The safety, feasibility & utility of 3-D Rotational Angiography with XperCT post-EVAR

Patrick ChongConsultant Vascular and Endovascular SurgeonThe Surrey Heart, Stroke and Vascular CentreFrimley Park Hospital NHS Foundation Trust

INDOVASCULAR SYMPOSIUM BANGALOREMarch 2014

DisclosuresTravel and Study GrantsCOOK MedicalMedtronic Limited UKSapheon Vascular B.V.

Paid speakerOtsuka Pharmaceuticals

BackgroundDemonstrates 4% of patients had an unidentified but correctable technical error not diagnosed by Uniplanar AngiographyBiasi et al. 2009 JVS

Philips Allura Xper FD20 system + Xper Guide(Philips, Best, The Netherlands)

Post EVAR Xper CT TechniqueEnsure C Arm is in the lateral positionDetector is set to landscapeRaise patients arms above headClear rotational area of obstacles + cover100 mls (50:50 contrast/saline) at 10mls/secIsocentre in AP then LateralSelect XperCT Module Final CHECKAcquire images via foot pedal control

STUDY OBJECTIVESPilot study forSafety renal functionFeasibility time takenUtility post-EVARCan additional XperCT aid quality control following satisfactory conventional uni-planar Angiography?Can XperCT replace routine CTA at 30-days for EVAR surveillance?

Study post-EVAR imaging protocol

RESULTS51 patients underwent conventional post-EVAR angiography & additional XperCT between April 2010 - July 2013.Median Age 77 (64-90) years Median time required to perform Xper CT 11 (6-23) minutesMedian LOS 2 (1-50) daysIndicationDeviceElective 47 - Anaconda 2Urgent 3 - Cook 22Emergency 1 - Endurant25- Endologix1- Trivascular 1

Renal Functionpre-EVAR & pre-dischargeMedian eGFR (range)p = NSPre-EVAR 60 (30-60) mls/min/1.73m2Pre-discharge60 (29-60) mls/min/1.73m2

Median Serum Creatinine (range) p = NSPre-EVAR87 (38-202) mol/LPre-discharge92 (45-187) mol/L

Xper CT findings post satisfactory conventional uni-planar angiography1 Type 1A endoleak (2%) ballooned small 1A persistent but not visible at 30 days5 new Type 2 (9.8%) not treated 2 visible at 30 days4 treated suboptimal limbs - all satisfactory all patent at 30-days3 new suboptimal limbs (6%) all stented all patent at 30-days

Type 1A Endoleak

Conventional Angiography Xper CT

Right iliac limb thrombus

30-day Surveillance CTA findings5 new type 2 endoleaks (9.8%) not detected by previous XperCTNone required intervention

2 new limb occlusions (4%)Right limb occlusion 8 days post-EVAR (Endurant) asymptomaticLeft limb occlusion 3 days post-EVAR (Endurant) symptomatic requiring fem-fem crossover bypass

Summary of findings

XperCT detected new findings not identified by conventional uni-planar angiography in 9 (17.6%) patients. Of these 4 (7.8%) underwent further on-table intervention for a correctable technical error.Following satisfactory XperCT, 7 (13.7%) patients had new surveillance CTA findings at 30-days. 30-day mortality was 3.9%Emergency 73m 13.5cm ruptured AAA died Day 24 post-EVAR PneumoniaElective 78m discharged Day 1 post-EVAR. Re-admitted day 10 post-EVAR with peritonitis and died Day 14 post-EVAR of sepsis

CONCLUSIONS

It is feasible to perform XperCT post-EVAR safely for patients with eGFR > 30mls/min/1.73m2. XperCT may be a useful adjunct in immediate post-EVAR quality control on table.This study shows that at present the post-EVAR 30-day surveillance CTA may not be replaced by on-table XperCT.A randomised study comparing conventional angiography versus XperCT post-EVAR is required.

FUTURE THERAPEUTIC OPTIONS?XperCT guided needle injection of ONYX for Type 2 Endoleak Van Bindsbergen et al. JVIR 2010

THANK YOUL. Everson, R.Limbu, A. Bajwa, S. Stevenson, P. Leopold, D. Gerrard, A. Hatrick, J. Taylor