysm is known as a bulging or dilatation of the aorta for more than one and half of its normal diameter result in making the wall of the aorta thinner and at the risk of dissection or rupture. For a long time ago surgeons have worked hard to find the best surgical technique to treat this pathology. Open surgery with the replacement of the aneurysmatic segment by a synthetic graft is still the standard surgical treatment method. In the past, some surgeons tried patching the aneurysmatic segment with synthetic patches. This technique was not accepted by many surgeons. In our cardiovascular surgical center, we perform linear plication and external wrapping (LPEW) surgical technique for more than ten years in well-selected patients whose aortic aneurysm diameter is less than 6 cm with normal aortic root and who has not any connective tissue disease, dissection, or rupture. Our results are satisfying with low morbidity and mortality.

Semi-automated cerebral aneurysm segmentation and geometric analysis for WEB sizing utilizing a cloud-based computational platform

Background Accurate aneurysm measurements are important for selecting the WEB device. The objective was to validate a cloud-based platform, SurgicalPreview (SP) against manual measurements for aneurysm analysis. Methods Two sets of measurements each for SP and manual methods were obtained for 40 aneurysms. Reliability and agreement were assessed with intra-class correlation coefficient (ICC) and Bland-Altman plots respectively. Kappa coefficient was used to assess agreement for predicting WEB size. Results There was good reliability for repeat SP measurements: aneurysm diameter (ICC-1, 95%CI 0.98–1), height (ICC-1, 95%CI 0.99–1) and neck diameter (ICC-0.96, 95%CI 0.93–0.98). There was good reliability for the two manual diameter (ICC-0.97, 95%CI 0.9–0.97) and height (ICC-0.93, 95%CI 0.87–0.96) measurements and moderate for neck diameter (ICC-0.76, 95%CI 0.54–0.87). There was greater agreement for SP versus manual repeat measurements on Bland-Altman plots. Reliability between the SP and manual methods was good for aneurysm diameter (ICC-0.98, 95%CI 0.95–1) and height (ICC-0.96, 95%CI-0.93–0.98) and moderate for neck. (ICC-0.6, 95%CI -0.22–0.87). The Bland-Altman plots confirmed better agreement between the two methods for the aneurysm diameter and height than the neck. There was strong agreement between the methods for predicting the WEB diameter (Kappa-0.84, 95%CI 0.71–0.97) and moderate for predicting WEB height (Kappa-0.66, 95%CI 0.43–0.89). There was moderate agreement for predicted versus deployed WEB diameter: SP (Kappa-0.56, 95%CI 0.38–0.74), Manual (Kappa-0.53, 95%CI 0.34–0.71). Conclusion The SurgicalPreview® had greater agreement for repeat measurements. There was good reliability between the two methods for predicting WEB diameter and height and moderate agreement between predicted versus deployed WEB diameter.

The reproducibility of measuring maximum abdominal aortic aneurysm diameter from ultrasound images

Background Accurate repeat assessment of the diameter of an abdominal aortic aneurysm (AAA) is important. This study investigated the reproducibility of different methods of measuring AAA diameter from ultrasound images. Methods Fifty AAA patients were assessed by ultrasound. Maximum AAA diameter was measured independently by three trained observers on two separate occasions using a standardised protocol. Five diameters were measured from each scan, three in the anterior–posterior (AP) and two in the transverse (TV) plane, including inner-to-inner (ITI), outer-to-outer (OTO) and leading edge-to-leading edge (LETLE). Intra- and inter-observer reproducibility were reported as reproducibility coefficients. Statistical comparison of methods was performed using linear mixed effects models. Results Intra-observer reproducibility coefficients (AP LETLE 2.2 mm; AP ITI 2.4 mm; AP OTO 2.6 mm) were smaller than inter-observer reproducibility coefficients (AP LETLE 4.6 mm: AP ITI 4.5; and AP OTO 4.8 mm). There was no statistically significant difference in intra-observer reproducibility of three types of measurements performed in the AP plane. Measurements obtained in the TV plane had statistically significant worse intra-observer reproducibility than those performed in the AP plane. Conclusions This study suggests that the comparison of maximum AAA diameter between repeat images is most reproducibly performed by a single trained observer measuring diameters in the AP plane.

Arterial diameter following arteriovenous fistula creation predicts aneurysm progression

Objective: To investigate the relationship between arteriovenous fistula (AVF) arterial diameter (AD) and AVF aneurysm development and progression. Methods: This study identified all patients who underwent fistulograms which demonstrated AVF aneurysms meeting criteria and requiring surgical intervention between 01/01/2014 and 7/30/2016. Patient demographics were collected and AVF dimensions were measured on fistulograms. A control group with nonaneurysmal AVFs who had undergone serial fistulograms between 2013 and 2016 were identified and identical datasets collected. Statistical analysis was performed with STATA 14.0 using student’s t-test, Chi square tests and linear regression. Results: 45 eligible patients were identified in the AVF aneurysm study group and 24 in the control group, with the mean age of AVF creation being older in the control group (61.8 vs 53 years, p = 0.03). The mean interval between AVF creation and first fistulogram in the study group was 1464 ± 282 days, compared to an interval of 263 ± 101 days in the control group ( p = 0.003). The AD on the first fistulogram in those study group patients with aneurysms evident on first fistulogram was greater than in the control group (6.5±1.8 mm vs 5.0 ± 1.8 mm, p = 0.003). The AD on first fistulogram of the study group predicted maximum aneurysm diameter on last fistulogram ( r = 0.6, p = 0.03) as well as the interval between first fistulogram and surgical revision ( r = −0.33, p = 0.03). Conclusion: AVF aneurysms are a later complication in access natural history and AD may help to predict their progression.