title: Could four-dimensional contrast-enhanced ultrasound replace computed tomography angiography during follow up of fenestrated endografts? Results of a preliminary experience.
abstract: OBJECTIVE
  To evaluate four-dimensional contrast-enhanced ultrasound (4D-CEUS) as an alternative imaging method to computed tomography angiography (CTA) during follow up of fenestrated endovascular aneurysm repair (FEVAR) for juxta- and para-renal abdominal aortic aneurysms (AAA).
  
  
  METHODS
  Between October 2011 and March 2012, all consecutive patients who underwent FEVAR follow up were included in the study and evaluated with both 4D-CEUS and CTA. The interval between the two examinations was always ≤ 30 days. Endpoints were the comparison of postoperative AAA diameter, AAA volume, presence of endoleaks, revascularized visceral vessel (RVV) visualization, and patency. Comparative analysis was performed using Bland-Altman plots and McNemar's Chi-square test.
  
  
  RESULTS
  Twenty-two patients (96% male, 4% female; mean age 74 ± 7 years; American Society of Anesthesiologists grade III/IV 82%/18%) were enrolled. Seventy-eight RVV (fenestrations: 60; scallops: 17; branches: 1) were analyzed. The mean AAA diameter evaluated by 4D-CEUS and CTA was 45 ± 10 mm (range 30-69 mm) and 48 ± 9 mm (range 32-70 mm), respectively. The mean difference was 3 ± 3 mm. The mean AAA volume evaluated by 4D-CEUS and CTA was 150 ± 7 cc (range 88-300 cc) and 159 ± 68 cc (range 80-310 cc), respectively. The mean difference was 7 ± 4 cc; a Bland-Altman plot revealed agreement in AAA diameter and volume evaluation (p < .01) between 4D-CEUS and CTA. The observed agreement for the detection of endoleaks was 95%. McNemar's Chi-square test confirmed that 4D-CEUS and CTA were equivalent (p > .05) at detecting endoleaks. The first segment of six (8%) RVVs (four renal and two superior mesenteric arteries) was not directly visualized by 4D-CEUS owing to obesity, but the contrast enhancement into the distal part of vessel or into the relative parenchyma gave indirect information about their patency. McNemar's Chi-square test demonstrated the superiority of CTA (p = .031) in visualizing RVVs. The patency of 77/78 RVVs was confirmed with both techniques. McNemar's Chi-square test confirmed that 4D-CEUS and CTA were equivalent in their ability to detect visceral vessel patency.
  
  
  CONCLUSIONS
  The data suggest that 4D-CEUS is as accurate as CTA in the evaluation of postoperative AAA diameter and volume, endoleak detection, and RVV patency after FEVAR. Four-dimensional CEUS could provide hemodynamic information regarding RVVs, and reduce radiation exposure and renal impairment during follow up. Obesity limits the diagnostic accuracy of 4D-CEUS.
authors.affiliation: Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Azienda Policlinico S. Orsola-Malpighi, Padiglione 5, III Piano Via Massarenti 9, 40138 Bologna, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Gargiulo
authors.affiliation: Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Azienda Policlinico S. Orsola-Malpighi, Padiglione 5, III Piano Via Massarenti 9, 40138 Bologna, Italy. Electronic address: enrico.gallitto@gmail.com.
authors.forename: E
authors.initials: E
authors.lastname: Gallitto
authors.affiliation: Ultrasound Unit, Department of Internal Medicine and Gastroenterology, Azienda Policlinico S. Orsola-Malpighi, Bologna, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Serra
authors.affiliation: Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Azienda Policlinico S. Orsola-Malpighi, Padiglione 5, III Piano Via Massarenti 9, 40138 Bologna, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Freyrie
authors.affiliation: Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Azienda Policlinico S. Orsola-Malpighi, Padiglione 5, III Piano Via Massarenti 9, 40138 Bologna, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Mascoli
authors.affiliation: Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Azienda Policlinico S. Orsola-Malpighi, Padiglione 5, III Piano Via Massarenti 9, 40138 Bologna, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Bianchini Massoni
authors.affiliation: Radiology, Azienda Policlinico S. Orsola-Malpighi, Bologna, Italy.
authors.forename: M
authors.initials: M
authors.lastname: De Matteis
authors.affiliation: Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Azienda Policlinico S. Orsola-Malpighi, Padiglione 5, III Piano Via Massarenti 9, 40138 Bologna, Italy.
authors.forename: C
authors.initials: C
authors.lastname: De Molo
authors.affiliation: Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Azienda Policlinico S. Orsola-Malpighi, Padiglione 5, III Piano Via Massarenti 9, 40138 Bologna, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Stella
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography / Q000379:methods; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods; D057867:Endoleak / Q000175:diagnosis*; D057510:Endovascular Procedures; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018615:Ultrasonography, Doppler, Color / Q000379:methods; D058017:Vascular Grafting
keywords: Aortic aneurysm; Contrast-enhanced ultrasound; Fenestrated endograft; Follow up