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December 23, 2005
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Arno Teutelink, MD, Bart E. Muhs, MD, Koen L. Vincken, PhD, Mathias Prokop, MD, PhD, Frans L. Moll, MD, PhD, Hence J.M. Verhagen, MD, PhD.
UMC Utrecht, Utrecht, The Netherlands.
OBJECTIVES:
A dynamic 3-D pulsating aortic environment may possess serious implications regarding endograft sizing, intermittent type I endoleaks, and graft migration. Traditional sizing and choice of endograft has primarily been based on static aortic CTA images. Intraluminal endograft placement may affect physiologic aortic motion. It is unclear what comprises natural aortic motion per cardiac cycle, and how EVAR may distort this normal process. We studied these phenomena dynamically using ECG-gated 40-slice CTA.
METHODS:
Twelve CT scans were evaluated, 6 pre- and 6 post-EVAR. Aortic area was determined at surgically relevant anatomic landmarks, including 2.4 cm above the highest renal artery (native aorta) and 1.2 cm below the lowest renal artery (intra-graft). The pre-EVAR scan was used as the control for the identical patient’s post-EVAR scan. Data was acquired using a novel ECG-gated dynamic 40-slice CT scanner during a single breath hold with a standard dose of 17.5-21 mGy, 1.25 mm collimation and a pitch of 0.2-0.3. Eight gated data sets, covering the cardiac cycle were reconstructed, perpendicular to the central lumen line. Both pre- and post-EVAR aortic area change was determined and compared using a students T-test with p≤0.05 considered significant.
RESULTS:
There is an impressive change in aortic area at all measured levels that is unchanged by intraluminal endograft placement. Both proximal and distal area increased 10% with each cardiac pulsation (pre-EVAR 8.7% supra-renal and 10.6% infra-renal compared to post-EVAR 6.7% supra-renal and 13.5% infra-renal). There was no difference in aortic area increase following EVAR (p>0.05).
CONCLUSIONS:
ECG-gated dynamic CTA with standard radiation dose is feasible on a 40-slice scanner and provides insight into (patho) physiology of aortic conformational changes before and after EVAR. Most physicians oversize endografts by approximately 10%. With a similar increase in aortic area with each heart cycle, the potential for graft migration, intermittent type I endoleak, and poor patient outcome following EVAR can be anticipated. The complex dynamics resulting from EVAR deserve increased scrutiny in an effort to prevent potentially unforseen complications.
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Novel Dynamic Cine-CTA Insight Into Potential Endograft Undersizing: Consequences for Future Stentgrafts
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Arno Teutelink, MD, Bart E. Muhs, MD, Koen L. Vincken, PhD, Mathias Prokop, MD, PhD, Frans L. Moll, MD, PhD, Hence J.M. Verhagen, MD, PhD.
UMC Utrecht, Utrecht, The Netherlands.
OBJECTIVES:
A dynamic 3-D pulsating aortic environment may possess serious implications regarding endograft sizing, intermittent type I endoleaks, and graft migration. Traditional sizing and choice of endograft has primarily been based on static aortic CTA images. Intraluminal endograft placement may affect physiologic aortic motion. It is unclear what comprises natural aortic motion per cardiac cycle, and how EVAR may distort this normal process. We studied these phenomena dynamically using ECG-gated 40-slice CTA.
METHODS:
Twelve CT scans were evaluated, 6 pre- and 6 post-EVAR. Aortic area was determined at surgically relevant anatomic landmarks, including 2.4 cm above the highest renal artery (native aorta) and 1.2 cm below the lowest renal artery (intra-graft). The pre-EVAR scan was used as the control for the identical patient’s post-EVAR scan. Data was acquired using a novel ECG-gated dynamic 40-slice CT scanner during a single breath hold with a standard dose of 17.5-21 mGy, 1.25 mm collimation and a pitch of 0.2-0.3. Eight gated data sets, covering the cardiac cycle were reconstructed, perpendicular to the central lumen line. Both pre- and post-EVAR aortic area change was determined and compared using a students T-test with p≤0.05 considered significant.
RESULTS:
There is an impressive change in aortic area at all measured levels that is unchanged by intraluminal endograft placement. Both proximal and distal area increased 10% with each cardiac pulsation (pre-EVAR 8.7% supra-renal and 10.6% infra-renal compared to post-EVAR 6.7% supra-renal and 13.5% infra-renal). There was no difference in aortic area increase following EVAR (p>0.05).
CONCLUSIONS:
ECG-gated dynamic CTA with standard radiation dose is feasible on a 40-slice scanner and provides insight into (patho) physiology of aortic conformational changes before and after EVAR. Most physicians oversize endografts by approximately 10%. With a similar increase in aortic area with each heart cycle, the potential for graft migration, intermittent type I endoleak, and poor patient outcome following EVAR can be anticipated. The complex dynamics resulting from EVAR deserve increased scrutiny in an effort to prevent potentially unforseen complications.
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