CT Angiography in Stent-Graft Sizing: Impact of Using Inner vs Outer Wall Measurements of Aortic Neck Diameters J ENDOVASC THER 2011 Institute of Radiology.

Slides:

Advertisements

Similar presentations

Endovascular Treatment of Acute Aortic Emergencies: Early Results Badr Aljabri, MD, FRCSC King Khalid University Hospital Riyadh, Saudi Arabia.

Advertisements

CoreValve ® MSCT Scan Acquisition and Processing March 2013 Innovating for life. UC EE.

Novel single-source high-pitch protocol for CT angiography of the aorta: comparison to high-pitch dual-source protocol in the context of TAVI planning.

Abdominal Aortic Aneurysm (AAA) LECT7 ALI B ALHAILIY.

Stent Assisted Balloon Induced Intimal Disruption and Relamination in Aortic Dissection Repair: The STABILISE Concept Sophie C. Hofferberth 1, Andrew E.

June ‘XX Presents to Beaumont A&E c/o Abdominal Pain B/G: Known AAA Radiating through to the back Constant for 24 hrs Vomit x 6 Fever, Malaise No Hx of.

Number of Entry Tears Is Associated With Aortic Growth in Type B Dissections Ann Thorac Surg March 28, 2013 Thoracic Aortic Research Center, University.

What Is Being Done Where

MRA of Abdominal Aortic Aneurysms Martin R. Prince, MD, PhD

CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Minimal aortic injury of the thoracic aorta: imaging appearances and outcome Emerg Radiol, 2014 Harborview Medical Center, University of Washington.

Secondary Intervention in Unfavorable AAA Neck Anatomy Congress Symposium 2007 John T. Collins, MD Borgess Medical Center Kalamazoo, MI.

AAA Repair Justin Brown 4 September yo W transfer from OSH with ruptured Abdominal Aortic Aneurysm – Presented with acute onset of abdominal.

Jon S. Matsumura, MD, Wesley S. Moore, MD Journal of Vascular Surgery

Notice anything? Calcified infrarenal aortic aneurysm – posterior view.

EVAR Planning: Keys to Success

Endurant: A New Generation Endograft

Early experience with the snorkel technique for juxtarenal aneurysms

A randomized controlled trial of distal renal denervation vs conventional mode of the intervention for treatment of resistant hypertension Stanislav Pekarskiy.

Dynamic magnetic resonance angiography of the aneurysm neck: Conformational changes during the cardiac cycle with possible consequences for endograft.

Use of custom Dacron branch grafts for “hybrid” aortic debranching during endovascular repair of thoracic and thoracoabdominal aortic aneurysms G. Chad.

Christopher K. Zarins, MD, Rodney A. White, MD, Thomas J. Fogarty, MD

Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology Salvatore T. Scali, MD, Dan Neal, MS, Vida Sollanek, BS,

Hemodynamic evaluation using four-dimensional flow magnetic resonance imaging for a patient with multichanneled aortic dissection Baolei Guo, MD, PhD,

Lee J. Goldstein, MD, Combiz Rezayat, MD, Gautam V

Outcome of visceral chimney grafts after urgent endovascular repair of complex aortic lesions Adel Bin Jabr, MD, PhD, Bengt Lindblad, MD, PhD, Thorarinn.

An evaluation of centerline of flow measurement techniques to assess migration after thoracic endovascular aneurysm repair Sean O’Neill, MD, Roy K. Greenberg,

Aortic neck enlargement after endovascular aneurysm repair using balloon-expandable versus self-expanding endografts Janis Savlovskis, MD, Dainis Krievins,

A randomized, placebo-controlled trial of doxycycline after endoluminal aneurysm repair Amy E. Hackmann, MD, Brian G. Rubin, MD, Luis A. Sanchez, MD,

Initial experience characterizing a type I endoleak from velocity profiles using time- resolved three-dimensional phase-contrast MRI Thomas A. Hope, MD,

Novel technique for endovascular salvage of a folded aortic endograft

Impact of transrenal aortic endograft placement on endovascular graft repair of abdominal aortic aneurysms Michael L. Marin, MD, Richard E. Parsons,

Prospective intraindividual comparison of unenhanced magnetic resonance imaging vs contrast-enhanced computed tomography for the planning of endovascular.

