title: Use of three-dimensional contrast-enhanced duplex ultrasound imaging during endovascular aneurysm repair.
abstract: BACKGROUND
  Iodinated contrast during endovascular aneurysm repair (EVAR) is used with caution in patients with chronic kidney disease. Contrast-enhanced ultrasound (CEUS) imaging using nonnephrotoxic sulphur hexafluoride microbubble contrast is a novel imaging modality that accurately identifies and characterizes endoleaks during EVAR follow-up. We report our initial experience of using three-dimensional (3D) CEUS imaging intraoperatively as completion imaging after endograft deployment. Our aim was to compare intraoperative 3D CEUS against uniplanar angiography in the detection of endoleak, stent deformity, and renal artery perfusion during EVAR.
  
  
  METHODS
  The study enrolled 20 patients undergoing elective conventional infrarenal EVAR, after which a completion angiogram was performed and the presence of endoleak, renal artery perfusion, or device deformity were recorded. With the patient still under anesthetic, a vascular scientist blinded to angiographic findings performed 3D CEUS and reported on the same parameters.
  
  
  RESULTS
  Three endoleaks, one type I and two type II, were detected on uniplanar angiography and 13 endoleaks, 11 type II and two type I, were found using 3D CEUS imaging. Of note, one of these type I endoleaks was not seen on angiography, and this patient underwent balloon moulding of the neck with resolution of the endoleak on repeat imaging. Of the 11 type II endoleaks seen with 3D CEUS imaging, the inflow vessel was identified in nine cases. No graft deformity or limb kinking was seen in any patient. Both renal arteries could be visualized in 10 patients, whereas the target renal artery was seen in 11 patients. In the remaining patients, the renal arteries could not be visualized, mainly due to intra-abdominal gas or patient body habitus.
  
  
  CONCLUSIONS
  3D CEUS imaging detected endoleaks not seen on uniplanar digital subtraction angiography, including a clinically important type I endoleak, and was also more sensitive than 2D CEUS imaging for the detection of the source of endoleak. This technology has the potential to supplement or replace digital subtraction angiography for completion imaging to reduce the use of x-ray contrast. Intraoperative 3D CEUS has been applied to allow safe EVAR with ultralow or no iodinated contrast usage in selected cases, without compromising completion imaging.
authors.affiliation: Department of Vascular Surgery, University Hospital of South Manchester, Manchester, United Kingdom.
authors.forename: David C
authors.initials: DC
authors.lastname: Ormesher
authors.affiliation: Department of Vascular Surgery, University Hospital of South Manchester, Manchester, United Kingdom.
authors.forename: Christopher
authors.initials: C
authors.lastname: Lowe
authors.affiliation: Independent Vascular Services, University Hospital of South Manchester, Manchester, United Kingdom.
authors.forename: Nicola
authors.initials: N
authors.lastname: Sedgwick
authors.affiliation: Department of Vascular Surgery, University Hospital of South Manchester, Manchester, United Kingdom.
authors.forename: Charles N
authors.initials: CN
authors.lastname: McCollum
authors.affiliation: Department of Vascular Surgery, University Hospital of South Manchester, Manchester, United Kingdom. Electronic address: jonathan.ghosh@nhs.net.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Ghosh
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015901:Angiography, Digital Subtraction; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation; D003287:Contrast Media; D057867:Endoleak / Q000000981:diagnostic imaging / Q000209:etiology; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000295:instrumentation; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D021621:Imaging, Three-Dimensional; D008297:Male; D045423:Microbubbles; D011183:Postoperative Complications / Q000000981:diagnostic imaging* / Q000503:physiopathology; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011475:Prosthesis Failure; D012077:Renal Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D015607:Stents; D013459:Sulfur Hexafluoride; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014654:Vascular Patency
chemical_list: D003287:Contrast Media; D013459:Sulfur Hexafluoride