Duplex Ultrasound Versus Computed Tomography for Follow Up of Complications after Evar with Nellix Endograft: First Clinical Experience

Open access


Introduction.Contrast-enhanced computed tomography (CT) has become the ‘gold-standard’ imaging modality for surveillance following EVAR (2, 20). However repeated CT is related to increased cost, risk of contrast nephropathy and radiation exposure. Duplex ultrasound (DUS) is a less invasive but considered less accurate method than CT.

Aim of the study. The aim of this study was to determine the diagnostic accuracy of both imaging modalities for detection of complications in post-EVAR patients where the new generation sac-sealing endograft was used and to compare cost-effectiveness and sensitivity of both imaging modalities.

Methods. Analysis of 23 post-EVAR patients with implantation of new generation sac-sealing endograft device (Nellix®, Endologix, USA) was performed, making a comparison of CT and DUS. Contrast-enhanced computed tomography was taken as the ‘goldstandard’ investigation. DUS was compared to CT for analysis of sensitivity, post-imaging complications and cost-effectiveness. Statistical analysis of data was performed using v19.0 SPSS software (IBM).

Results. Analysis of CT and DUS studies compared in 23 patients. Both imaging modalities can detect AAA sac dimensions, endoleaks, and graft patency. The cost difference between two imaging techniques is substantial. Our results demonstrate that DUS surveillance during follow-up after EVAR where new generation sac-sealing endograft is used can accurately detect aneurysm size, endoleaks, graft deformations and stenotic or kinked graft limbs while lowering the overall costs of surveillance and eliminating CT related radiation and nephrotoxicity.

Conclusion. CT and DUS imaging can both detect AAA sac dimensions, endoleaks, and graft patency. The cost difference between the two imaging techniques is substantial. Our results demonstrate that in post-EVAR patients where new-generation sac-sealing endograft was deployed DUS surveillance performed by experienced radiologist can accurately detect aneurysm size, endoleaks, graft deformations and stenotic or kinked graft limbs while lowering the overall costs of surveillance and avoiding CT-related complications.

  • 1. Akro FR, Filas KA, Siedel SA, Johnson BL, Drake AR, Fogarty TJ, et al. Intrasac flow velocities predict sealing of type II endoleaks after endovascular abdominal aneurysm repair // J Vasc Surg, 2003; 37:8-15.

  • 2. Badri H, El Haddad M, Ashour H, Nice C, Timmons G, Bhattacharya V. Duplex ultrasound scanning (DUS) versus computed tomography angiography (CTA) in the follow-up after EVAR // Angiology, 2010 Feb; 61(2):131-6.

  • 3. Bakken AM, Illig KA. Long-term follow-up after endovascular aneurysm repair: is ultrasound alone enough? // Perspect Vasc Surg Endovasc Ther, 2010 Sep; 22(3):145-51.

  • 4. Bargellini I, Cioni R, Napoli V, Petruzzi P, Vignali C, Cicorelli A, Sardella S, Ferrari M, Bartolozzi C. Ultrasonographic surveillance with selective CTA after endovascular repair of abdominal aortic aneurysm // J Endovasc Ther, 2009 Feb;16(1):93-104.

  • 5. Beeman BR, Doctor LM, Doerr K, McAfee- Bennett S, Dougherty MJ, Calligaro KD. Duplex ultrasound imaging alone is sufficient for midterm endovascular aneurysm repair surveillance: a cost analysis study and prospective comparison with computed tomography scan // J Vasc Surg, 2009 Nov; 50(5):1019-24.

  • 6. Bosch JL, Kaufman JA, Beinfeld MT, Miraude EA, Brewster DC, Gazelle GS. Abdominal aortic aneurysms: cost-effectiveness of elective endovascular and open surgical repair // Radiology, 2002; 225:337-344.

  • 7. Bosch JL, Lester JS, McMahon PM, Beinfeld MT, Halpern EF, Kaufman JA, et al. Hospital costs for elective endovascular and surgical repairs of infrarenal abdominal aortic aneurysms // Radiology, 2001; 220:492-497.

  • 8. Chaer RA, Gushchin A, Rhee R, Marone L, Cho JS, Leers S, Makaroun MS. Duplex ultrasound as the sole long-term surveillance method postendovascular aneurysm repair: a safe alternative for stable aneurysms // J Vasc Surg, 2009 Apr; 49(4):845-9; discussion 849-50.

  • 9. Chisci E, Setacci F, Iacoponi F, de Donato G, Cappelli A, Setacci C. Surveillance imaging modality does not affect detection rate of asymptomatic secondary interventions following EVAR // Eur J Vasc Endovasc Surg, 2012 Mar; 43(3):276-81.

  • 10. Clair DG, Gray B, O’Hara PJ, Ouriel K. An evaluation of the costs to health care institutions of endovascular aortic aneurysm repair // J Vasc Surg, 2000; 32:148-152.

  • 11. Collins JT, Boros MJ, Combs K. Ultrasound surveillance of endovascular aneurysm repair: a safe modality versus computed tomography //Ann Vasc Surg, 2007; 21:671-675.

  • 12. Donayre CE, Zarins CK, Krievins D, Holden A, Hill A, Calderas C, Velez J, White RA. Initial clinical experience with a sac-anchoring endoprosthesis for aortic aneurysm repair // J Vasc Surg, 2011; 53(3):574-582.

