Surveillance Imaging Following Endovascular Aneurysm Repair

Abstract

There is a significant risk of complication following endovascular abdominal repair (EVAR), including endoleak, graft translocation, thrombosis, and infection. Surveillance imaging is important for detecting EVAR complication. Surveillance modalities include conventional X-ray, computed tomography, magnetic resonance imaging, ultrasound, and conventional angiography, with inherent advantages and drawbacks to each modality. The authors present common complications following EVAR, and recent advances in the key modalities for surveillance.

Keywords: abdominal aortic aneurysm; endoleak; endovascular aneurysm repair; interventional radiology; surveillance imaging.

Fig. 1

Drawings illustrating the various types of endoleak: type I, attachment site; type II, collateral vessel; type III, graft failure, type IV, graft porosity. (Reprinted with permission from Agarwal P et al. Multidetector CT of thoracic aortic aneurysms. Radiographics 2009; 29:537–552).

Fig. 2

(a) Graft migration with type 1 endoleak (arrow), (b) graft kinking with turbulent flow in lumen, (c) graft kinking with thrombosis of left iliac limb (arrow).

Fig. 3

(a) Graft infection with air in the sac (arrow); (b) graft infection with aorto-ureteric fistula and pyelonephritis.

Fig. 4

CTA of EVAR. (a) Misleading high attenuation due to neointimal calcium seen on unenhanced imaging (arrow); (b) true endoleak revealed on delayed imaging (arrow).

Fig. 5

DE-CTA of EVAR. (a) Dose saving from virtual unenhanced reconstruction shown on left; posterior endoleak shown on delayed image on right (arrow). (b) Reduction in coil photon attenuation with monoenergetic beam reconstruction at low (left) and high (right) keV settings.

Fig. 6

MRA maximum intensity projection of EVAR showing kinking in the iliac limbs (arrow).

Fig. 7

Conventional angiography of EVAR. (a) Previously embolized endoleak via translumbar approach shows residual type 2 endoleak supplied via the IMA (circle), here injected through the marginal artery from an SMA approach; (b) successful coil embolization of the IMA with resolution of endoleak (arrow).