The safety, feasibility and utility of XperCT post-EVAR
Dr. Patrick Chong
Surrey Heart Stroke and Vascular Centre
Frimley Park Hospital NHS Foundation Trust
BSET June 2014
The safety, feasibility and utility of XperCT post-EVAR
Dr. Patrick Chong
Surrey Heart Stroke and Vascular Centre
Frimley Park Hospital NHS Foundation Trust
BSET June 2014
The safety, feasibility and utility of XperCT post-EVAR
Dr. Patrick Chong
Surrey Heart Stroke and Vascular Centre
Frimley Park Hospital NHS Foundation Trust
BSET June 2014
Patrick Chong Consultant Vascular and Endovascular Surgeon The Surrey Heart, Stroke and Vascular Centre Frimley Park Hospital NHS Foundation Trust
INDOVASCULAR SYMPOSIUM BANGALORE March 2014 Disclosures Travel and Study Grants COOK Medical Medtronic Limited UK Sapheon Vascular B.V.
Paid speaker Otsuka Pharmaceuticals Background Demonstrates 4% of patients had an unidentified but correctable technical error not diagnosed by Uniplanar Angiography Biasi et al. 2009 J VS Philips Allura Xper FD20 system + Xper Guide (Philips, Best, The Netherlands) Post EVAR Xper CT Technique Ensure C Arm is in the lateral position Detector is set to landscape Raise patients arms above head Clear rotational area of obstacles + cover 100 mls (50:50 contrast/saline) at 10mls/sec Isocentre in AP then Lateral Select XperCT Module Final CHECK Acquire images via foot pedal control STUDY OBJECTIVES Pilot study for Safety renal function Feasibility time taken Utility post-EVAR Can 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 P O S T
E V A R
STANDARD UNI-PLANAR ANGIOGRAPHY
Intervene for the following Malposition Endoleaks 1A 1A 3 Limb kinking Thrombus P O S T
R O U T I N E
A N G I O G R A P H Y
o r
I N T E R V E N T I O N
XperCT ANGIOGRAPHY
Exclude patients with pre- op eGFR of < 30mls/min.1.73m2
Intervene further for technical errors until clinically satisfactory
ROUTINE CTA at 30-days
RESULTS 51 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) minutes Median LOS 2 (1-50) days Indication Device Elective 47 - Anaconda 2 Urgent 3 - Cook 22 Emergency 1 - Endurant 25 - Endologix 1 - Trivascular 1
Renal Function pre-EVAR & pre-discharge Median eGFR (range) p = NS Pre-EVAR 60 (30-60) mls/min/1.73m2 Pre-discharge 60 (29-60) mls/min/1.73m2
Median Serum Creatinine (range) p = NS Pre-EVAR 87 (38-202) mol/L Pre-discharge 92 (45-187) mol/L
Xper CT findings post satisfactory conventional uni-planar angiography 1 Type 1A endoleak (2%) ballooned small 1A persistent but not visible at 30 days 5 new Type 2 (9.8%) not treated 2 visible at 30 days 4 treated suboptimal limbs - all satisfactory all patent at 30-days 3 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 findings 5 new type 2 endoleaks (9.8%) not detected by previous XperCT None required intervention
2 new limb occlusions (4%) Right limb occlusion 8 days post-EVAR (Endurant) asymptomatic Left 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 Pneumonia Elective 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 YOU L. Everson, R.Limbu, A. Bajwa, S. Stevenson, P. Leopold, D. Gerrard, A. Hatrick, J. Taylor
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