Detection of Complications After Aortic Stent Grafting
(see Figure 5). It has been suggested that MRA and MDCTA can detect endoleaks with the same sensitivity.43–45 authors43,46
Some
have reported that MRA can even have higher sensitivity to detect type II endoleaks compared with mono- or bi-phasic MDCTA. Cohen et al.42
found a very high agreement level (up to 97%) between MRA and DSA in terms of endoleak classification. MRA angiography can be also safely used for the follow-up of patients after thoracic aorta stent-graft.45
Generally, MRA lacks the disadvantages of CTA, such as contrast- medium-associated nephrotoxicity, potential anaphylactic reaction and ionising radiation exposure. On the other hand, gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after administration of gadolinium-based contrast agents.47
Patients with pacemakers and other metallic implants are
unsuitable for MR surveillance. Digital Subtraction Angiography
DSA is considered the gold standard for the detection and classification of endoleaks.26
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Due to its invasive character it is usually
Most studies use dynamic gadolinium-enhanced 3D and delayed 2D gradient-echo sequences. New techniques (time-resolved sequences) have been applied with good results for better characterisation of endoleak type42
used for better delineation of an already proven (with MDCTA or MRA) endoleak, or in cases with sac aneurysm enlargement and no apparent endoleak on MDCTA, MRA or CEUS. The main advantage of DSA is its ability to determine blood flow direction and thus differentiate type I and III from type II endoleaks. DSA should always be performed before an endoleak is characterised as type V (endotension) and before the patient is referred for open surgical repair for endotension. Finally, DSA offers the major advantage of therapeutic treatment of the proven endoleaks.
Conclusion
and properly adjusted follow-up is pressing. Some authors suggest that US imaging could be advocated in patients with stable or shrinking aneurysm surveillance.40
MRA has a
similar sensitivity rate to MDCTA for the detection of endoleaks, with no radiation-related exposure risk. DSA should be used for better delineation and possible treatment of an endoleak after it has been detected. n
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37. Sun Z, J Vasc Interv Rad, 2006;17:759–64. 38. Bendick PJ, Bove PG, Long GW, et al., J Vasc Surg, 2003;37:381–5.
39. McWilliams RG, Martin J, White D, et al., J Endovasc Ther, 2002; 9:170–79.
40. Chaer RA, Gushchin A, Rhee R, et al., J Vasc Surg, 2009;49:845–9, discussion 849–50.
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49. Lezzi R, Cotroneo AR, Giammarino A, et al., Eur J Radiol, 2010 (Epub ahead of print).
Lifelong surveillance is mandatory after EVAR in order to detect possible complications. Current strategies and modalities for the follow-up of patients after EVAR are far from satisfactory. The medical community is still on an ongoing quest for the ideal follow- up method. MDCTA is considered the gold standard for follow-up of patients after EVAR, but radiation exposure risk is a concern and the need for alternative imaging modalities,48 CT protocols49
low-dose acquisition
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