Christopher K. Zarins, MD, Rodney A. White, MD, Thomas J. Fogarty, MD

Endovascular treatment of isolated abdominal aortic dissection and postoperative aortic remodeling Qian-qian Zhu, MD, Dong-lin Li, MD, Ming-chun Lai,

Early versus late experience in fenestrated endovascular repair for abdominal aortic aneurysm Magnus Sveinsson, MD, Jonathan Sobocinski, MD, PhD, Timothy.

David Nabi, MD, Erin H. Murphy, MD, Jimmy Pak, MD, Christopher K

Evolving experience with thoracic aortic stent graft repair

Fourteen-year outcomes of abdominal aortic endovascular repair with the Zenith stent graft Fabio Verzini, MD, PhD, FEBVS, Lydia Romano, MD, Gianbattista.

Preoperative assessment of abdominal aortic aneurysm: The value of helical and three- dimensional computed tomography Mario N. Gomes, MD, William J. Davros,

Evaluation of aortoiliac aneurysm before endovascular repair: Comparison of contrast- enhanced magnetic resonance angiography with multidetector row computed.

Midterm results from a physician-sponsored investigational device exemption clinical trial evaluating physician-modified endovascular grafts for the treatment.

Late endoleak after endovascular repair of an abdominal aortic aneurysm with multiple proximal extender cuffs Yehuda G. Wolf, MD, Bradley B. Hill, MD,

Technical aspects of repair of juxtarenal abdominal aortic aneurysms using the Zenith fenestrated endovascular stent graft Gustavo S. Oderich, MD, Mateus.

Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair Adel Bin Jabr, MD, Bengt Lindblad, MD,

Seyed Ameli-Renani, MBBS, FRCR, Vyzantios Pavlidis, MD, Robert A

Tuberculous aneurysms of the abdominal aorta

Thomas S. Monahan, MD, Timothy A. M. Chuter, MD, Linda M

Contrast-enhanced ultrasound versus color duplex ultrasound imaging in the follow-up of patients after endovascular abdominal aortic aneurysm repair

A case-control study of intentional occlusion of accessory renal arteries during endovascular aortic aneurysm repair Rafael D. Malgor, MD, Gustavo S.

Stent graft migration after endovascular aneurysm repair: importance of proximal fixation Christopher K Zarins, MD, Daniel A Bloch, PhD, Tami Crabtree,

Intra-operative DynaCT improves technical success of endovascular repair of abdominal aortic aneurysms Lukla Biasi, MD, Tahir Ali, MBChB, MRCS, Lakshmi.

Initial experience with a new fenestrated stent graft

The effect of endograft relining on sac expansion after endovascular aneurysm repair with the original-permeability Gore Excluder abdominal aortic aneurysm.

Jon S. Matsumura, MD, Wesley S. Moore, MD Journal of Vascular Surgery

Mid- and long-term device migration after endovascular abdominal aortic aneurysm repair: A comparison of AneuRx and Zenith endografts Britt H. Tonnessen,

First experience using intraoperative contrast-enhanced ultrasound during endovascular aneurysm repair for infrarenal aortic aneurysms Reinhard Kopp,

Endovascular aneurysm repair for ruptured abdominal aortic aneurysm: The Albany Vascular Group approach Manish Mehta, MD, MPH Journal of Vascular Surgery

Dissection of the abdominal aorta in blunt trauma: endovascular or conventional surgical management? Jean-Philippe Berthet, MD, Charles-Henri Marty-Ané,

Endovascular management of thoracic aortic aneurysms

Duplex ultrasound scanning versus computed tomographic angiography for postoperative evaluation of endovascular abdominal aortic aneurysm repair Yehuda.

Predictive factors and clinical consequences of proximal aortic neck dilatation in 230 patients undergoing abdominal aorta aneurysm repair with self-expandable.

