Bastos Gonçalves, F.

European Journal of Vascular and Endovascular Surgery

English

Repositório da Universidade Nova de Lisboa

Eur J Vasc Endovasc Surg (2014) 48, 543e544INVITED COMMENTARYCommentary on: “Could Four Dimensional Contrast-enhanced UltrasoundsReplace Computed Tomography Angiography During Follow-up ofFenestrated Endografts? Results of a Preliminary Experience”F. Bastos Gonçalves a,b,*a Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlandsb Department of Angiology and Vascular Surgery, Hospital de Santa Marta, CHLC e Fac. Ciências Médicas da Universidade Nova, Lisbon, PortugalFenestrated endovascular aneurysm repair (fEVAR) is a well-established alternative to open repair for patients withjuxtarenal or short-neck AAAs.1e3 While computed tomog-raphy angiography (CTA) is considered the gold standard forsurveillance, it bears the risk of contrast nephropathy andexposure to ionizing radiation, and is associated with highcost and resource allocation. Recommendations for stan-dard EVAR have progressively changed to accept Duplexultrasound (DUS)-based strategies, at least for patients atlower risk of complications. Currently, there are no specificrecommendations from scientific societies regarding fEVARsurveillance, but expert opinion suggests close surveillanceis necessary to insure lasting results.1,2Gargiulo et al.4 addressed the issue of surveillance afterfEVAR in a retrospective study comparing CTA and four-dimensional contrast-enhanced ultrasound (4D-CEUS). Theauthors suggest that 4D-CEUS is as accurate as CTA fordetecting diameter and volume changes, endoleaks, andrevascularized visceral vessel patency.While the conclusionsare interesting, these data must be analyzed with caution.In fact, endoleak detection may be sub-optimal, as one inthree endoleaks were not detected with CEUS. A sample of22 patients is clearly underpowered to obtain conclusionsthat may influence clinical practice. It may be possible that,due to the relative rarity of fEVAR, one may never obtainenough power for robust conclusions.Also, the added value of 4D (compared to “standard”CEUS) appears only pertinent for volumetric measurements.While this is a valuable research tool, it is not regularly usedin clinical practice and may have very limited influence onthe course of treatment.5 As such, the present study doesnot add significantly to the larger study by Perini et al.,6where CEUS was compared favorably to CTA.Lastly, DUS and CEUS have important limitations thatlimit its applicability. These are largely related to access toDOI of original article: http://dx.doi.org/10.1016/j.ejvs.2014.05.025* F.B. Gonçalves, Erasmus University Medical Centre, Rotterdam,’s-Gravendijkwal 230 3015 CE Rotterdam, The Netherlands.E-mail address: f.bastosgoncalves@erasmusmc.nl (F. Bastos Gonçalves).1078-5884/$ e see front matter  2014 European Society for VascularSurgery. Published by Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.ejvs.2014.08.001technology, operator-dependency and anatomical restrains(temporary like bowel gas interposition, or permanent likeobesity as the authors rightfully point out). A frequentlydisparaged aspect is that DUS-based surveillance limits thepossibility of pre-emptive treatment, or treatment before acomplication actually occurs. Migration, componentdisconnection, and material fatigue are generally unrecog-nized with DUS until they result in endoleak, rupture, orocclusion. For fEVAR this may be especially true, given thecomplexity of the procedure and higher chance of compli-cations, particularly regarding vascularized visceral ves-sels.1,3,7 The latter were not directly visualized with CEUS in8% of patients in the present study.Current evidence suggests that it is wise to individualizesurveillance after EVAR according to the patient’s life ex-pectancy and renal function, and adapt the strategy ac-cording to postoperative evolution. Despite these promisingresults, CEUS (or 4D-CEUS) still seems a second-best mo-dality, best suited for patients who have impaired renalfunction or favorable aneurysm regression and evidence ofgraft stability over time. As for standard EVAR, commonsense suggests that tailoring the intensity of surveillance toindividual patient risk, whatever the chosen image modality,may be the preferred strategy.REFERENCES1 Amiot S, Haulon S, Becquemin JP, Magnan PE, Lermusiaux P,Goueffic Y, et al. Fenestrated endovascular grafting: the Frenchmulticentre experience. Eur J Vasc Endovasc Surg 2010;39(5):537e44.2 Verhoeven EL, Vourliotakis G, Bos WT, Tielliu IF, Zeebregts CJ,Prins TR, et al. Fenestrated stent grafting for short-neckedand juxtarenal abdominal aortic aneurysm: an 8-year single-centre experience. Eur J Vasc Endovasc Surg 2010;39(5):529e36.3 Mastracci TM, Greenberg RK, Eagleton MJ, Hernandez AV.Durability of branches in branched and fenestrated endografts.J Vasc Surg 2013;57(4):926e33 [discussion 33].4 Giargiulo M, Gallitto E, Serra C, Freyrie A, Mascoli C, Massoni CB,et al. Could four dimensional contrast-enhanced ultrasoundsreplace computed tomography angiography during follow-up offenestrated endografts? Results of a preliminary experience. EurJ Vasc Endovasc Surg 2014 Jul 9. [Epub ahead of print].544 F. Bastos Gonçalves5 Hahne JD, Arndt C, Herrmann J, Schonnagel B, Adam G,Habermann CR. Follow-up of abdominal aortic aneurysm afterendovascular aortic repair: comparison of volumetric and dia-metric measurement. Eur J Radiol 2012;81(6):1187e91.6 Perini P, Sediri I, Midulla M, Delsart P, Gautier C, Haulon S.Contrast-enhanced ultrasound vs. CT angiography in fenestratedEVAR surveillance: a single-center comparison. J Endovasc Ther2012;19(5):648e55.7 Troisi N, Donas KP, Austermann M, Tessarek J, Umscheid T,Torsello G. Secondary procedures after aortic aneurysm repairwith fenestrated and branched endografts. J Endovasc Ther2011;18(2):146e53.

