Dynamic,Time-Resolved CT Angiography After EVAR: A Quantitative Approach to Accurately Characterize Aortic Endoleak Type and Identify Inflow Vessels

Abstract

Purpose:

Our purpose was to study the accuracy of dynamic computed tomography angiography (d-CTA) in characterizing endoleak type, inflow vessels as compared with digital subtraction angiography (DSA) using qualitative and quantitative analysis.

Methods:

Between March 2019 and January 2021, all patients who underwent d-CTA imaging after EVAR were retrospectively reviewed. Two blinded independent reviewers qualitatively reviewed d-CTA and DSA images. Quantitative region of interest (ROI) analysis was performed by measuring time-resolved contrast enhancement within the aorta and endoleak lesion(s) in the aneurysm sac. Differences between time-to-peak enhancement (Δ TTP) across different ROIs were quantified.

Results:

A total of 48 patients underwent d-CTA during the study period, of whom 24 patients had abdominal EVAR and DSA imaging for comparison. Qualitative review of DSA imaging showed type I (n=4), type II (n=16), and type III (n=2) and no endoleak (n=2). In 23 of 24 patients (95.8%), d-CTA findings correlated with DSA findings for endoleak type. One patient had a type III endoleak that was demonstrated only in d-CTA (arising from defect in polymer sealing ring of Ovation stent graft) imaging. In type II endoleak cases, d-CTA identified more inflow vessels than DSA imaging (33 vs 21 vessels, p=0.010). Quantitative analysis showed mean (±SD) Δ TTP values for type I endoleak as 1.8 (±1.8) seconds, type II as 9.6 (±3.5) seconds, and for type III endoleak as 5.6 (±1.3) seconds.

Conclusion:

Dynamic CTA can accurately characterize aortic endoleak type, inflow vessels as compared with DSA imaging. Quantitative parameters such as Δ TTP enhancement can help better differentiate endoleak types and provide an objective approach to endoleak diagnosis.

Keywords

dynamic CTA time-resolved CTA endoleak endoleak imaging EVAR surveillance time-attenuation curve analysis time to peak quantitative analysis target vessel inflow vessel

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References

De Bruin

Baas

Buth

, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362(20):1881–1889.

Chaikof

Dalman

Eskandari

, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67(1): 2–77.e2.

Wanhainen

Verzini

Van Herzeele

, et al. Editor’s choice: European society for vascular surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg. 2019;57(1):8–93.

Powell

Sweeting

Ulug

, et al. Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years. Br J Surg. 2017;104(3):166–178.

Madigan

Singh

Chaer

, et al. Occult type I or III endoleaks are a common cause of failure of type II endoleak treatment after endovascular aortic repair. J Vasc Surg. 2019; 69(2):432–439.

Eden

Long

Major

, et al. Type II endoleak with an enlarging aortic sac after endovascular aneurysm repair predisposes to the development of a type IA endoleak. J Vasc Surg. 2020;72(4):1354–1359.

Blackham

Passalacqua

Sandhu

, et al. Applications of time-resolved MR angiography. AJR Am J Roentgenol. 2011;196(5):W613–W620.

Grist

Mistretta

Strother

, et al. Time-resolved angiography: past, present, and future. J Magn Reson Imaging. 2012;36(6):1273–1286.

Zhou

Han

Rapacchi

, et al. Accelerated ferumoxytol-enhanced 4D multiphase, steady-state imaging with contrast enhancement (MUSIC) cardiovascular MRI: validation in pediatric congenital heart disease. NMR Biomed. 2017;30(1): e3663.

10.

Azarine

Garcon

Stansal

, et al. Four-dimensional flow MRI: principles and cardiovascular applications. Radiographics. 2019;39(3):632–648.

11.

Sommer

Becker

Haack

, et al. Time-resolved CT angiography for the detection and classification of endoleaks. Radiology. 2012;263(3):917–926.

12.

Lehmkuhl

Andres

Lucke

, et al. Dynamic CT angiography after abdominal aortic endovascular aneurysm repair: influence of enhancement patterns and optimal bolus timing on endoleak detection. Radiology. 2013;268(3):890–899.

13.

Lehmkuhl

Andres

Lucke

, et al. Dynamic CT angiography after abdominal aortic endovascular aneurysm repair: differences in contrast agent dynamics in the aorta and endoleaks–preliminary results. J Vasc Interv Radiol. 2012;23(6):744–750.

14.

Berczeli

Lumsden

Chang

, et al. Dynamic, time-resolved computed tomography angiography technique to characterize aortic endoleak type, inflow and provide guidance for targeted treatment [published online ahead of print August 13, 2021]. J Endovasc Ther. doi:10.1177/15266028211037986.

15.

Hou

Zhu

Zhang

, et al. Dynamic volumetric computed tomography angiography is a preferred method for unclassified endoleaks by conventional computed tomography angiography after endovascular aortic repair. J Am Heart Assoc. 2019;8(8):e012011.

16.

Bent

Jaskolka

Lindsay

, et al. The use of dynamic volumetric CT angiography (DV-CTA) for the characterization of endoleaks following fenestrated endovascular aortic aneurysm repair (f-EVAR). J Vasc Surg. 2010;51(1):203–206.

17.

Sommer

Clevert

Bamberg

, et al. Time-resolved computed tomography imaging of the aorta: a feasibility study. J Thorac Imaging. 2010;25(2):161–167.

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