Aortic neck enlargement after endovascular aneurysm repair using balloon-expandable versus self-expanding endografts Janis Savlovskis, MD, Dainis Krievins,

Endoleaks after endovascular graft treatment of aortic aneurysms: Classification, risk factors, and outcome Reese A. Wain, MD, Michael L. Marin, MD,

What imaging studies are necessary for abdominal aortic endograft sizing? A prospective blinded study using conventional computed tomography, aortography,

University of Florida, Gainesville

Dr. Christopher Smolock

Fenestrated endograft for recurrent paravisceral aortic pseudoaneurysm after thoracoabdominal aortic aneurysm open repair Mauro Gargiulo, MD, PhD, Enrico.

Complete regression of a symptomatic, mycotic juxtarenal abdominal aortic aneurysm after treatment with fenestrated endovascular aneurysm repair Jonathan.

Presentation transcript:

CT Angiography in Stent-Graft Sizing: Impact of Using Inner vs Outer Wall Measurements of Aortic Neck Diameters J ENDOVASC THER 2011 Institute of Radiology and Vascular Surgery Rome, Italy

INTRODUCTON Endovascular aneurysm repair (EVAR) is playing an increasing role in the treatment of abdominal aortic aneurysm (AAA). Patients treated with EVAR require reintervention during mid-and long-term follow-up due to complications related to the procedure.

Incorrect graft sizing can lead to both attachment site endoleaks as well as migration. The instructions of current endografts recommend the reference diameter measurement method to use for sizing: outer-to-outer wall (adventitia-to- adventitia) or inner-to-inner wall (intima-to-intima), but there is no consensus with regard to the correct strategy for endograft sizing in EVAR planning.

In some clinical situations, the neck measurements could be made in advance of selecting the stent-graft type to implant. CTA of preoperative evaluation acquires static images of the aorta at any random moment during the cardiac cycle. However, dynamic imaging has documented significant changes in aortic diameters during the cardiac cycle.

The presence of significant pulsatile aortic neck variations may have serious implications for EVAR design( endograft size). The purpose of this study was to assess the potential impact of using inner vs. outer wall measurements based on static CTA to select stent-graft sizes.

METHODS Prospective single-center pilot study. 40 consecutive patients>75years old with infrarenal AAA and referred to our institution for routine preoperative CTA. 29 men; mean age years, range 75–89. Excluded standard: Patients 1.5 mg/dL, or creatinine clearance rate <60 mg/mL.

Mean body mass index kg/m2 (range 22–35.2). All enrolled patients underwent both standard static and dynamic ECG-gated CTA with double CT acquisition and double contrast injection. The ethical conduct of the study was approved by our departmental review board. All patients provided written informed consent for the protocol with specific acceptance of double CT acquisitions.

Scanning Protocols A double-phase (unenhanced and contrastenhanced arterial) static CT acquisition was first performed on a 64-detector row helical scanner. (Light Speed VCT XT; GE Medical System) using standard parameters (120 kV, 800 mAs). From suprarenal abdominal aorta to the common femoral artery. Trigger scanning after capture of 150 HU on the abdominal aorta at the level of the celiac trunk.

Dynamic scan mode acquires data in a nonstop, helical fashion while an independent ECG trace is generated. Dynamic ECG-gated datasets were acquired with a low-dose acquisition protocol (100 kV) Range extending from the origin of the celiac trunk to the aortic bifurcation using the same settings as above.

Standardized incremental 10% reconstructions were done by the technologist from 5% to 95% of the R-R cardiac cycle at 10 equidistant time points.

Image Evaluation All images were processed and evaluated using the cardiac review program on a dedicated 3- dimensional workstation. The specific image sets were randomly selected by a radiologist not involved in image analysis.

The coordinator of the study selected for evaluation 3 static and 3 dynamic images located ①1 cm above the highest renal artery (suprarenal level) ② Immediately below the lowest renal artery (juxtarenal level) ③1 cm below the lowest renal artery (infrarenal level).

Measurements were performed on a plane perpendicular to the largest portion of the aneurysm. First on sagittal multiplanar reconstructions (MPR), then on coronal MPR, creating a ‘‘modified axial’’ plane perpendicular to the long axis of the aortic neck in 2 orthogonal planes (Fig. 1).

