Avnesh S. Thakor, PhD, FRCR, James Tanner, MB, BChir, Shao J

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Presentation transcript:

Radiological Evaluation of Abdominal Endovascular Aortic Aneurysm Repair Avnesh S. Thakor, PhD, FRCR, James Tanner, MB, BChir, Shao J. Ong, MBBS, PhD, Ynyr Hughes-Roberts, FRCR, Shahzad Ilyas, FRCR, Claire Cousins, FRCR, Teik C. See, FRCR, Darren Klass, MD, FRCR, Andrew P. Winterbottom, FRCR Canadian Association of Radiologists Journal Volume 66, Issue 3, Pages 277-290 (August 2015) DOI: 10.1016/j.carj.2014.12.003 Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 1 Axial arterial phase computed tomography images showing (A) the normal appearance of contrast medium lying outside the stent (black star) but inside the graft material of the Endologix AFX stent graft as opposed to (B) the normal appearance of contrast medium contained by both graft material and stent in a Medtronic Endurant stent graft. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 2 Volume rendered computed tomography images showing the proximal fixation of the aortic stent graft in relation to the renal arteries. (A) Gore C3 Excluder with no suprarenal fixation and castellated edge to the graft. (B) Medtronic Endurant, (C) Endologix AFX, and (D) Cook Zenith aortic stent grafts all with similar suprarenal fixation stent lying across the renal artery origins with a straight top edge to the stent graft. (E) Anteroposterior (AP) and (F) lateral views of the Lombard Aorfix stent graft with no suprarenal fixation and fish mouth configuration to the proximal edge of the stent graft. (G) AP and (H) lateral view of a Cook fenestrated stent graft with supraceliac bare stent fixation, scalloped top edge to the stent graft accommodating the celiac trunk, and 3 fenestrations for the superior mesenteric artery and renal arteries. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 3 Axial computed tomography (CT) images showing an Endologix Nellix aortic aneurysm sealing system with 2 stents eccentrically surrounded by polymer filled endobags sealing the aneurysm lumen. (A) noncontrast CT showing intermediate density polymer bags (black stars) and (B) arterial phase showing luminal enhancement of the stent. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 4 Volume rendered computed tomography image showing a chimney stent graft (white arrow) within the SMA, which lies between the aortic wall and the second abdominal aortic stent graft (the celiac axis was intentionally covered as it was already occluded from long standing thrombus). Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 5 Contrast-enhanced (A) volume rendered and (B) axial computed tomography (CT) images showing an internal iliac artery embolization with an Amplatzer plug (white arrowhead). Contrast-enhanced (C) volume rendered and (D) axial CT images showing an internal iliac artery branch graft (white arrow). This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 6 Type Ia endoleak with contrast medium between the right lateral wall of the aorta and the stent graft (white arrow) due to inferior migration of the stent graft in the neck of the aneurysm on (A) axial computed tomography (CT) and (B) multiplanar reconstruction. Left aorto uni-iliac stent graft with Type Ib endoleak with contrast medium between the distal end of iliac limb and the left common iliac artery wall (white arrow) due to dilatation of the common iliac artery on (C) axial CT and (D) multiplanar reconstruction. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 7 Type II endoleak (black star) supplied by the inferior mesenteric artery (white arrow) seen on (A) axial computed tomography and (B) volume rendered images, which shows the direct route from the superior mesenteric artery (SMA) via the middle and left colic arteries to fill the aneurysm sac via retrograde flow in the inferior mesenteric artery (distal branches of the SMA and renal arteries have been removed). This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 8 Type III endoleak (black star) seen on (A) axial computed tomography and (B) sagittal curved reformat images that demonstrates limb dislocation. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 9 An arteriogram showing a Type IV endoleak (white arrow) due to graft material porosity during stent graft insertion. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 10 Computed tomography axial (A) unenhanced, (B) arterial phase, and (C) portal venous phase images showing a Type II endoleak, which is only visible in the portal venous phase. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 11 Computed tomography (A) axial and (B) sagittal images of an aorto uni-iliac aortic stent graft with subsequent change in configuration following aneurysm shrinkage resulting in a kink between the body and limb seen on corresponding computed tomography (C) axial and (D) sagittal images. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 12 Axial computed tomography images showing (A) concentric partial limb thrombosis and (B) complete limb occlusion due to thrombosis. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 13 Type II lumbar artery endoleak lying between the limbs of the stent graft on (A) noncontrast and (B) arterial phase computed tomography images with corresponding (C) greyscale and (D) power Doppler ultrasound images. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 14 Normal (A) anteroposterior and (B) lateral plain film radiograph of a Cook Zenith aortic stent graft. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 15 Magnified (A) anteroposterior and (B) lateral plain film radiograph of a Cook fenestrated aortic stent graft with multiple radio-opaque markers indicating fenestration and scallop orientation. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 16 Magnified (A) anteroposterior plain radiograph and (B) corresponding thick coronal reformat showing inadequate overlap of the contralateral limb in this Cook Zenith aortic stent graft with the dashed line showing the ideal minimum overlap required as opposed to the current position indicated by the solid arrow. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 17 Magnified anteroposterior plain radiograph showing a significant kink (solid white arrow) in the iliac limb at the native aortic bifurcation (A) before and (B) after correction using a self-expanding stent insertion (solid white star). Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 18 Axial computed tomography in the (A) arterial phase and (B) venous phase showing an infected aortic stent graft with a thick enhancing aortic wall in the venous phase. Radiolabeled white cell scans in (C) the early phase and (D) at 24 hours showing a focal increase in uptake in the 24 hour image (white arrow). Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 19 A flow diagram outlining when and how to use each imaging modality to assess and follow up aortic stent grafts. AP/Lat = anteroposterior/lateral; CEUS = contrast-enhanced ultrasound; CT = computed tomography; EVAR = endovascular aortic aneurysm repair. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 277-290DOI: (10.1016/j.carj.2014.12.003) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions