Sonographic Evaluation of Aortic Endografts
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Abstract:
The selective use of endovascular devices to repair abdominal aortic aneurysms was introduced in the early 1990s. Although placement of an aortic endograft offers patients a less morbid alternative to surgical repair, this procedure is not without complications. Persistent perfusion of the residual aneurysmal sac via endoleaks may place the patient at risk for aneurysmal enlargement and subsequent rupture. Historically, serial computed tomographic angiography has been used as the primary modality for assessment of aortic endografts. In recent years, sonography has been shown to provide a valued tool for ongoing surveillance of aortic endografts and identification of endoleaks, increasing aneurysmal size, hemodynamic disorders, and graft migration and/or kinking. Standardization of the sonographic evaluation yields accurate information vital to the long-term patency of these conduits.Keywords:
Computed tomographic angiography
Aortic repair
Background: During anterolateral thigh flap harvest, inadequate perforators may necessitate modification of the flap design, exploration of the contralateral thigh, or additional flap harvest. Computed tomographic angiography may facilitate perforator mapping and optimize flap design. The authors performed this pilot study to determine the predictive power of computed tomographic angiography in anterolateral thigh flap planning and execution. Methods: Sixteen consecutive computed tomographic angiography–mapped anterolateral thigh flaps for head and neck reconstruction were studied. Perforator location, origin, caliber, and course were compared between computed tomographic angiography and intraoperative findings. The relationship of patient characteristics, imaging studies, and intraoperative factors to flap design and surgical outcomes was analyzed. Results: Among the 16 anterolateral thigh flaps, 40 of 54 perforators identified intraoperatively were visible on computed tomographic angiography, resulting in 74 percent sensitivity. Intraoperative perforator location averaged 0.35 cm from the computed tomographic angiography–predicted location. The overall ability of computed tomographic angiography to predict perforator size was 67.5 percent. Its overall accuracy in predicting whether a perforator took a septocutaneous or intramuscular course before perforating the deep fascia was 77.5 percent. Preoperative angiography resulted in surgeons modifying the operative plan in 37 percent of cases and 57 percent of double-island flap cases. All flaps were elevated successfully and survived. Conclusions: Computed tomographic angiography identified larger perforators better than smaller ones and proximal perforators better than distal ones. It accurately predicted the location and origin of visible perforators and less accurately predicted the size and course of visible perforators. Most importantly, the information it provided influenced surgeons to modify their reconstructive strategy, resulting in a higher level of recipient-site specificity.
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Computed tomographic angiography (CTA) is a relatively new diagnostic modality in the field of vascular surgery. Despite being new it has already been introduced into a wide range of diagnostic applications in this field and in many cases it can precede or replace the conventional intra-arterial angiography. During a 12 month period between 1.8.98 and 1.8.99 sixty five peripheral arterial imaging scans were performed using a CT Twin--2 helical scanner (Spiral Twin Flash., Elscint, Israel) with a 100% technical success rate and no complications at all. Twelve patients (18.5%) were operated upon and 20 (30.7%) underwent endovascular procedures with full intra-procedural agreement with the pre-operative or pre-procedure CTA findings. Despite possible pitfalls and a few disadvantages the technique carries major benefits and significant advantages to both the patient and the clinician. Therefore we recommend considering CTA as a first line diagnostic modality whenever peripheral vasculature has to be demonstrated whether electively or urgently and to spare the conventional angiography for selected cases only.