Static imaging datasets were read in consensus by an experienced vascular interventional radiologist and vascular surgeon.

Measured maximum aortic neck diameters using an electronic cursor from intima-to-intima (inner wall) and from adventitia- to-adventitia (outer wall). On the basis of these measurements, they selected the size of the stent-graft according to the institution’s recommended oversizing (20%–30%).

RESULTS An excellent interobserver repeatability coefficient was obtained (kappa 0.87). Aortic Pulsatility Changes in proximal neck diameters reflected the significant aortic pulsatility within the aneurysm neck during the cardiac cycle.

Mean variations for the inner and outer wall diameters of 9.75% % and 8.66% % The absolute changes in diameters were mm and mm.

No statistically significant differences in aortic pulsatility at the 3 levels in the neck for the inner or outer wall diameters. Significant variability was seen between inner (mean mm) vs outer (mean mm; p<0.05) wall diameters. Stent-graft sizes significantly changed on the basis of the measurement method and device.

Selecting the stent-graft using the incorrect outer wall measurement changed the device size in 14 (35.5%) of 40 patients, with a consequent excessive oversizing in 8 (20%) patients. The oversizing was inadequate in 36 (90.3%) of 40 patients when the size of the stent-graft incorrectly selected on the basis of outer diameters. For a device that requires inner wall measurements as reference

When considering a stent-graft that requires outer wall diameter measurements as reference The stent-graft size changed in 15 (38.7%) of 40 patients when using the wrong inner wall diameters, with a consequent inadequate oversizing in 13 (32.5%) patients. The oversizing was inadequate in 17 (41.9%) of 40 patients when the size of the stent-graft selected incorrectly using inner diameters.

For example, Using the outer diameter to size a stent-graft that requires an inner diameter reference changed 36% of the selected stent-graft sizes, with,20% being excessively oversized. Conversely, using the inner diameter to size an outer- diameter–based stent-graft resulted in nearly 40% of the sizes being altered. Based on dynamic measurements, the changes were more dramatic: the oversizing was considered excessive in up to 90% of patients if the measurement method did not match the stent-graft’s stipulated reference.

DISCUSSION There are several factors that have been implicated in aortic neck dilatation and elongation: including aggressive stent-graft oversizing and the natural course of progressive aortic aneurysmal disease. Adequate oversizing is mandatory to obtain a seal between the stent-graft and the aortic wall to prevent subsequent perigraft.

As demonstrated by recent studies on dynamic CTA imaging, the aorta changes significantly during the cardiac cycle. Thus, both aortic pulsatility and the method of measuring the neck diameter play roles in successful EVAR planning.

Our data confirmed that significant aortic pulsatility exists within the aneurysm neck during the cardiac cycle. Furthermore, there is substantial variability in aortic neck inner wall and outer wall measurements on static CTA images. Thus, stent-graft sizing could be significantly impacted if one incorrectly used the inner or outer static diameters to select a stent-graft.

Using dynamic measurements is even more dramatic: in the first scenario above (outer diameter with an inner-diameter–based stent-graft), most of the devices would be excessively oversized. Inadequate oversizing due to incorrectly measured baseline diameters could explain postoperative stent-graft–related complications (such as migration, type I endoleaks, and subsequent poor patient outcomes).

In our opinion, to avoid incorrect (inadequate or excessive) oversizing, stent-graft sizing should be based on the mean value between diastolic and systolic diameters.

LIMITATIONS Main limitation relatively small number of patients examined. patients >75 years (to reduce the potential consequences of increased radiation exposure from the double CT acquisition). Aortic pulsatility may be age-dependent and correlate with cardiac status, so the results obtained in this patient cohort may differ from those seen in younger patients.

We have not suggested a ‘‘standard’’ over-sizing. It has to be selected individually on the basis of dynamic characteristics. If the oversizing performed on the basis of dynamic imaging impacted post-EVAR outcomes by reducing complications. This falls outside the scope of this pilot study and remains a goal for future studies.

CONCLUSIN Our study suggests that stent-graft sizing should follow the manufacturer’s recommendations for using inner or outer diameter references based on dynamic patterns (mean value between diastolic and systolic diameters).