"could four dimensional contrast-enhanced ultrasounds replace computed tomography angiography during follow-up of fenestrated endografts? Results of a preliminary experience"

Bastos Gonçalves, F.

Elsevier - Publisher Connector 

Eur J Vasc Endovasc Surg (2014) 48, 543e544INVITED COMMENTARYCommentary on: “Could Four Dimensional Contrast-enhanced Ultrasounds
Replace Computed Tomography Angiography During Follow-up of
Fenestrated Endografts? Results of a Preliminary Experience”
F. Bastos Gonçalves a,b,*
a Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
b Department of Angiology and Vascular Surgery, Hospital de Santa Marta, CHLC e Fac. Ciências Médicas da Universidade Nova, Lisbon, PortugalFenestrated endovascular aneurysm repair (fEVAR) is a well-
established alternative to open repair for patients with
juxtarenal or short-neck AAAs.1e3 While computed tomog-
raphy angiography (CTA) is considered the gold standard for
surveillance, it bears the risk of contrast nephropathy and
exposure to ionizing radiation, and is associated with high
cost and resource allocation. Recommendations for stan-
dard EVAR have progressively changed to accept Duplex
ultrasound (DUS)-based strategies, at least for patients at
lower risk of complications. Currently, there are no speciﬁc
recommendations from scientiﬁc societies regarding fEVAR
surveillance, but expert opinion suggests close surveillance
is necessary to insure lasting results.1,2
Gargiulo et al.4 addressed the issue of surveillance after
fEVAR in a retrospective study comparing CTA and four-
dimensional contrast-enhanced ultrasound (4D-CEUS). The
authors suggest that 4D-CEUS is as accurate as CTA for
detecting diameter and volume changes, endoleaks, and
revascularized visceral vessel patency.While the conclusions
are interesting, these data must be analyzed with caution.
In fact, endoleak detection may be sub-optimal, as one in
three endoleaks were not detected with CEUS. A sample of
22 patients is clearly underpowered to obtain conclusions
that may inﬂuence clinical practice. It may be possible that,
due to the relative rarity of fEVAR, one may never obtain
enough power for robust conclusions.
Also, the added value of 4D (compared to “standard”
CEUS) appears only pertinent for volumetric measurements.
While this is a valuable research tool, it is not regularly used
in clinical practice and may have very limited inﬂuence on
the course of treatment.5 As such, the present study does
not add signiﬁcantly to the larger study by Perini et al.,6
where CEUS was compared favorably to CTA.
Lastly, DUS and CEUS have important limitations that
limit its applicability. These are largely related to access toDOI of original article: http://dx.doi.org/10.1016/j.ejvs.2014.05.025
* F.B. Gonçalves, Erasmus University Medical Centre, Rotterdam,
’s-Gravendijkwal 230 3015 CE Rotterdam, The Netherlands.
E-mail address: f.bastosgoncalves@erasmusmc.nl (F. Bastos Gonçalves).
1078-5884/$ e see front matter  2014 European Society for Vascular
Surgery. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejvs.2014.08.001technology, operator-dependency and anatomical restrains
(temporary like bowel gas interposition, or permanent like
obesity as the authors rightfully point out). A frequently
