The Assessment of Carbon Dioxide Automated Angiography in Type II Endoleaks Detection: Comparison with Contrast-Enhanced Ultrasound

Chiara Mascoli, Gianluca Faggioli, Enrico Gallitto, Vincenzo Vento, Giuseppe Indelicato, Rodolfo Pini, Andrea Vacirca, Andrea Stella, Mauro Gargiulo, Chiara Mascoli, Gianluca Faggioli, Enrico Gallitto, Vincenzo Vento, Giuseppe Indelicato, Rodolfo Pini, Andrea Vacirca, Andrea Stella, Mauro Gargiulo

Abstract

Introduction: Iodinated contrast media completion angiography (ICM-A) may underestimate the presence of type II endoleak (ELII) after endovascular aortic repair (EVAR), particularly if they are at low flow. Contrast-enhanced ultrasound (CEUS) has been proposed as the gold standard in ELII detection during EVAR follow-up. Intraprocedural carbon dioxide (CO2) angiography has been shown to be useful in this setting; however no comparative studies including these three techniques are currently available. Our aim was to investigate the accuracy of a new automated CO2 angiographic (CO2-A) system in the detection of ELII, by comparing it with ICM-A and CEUS.

Methods: A series of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) were enrolled and submitted to ICM-A and CO2-A during the procedure. The iodinated contrast media were delivered through an automatic injector connected to a pigtail catheter in the suprarenal aorta. CO2 was delivered through a recently available automatic injector connected to a 10 F sheath positioned in the external iliac artery. All patients were blindly evaluated by CEUS within postoperative day 1. The ICM-A and CO2-A ability to detect ELII was compared with that of CEUS through Cohen's concordance Index (K).

Results: Twenty-one patients were enrolled in the study. One (5%), seven (33%), and four (19%) ELII were detected by ICM-A, CO2-A, and CEUS, respectively. The only ELII detected by ICM-A was also detected by CO2-A and CEUS. Three cases of ELII detected by CO2-A were not detected by CEUS. All ELII detected by CEUS were visualized by CO2-A. CEUS and ICM-A showed a poor agreement (Cohen's K: 0.35) while CEUS and CO2-A showed a substantial agreement (Cohen's K: 0.65) for ELII detection.

Conclusion: CO2-A is safe and effective method for ELII detection in EVAR, with a significantly higher agreement with CEUS if compared with ICM-A. This trial is registered with 155/2015/U/Oss.

Figures

Figure 1
Figure 1
Angiodroid injection system that shows CO2 injection volume and pressure on the display.
Figure 2
Figure 2
(a) Iodinated contrast media completion angiography that shows the good positioning of the infrarenal fixation endograft and the absence of endoleaks. (b) Carbon dioxide completion angiography that shows the good positioning of the infrarenal fixation endograft and the presence of ELII. (c) Magnification of ELII from sacral artery (red arrows indicates ELII coming from sacral artery). (d) Contrast-enhanced ultrasound that shows the presence of ELII with the inflow from sacral artery (red arrow).
Figure 3
Figure 3
(a) Iodinate contrast media completion angiography that shows the good positioning of the suprarenal fixation endograft and the absence of endoleaks. (b) Carbon dioxide completion angiography that shows the good positioning of the suprarenal fixation endograft and the presence of ELII (as indicated by the red arrows). (c) Contrast-enhanced ultrasound that shows the presence of ELII with the inflow from inferior mesenteric artery (as indicated by the red arrow).

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