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Sir: The use of preoperative imaging in perforator flap surgery has been a recent advance that has been shown to improve a range of operative outcome measures.1 In deep inferior epigastric artery perforator flap surgery, flap survival, donor-site morbidity, and length of operation have all been shown to be significantly reduced with the use of preoperative computed tomographic angiography. The use of computed tomographic angiography has thus been incorporated as routine in many centers internationally. Despite these clear benefits of its use, hesitation still exists toward its inherent association with ionizing radiation. Several techniques have recently been described in a move to minimize this radiation exposure. Changes in scanning protocols have achieved substantial dose reduction, with initial scanning techniques using scanning protocols similar to computed tomographic angiography of the abdomen for intraabdominal abnormalities, with calculated radiation doses of up to 10 mSv being received.2 By modifying the protocols specifically for flap planning, the radiation dose of computed tomographic angiography was able to be reduced by 40 percent to 6 mSv.3 To eliminate this exposure completely, the use of magnetic resonance angiography has been investigated; however, descriptions of its use do not yet match those of computed tomographic angiography, and certainly no outcome studies have been reported.4,5 Given that computed tomographic angiography is thus still considered the standard means of preoperative imaging, we describe a recent advance in computed tomographic angiography thus substantially reduces the radiation exposure with its use. Although the use of multidetector row computed tomography scanners has been a great advance in imaging technologies, all previously reported scanners used for perforator imaging have required movement of the computed tomography scanning table to achieve the multiple slices that the computed tomographic scanner acquires (four-slice, 16-slice, and 64-slice multidetector rows). This movement involves some time delay. The capture of multiple slices with these scanners also requires some overlap between adjacent slices. A new advance in computed tomography hardware is the 320-slice multidetector row computed tomographic angiography scanner. This scanner enables 320 data sets to be acquired simultaneously in a single-image “volume” capture, eliminating the need for table movement or multiple slices. These both serve to substantially reduce radiation exposure to the patient. In our experience with the 320 multidetector row computed tomography scanner (Aquilion One; Toshiba America Medical Systems, Tustin, Calif.), we have been able to achieve perforator imaging of the same resolution and quality as previously reported, and with axial slices of 0.5 mm (compared with 0.63 mm with 64-slice scanners), the resolution of three-dimensional reconstructions may in fact be enhanced (Fig. 1). In performing this new technique of “single-volume acquisition” scanning, the radiation dose is substantially reduced to 1.78 mSV. This is equivalent to the radiation dose of approximately three plain abdominal radiographs.2Fig. 1.: (Above) Preoperative computed tomographic angiography, volume-rendered reconstruction of the abdominal wall vasculature, using a 320-slice multidetector row computed tomography scanner (Aquilion One, Toshiba, Calif.), highlighting a single, large, 1.5-mm perforator (blue arrow). (Center) Grid based at the umbilicus applied for localization. (Below) Maximum intensity projection view of perforators relative to the deep inferior epigastric arteries.Since the first reports of computed tomographic angiography for perforator imaging only 3 years ago, there has been a revolution in advanced imaging technologies for perforator flap imaging. With ongoing research, these techniques have continued to become safer and provide growing levels of anatomical detail. Through increasing patient accessibility to imaging technologies, ongoing validation of the benefits from the use of these tools will be increasingly available. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Warren M. Rozen, M.B.B.S., B.Med.Sc., Ph.D. Daniel Chubb, M.B.B.S., B.Med.Sc. Jack Brockhoff Reconstructive Plastic Surgery Research Unit University of Melbourne Parkville, Victoria, Australia Marcus Crossett, Ba.App.Ph. Monash Heart Department of Radiology Monash Medical Center Clayton, Victoria, Australia Mark W. Ashton, M.B.B.S., M.D. Jack Brockhoff Reconstructive Plastic Surgery Research Unit University of Melbourne Parkville, Victoria, Australia
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We read with interest the article by Fukaya et al, “Magnetic Resonance Angiography for Free Fibula Flap Transfer,” in which a significant advancement in imaging technologies prior to perforator flap surgery is described—namely, the identification and analysis of the course of perforating arteries as a tool for preoperative planning.[1] Although magnetic resonance angiography (MRA),[2] computed tomographic angiography (CTA),[3] [4] and conventional angiography have each been used prior to free fibular flap surgery as a tool for mapping the vascular pedicles,[5] Fukaya et al have described advancements in MRA that permit analysis of individual perforators as small as 1 mm in diameter.
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The diagnostic evaluation of stable patients with penetrating trauma to the neck remains controversial. Conventional angiography has traditionally been considered the gold standard for evaluation of vascular injuries. The use of angiography for stable patients with penetrating neck trauma has been questioned because of its invasive nature and reported low yield. In recent years, there has been a renewed interest in the use of noninvasive techniques such as helical computed tomographic (CT) angiography for the evaluation of these patients. Helical CT angiography, a low-risk, rapid, accurate, noninvasive, reproducible technique, is less expensive than conventional angiography. Helical CT angiography also can provide information about potential lesions of associated vital structures such as the cervical spine and the aerodigestive tract. This review evaluates the authors' current protocol for penetrating neck wounds and identifies indications for helical CT angiography.