  • 13. Prinssen M, Buskens E, Blankensteijn JD; DREAM trial participants. Quality of life endovascular and open AAA repair. Results of a randomised trial // Eur J Vasc Endovasc Surg, 2004 Feb; 27(2):121-7.

  • 14. EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomized controlled trial // Lancet, 2005; 356:2179-2186.

  • 15. Harrison GJ, Oshin OA, Vallabhaneni SR, Brennan JA, Fisher RK, McWilliams RG. Surveillance after EVAR based on duplex ultrasound and abdominal radiography // Eur J Vasc Endovasc Surg, 2011 Aug; 42(2):187-92.

  • 16. Kim JK, Tonnessen BH, Noll RE, Money SR, Sternberg WC. Reimbursement of long-term postplacement costs after endovascular abdominal aortic aneurysm repair // J Vasc Surg, 2008; 48:1390-1395.

  • 17. Kisis K, Krievins D, Naskovica K, Gedins M, Savlovskis J, Ezite N, Lietuvietis E, Zarins K. Quality of life after endovascular abdominal aortic aneurysm repair: Nellix sac-anchoring endoprosthesis versus open repair // Medicina, 2012; 48(6):286-291.

  • 18. Krievins D, Holden A, Savlovskis J, Calderas C, Donayre CE, Moll FL, Katzen B, Zarins CK. EVAR using the Nellix Sac-anchoring endoprosthesis: treatment of favourable and adverse anatomy // Eur J Vasc Endovasc Surg, 2011; 42(1):38-46.

  • 19. Kranokpiraksa P, Kaufman JA. Follow-up of endovascular aneurysm repair: plain radiography, ultrasound, CT/CT angiography, MR imaging/MR angiography, or what? // J Vasc Interv Radiol, 2008; 19:S27-S36.

  • 20. Karthikesalingam A, Al-Jundi W, Jackson D, Boyle JR, Beard JD, Holt PJ, Thompson MM. Systematic review and meta-analysis of duplex ultrasonography, contrast-enhanced ultrasonography or computed tomography for surveillance after endovascular aneurysm repair // Br J Surg, 2012 Nov; 99(11):1514-23.

  • 21. Manning BJ, O’Neill SM, Haider SN, Colgan MP, Madhavan P, Moore DJ. Duplex ultrasound inaneurysm surveillance following endovascular aneurysm repair: a comparison with computed tomography aortography // J Vasc Surg, 2009 Jan; 49(1):60-5.

  • 22. Noll RE, Tonnessen BH, Mannava K, Money SR, Sternbergh CW. Long-term postplacement cost after endovascular aneurysm repair // J Vasc Surg, 2007; 46:9-15.

  • 23. Parfrey PS, Griffiths SM, Barrett BJ, Paul MD, Genge M, Withers J, et al. Contrast materialinduced renal failure in patients with diabetes mellitus, renal insufficiency, or both (A prospective controlled study) // N Engl J Med, 1989; 320:143-149.

  • 24. Prinssen M, Wixon CL, Buskens E, Blankensteijn JD. Surveillance after endovascular aneurysm repair: diagnostics, complications, and associated costs // Ann Vasc Surg, 2004; 18:421-427.

  • 25. Raman KG, Missig-Carroll N, Richardson T, Muluk SC, Makaroun MS. Color-flow duplex ultrasound scan versus computed tomographic scan in the surveillance of endovascular aneurysm repair // J Vasc Surg, 2003; 38:645-651.

  • 26. Radiation risk: directorate-general for the environment of the European Commission: Referral guidelines for imaging // European Commission, Radiation Protection Report, 2000;118.

  • 27. Schmieder GC, Stout CL, Stokes GK, Parent FN, Panneton JM. Endoleak after endovascular aneurysm repair: duplex ultrasound imaging is better than computed tomography at determining the need for intervention // J Vasc Surg, 2009 Nov; 50(5):1012-8.

  • 28. Sternberg WC, Greenberg RK, Chuter TA, Tonnessen BH. Redefining postoperative surveillance after endovascular repair: recommendations based on 5-year follow-up in the US Zenith multicenter trial // J Vasc Surg, 2008; 48:278-283.

  • 29. Sun Z. Diagnostic value of color duplex ultrasonography in the follow-up of endovascular repair of abdominal aortic aneurysm // J Vasc Interv Radiol, 2006 May; 17(5):759-64.

  • 30. United Kingdom EVAR Trial investigators, Greenhalgh RM, Brown LC, et al. Endovascular versus open repair of abdominal aortic aneurysm // N Engl J Med, 2010; 362(20):1863-1871.

  • 31. Wolf YG, Johnson BL, Hill BB, Rubin GD, Fogarty TJ, Zarins CK. Duplex ultrasound scanning versus computed tomographic angiography for postoperative evaluation of endovascular abdominal aortic aneurysm repair // J Vasc Surg, 2000; 32:1142-1148.

  • 32. Verhoeven EL, Oikonomou K, Ventin FC, Lerut P, Fernandes E Fernandes R, Mendes Pedro L. Is it time to eliminate CT after EVAR as routine follow-up? // J Cardiovasc Surg (Torino), 2011 Apr; 52(2):193-8. Review.

Acta Chirurgica Latviensis

The Journal of Riga Stradins University; Latvian Association of Surgeons; Latvian Association of Paediatric Surgeons

Journal Information


All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 14 14 14
PDF Downloads 3 3 3