Ultrasound Evaluation for the Post-EVAR Patient: A Better Surveillance Study Than CT
Damaris P. Mejia, RVT-RDMS1, Chad E. Jacobs, MD2.
1Rush University Medical Center, Chicago, IL, USA, 2Advocate Lutheran General Hospital, Park Ridge, IL, USA.
Objective:
Although it is widely accepted that lifelong surveillance is needed after EVAR, there is debate regarding the ideal imaging modality. Given increased focus on cost, radiation exposure and contrast nephropathy, ultrasound has been recommended for surveillance of the post-EVAR patient. This case report highlights the usefulness of ultrasound, as well as its advantages over more commonly used imaging options.
Methods:
A 92 year-old female with HTN, AF, HLD and AAA underwent EVAR 10 years prior to presentation. She had two percutaneous interventions for type II endoleak with sac expansion, but was then lost to followup. She presented to her primary physician with complaints of mild lower abdominal and back pain for several months, and was referred for abdominal ultrasound evaluation.
Results:
Ultrasound revealed a 13.3 cm AAA with flow in the aneurysm sac, significant changes compared to the previous US performed 3 years ago, which demonstrated a fully excluded AAA sac measuring 9 cm. The ultrasound suggested that the endoleak was emanating from the distal left iliac limb landing zone (type 1b). CTA was performed to obtain further anatomic information and plan repair. This confirmed the size of the AAA and the presence of contrast outside the stent-graft, but was unable to identify the exact site of the endoleak. Furthermore, it demonstrated occlusion of the left limb of the endograft, which was discordant from the ultrasound examination as well as the palpable left femoral pulse. Given these conflicting results, the patient underwent an arteriogram which clearly demonstrated that both EVAR limbs were patent and there was a type 1b endoleak from the distal left iliac limb. The patient subsequently underwent uneventful percutaneous repair using an iliac extension limb (Medtronic Endurant), and was discharged home on POD1. She was seen 3 weeks postoperatively, and repeat ultrasound at that time demonstrated successful resolution of the endoleak with widely patent limbs.
Conclusions:
This case demonstrates superiority of ultrasound imaging for surveillance of post-EVAR patients. When performed by a skilled sonographer, ultrasound reveals specific anatomic information including AAA size, stent-graft configuration, and presence/location of endoleaks. Increased use of ultrasound surveillance in this patient population minimizes cost, radiation exposure, and contrast administration. It provides the necessary information to determine if intervention is warranted in this complex subset of patients.
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