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Background: Computed tomographic angiography is increasingly used during surgical planning for abdominally based microvascular breast reconstruction. Cost-analysis studies have demonstrated a benefit to the use of computed tomographic angiography, although the secondary costs of incidental findings have not been previously reported. This study investigates the cost of computed tomographic angiography, taking into account the cost of incidental findings found during imaging. Methods: Patients undergoing preoperative computed tomographic angiography in preparation for autologous abdominally based breast reconstruction from July of 2010 through May of 2014 were included in this study. Patient medical records were reviewed for imaging findings, need for follow-up, and any additional procedures. Costs were determined using the publicly available Healthcare Bluebook. Results: A total of 135 patients underwent computed tomographic angiography in preparation for abdominally based microvascular breast reconstruction. Twenty-eight patients (21 percent) were noted to have clinically significant incidental findings recommended for follow-up imaging or procedures. Inclusion of chest imaging with computed tomographic angiography of the abdomen/pelvis to assess for internal mammary and/or thoracodorsal artery patency increased the incidental findings approximately five-fold. The mean cost of computed tomographic angiography increased by 32 percent, from $1267 to $1677 per patient, when incidental findings were included. Conclusions: Computed tomography angiography is a tool for the preoperative evaluation of patients desiring autologous breast reconstruction. The true cost of preoperative computed tomographic angiography is likely 30 percent greater than the baseline cost when the subsequent evaluation of incidental findings is included and should be accounted for in future cost-analysis studies.
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Computed tomographic angiography in the preoperative evaluation of potential renal transplant donors
The preoperative screening of potential renal transplant donors has undergone a major evolution with the introduction of computed tomographic angiography. With computed tomographic angiography, the radiologist is able to provide the surgeon with precise and valuable preoperative details of renal arterial and venous anatomy. In addition, computed tomographic angiography provides valuable information regarding the renal parenchyma and adjacent organs. This helps reduce the risks and complications associated with transplant surgery and improves the chances of a successful outcome. Helical computed tomographic angiography is rapidly replacing intravenous urography and conventional angiography as the imaging modality of choice for evaluating renal donors.
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We discuss the preoperative application of computed tomographic (CT) angiography to identify legs suitable for free fibular flaps. Methods: The condition of 118 consecutive patients was prospectively evaluated by means of CT angiography for planned free fibula flap reconstructions. We retrospectively investigated whether fibular free flap transfer was performed in candidate patients and whether the presence of postoperative foot ischemia had been followed. Results: Multidetector row CT angiography demonstrated a normal arterial anatomy in 82 patients, anatomical variants in 30 patients, and peripheral arterial occlusive disease in 6 patients. The radiologists selected 20 legs as major variants that cannot ensure lower extremity viability after flap harvest. Sixty-three patients underwent fibula free flap transfer. The surgeons followed our imaging diagnosis and selected healthy legs as candidates for fibular free transfer in all but 2 patients. No postoperative foot ischemia presented in any patient. Conclusions: Computed tomographic angiography is a reliable preoperative imaging technique for the selection of appropriate legs as candidates for fibular free transfer.
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Abstract Abdominal aortic aneurysm (AAA) is the most common arterial dilatation disease. Computed tomographic angiography has been used all the time in the diagnosis of AAA. Applying the techniques in AAA, we can not only locate the position of AAA, but also classify it, and provide more valuable information for clinicians. Currently, post-processing methods include MPR, CPR, VR. These methods have their own advantages.
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Abdominal aortic aneurysm is a life-threatening condition due to the risk of aneurysm growth and rupture. There are no approved diagnostic or prognostic biomarkers for abdominal aortic aneurysm. We aimed to identify diagnostic and prognostic biomarkers for abdominal aortic aneurysm and to investigate their relationship with abdominal aortic aneurysm diameter and growth.In this case-control study, patients were included from an abdominal aortic aneurysm screening study on men aged ≥65 years. Of 24,589 examined men, 415 had abdominal aortic aneurysm, out of whom 134 consented to participate in the present study. One hundred and thirty-six screened men with aortic diameter <30 mm, matched for comorbidities and time of sampling were included as non-abdominal aortic aneurysm patients. Ninety-one cardiovascular specific proteins in plasma samples were measured by the Proseek Multiplex CVD III96x96 panel.After Bonferroni correction, plasma levels of 21 proteins associated with proteolysis, oxidative-stress, lipid metabolism, and inflammation were significantly increased, whereas levels of paraoxonase 3, associated with high-density lipoprotein metabolism, were decreased in abdominal aortic aneurysm patients. Combination of growth/differentiation factor 15 and cystatin B had the best ability to discriminate abdominal aortic aneurysm from non-abdominal aortic aneurysm (area under the curve, 0.76; sensitivity, 80% and specificity, 52%). Myeloperoxidase showed the best prognostic value (area under the curve, 0.71; sensitivity, 80% and specificity, 59%) and higher baseline levels of myeloperoxidase were significantly associated with faster abdominal aortic aneurysm growth compared with lower levels, independent of baseline diameter.We have identified multiple proteins associated with abdominal aortic aneurysm diameter and growth with a potential to become novel diagnostic and prognostic biomarkers for abdominal aortic aneurysm.
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