disparaged aspect is that DUS-based surveillance limits the
possibility of pre-emptive treatment, or treatment before a
complication actually occurs. Migration, component
disconnection, and material fatigue are generally unrecog-
nized with DUS until they result in endoleak, rupture, or
occlusion. For fEVAR this may be especially true, given the
complexity of the procedure and higher chance of compli-
cations, particularly regarding vascularized visceral ves-
sels.1,3,7 The latter were not directly visualized with CEUS in
8% of patients in the present study.
Current evidence suggests that it is wise to individualize
surveillance after EVAR according to the patient’s life ex-
pectancy and renal function, and adapt the strategy ac-
cording to postoperative evolution. Despite these promising
results, CEUS (or 4D-CEUS) still seems a second-best mo-
dality, best suited for patients who have impaired renal
function or favorable aneurysm regression and evidence of
graft stability over time. As for standard EVAR, common
sense suggests that tailoring the intensity of surveillance to
individual patient risk, whatever the chosen image modality,
may be the preferred strategy.REFERENCES
1 Amiot S, Haulon S, Becquemin JP, Magnan PE, Lermusiaux P,
Gouefﬁc Y, et al. Fenestrated endovascular grafting: the French
multicentre experience. Eur J Vasc Endovasc Surg 2010;39(5):
537e44.
2 Verhoeven EL, Vourliotakis G, Bos WT, Tielliu IF, Zeebregts CJ,
Prins TR, et al. Fenestrated stent grafting for short-necked
and juxtarenal abdominal aortic aneurysm: an 8-year single-
centre experience. Eur J Vasc Endovasc Surg 2010;39(5):
529e36.
3 Mastracci TM, Greenberg RK, Eagleton MJ, Hernandez AV.
Durability of branches in branched and fenestrated endografts.
J Vasc Surg 2013;57(4):926e33 [discussion 33].
4 Giargiulo M, Gallitto E, Serra C, Freyrie A, Mascoli C, Massoni CB,
et al. Could four dimensional contrast-enhanced ultrasounds
replace computed tomography angiography during follow-up of
fenestrated endografts? Results of a preliminary experience. Eur
J Vasc Endovasc Surg 2014 Jul 9. [Epub ahead of print].
544 F. Bastos Gonçalves5 Hahne JD, Arndt C, Herrmann J, Schonnagel B, Adam G,
Habermann CR. Follow-up of abdominal aortic aneurysm after
endovascular aortic repair: comparison of volumetric and dia-
metric measurement. Eur J Radiol 2012;81(6):1187e91.
6 Perini P, Sediri I, Midulla M, Delsart P, Gautier C, Haulon S.
Contrast-enhanced ultrasound vs. CT angiography in fenestratedEVAR surveillance: a single-center comparison. J Endovasc Ther
2012;19(5):648e55.
7 Troisi N, Donas KP, Austermann M, Tessarek J, Umscheid T,
Torsello G. Secondary procedures after aortic aneurysm repair
with fenestrated and branched endografts. J Endovasc Ther
2011;18(2):146e53.


Commentary on: “Could Four Dimensional Contrast-enhanced Ultrasounds Replace Computed Tomography Angiography During Follow-up of Fenestrated Endografts? Results of a Preliminary Experience” 

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"could four dimensional contrast-enhanced ultrasounds replace computed tomography angiography during follow-up of fenestrated endografts? Results of a preliminary experience"

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