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Meta-Analysis
. 2017 Jun 9;6(6):CD010296.
doi: 10.1002/14651858.CD010296.pub2.

Ultrasonography for endoleak detection after endoluminal abdominal aortic aneurysm repair

Iosief Abraha  1 , Maria Laura Luchetta, Rita De Florio, Francesco Cozzolino, Giovanni Casazza, Piergiorgio Duca, Basso Parente, Massimiliano Orso, Antonella Germani, Paolo Eusebi, Alessandro Montedori
Affiliations
Meta-Analysis

Ultrasonography for endoleak detection after endoluminal abdominal aortic aneurysm repair

Iosief Abraha et al. Cochrane Database Syst Rev. .

Abstract

Background: People with abdominal aortic aneurysm who receive endovascular aneurysm repair (EVAR) need lifetime surveillance to detect potential endoleaks. Endoleak is defined as persistent blood flow within the aneurysm sac following EVAR. Computed tomography (CT) angiography is considered the reference standard for endoleak surveillance. Colour duplex ultrasound (CDUS) and contrast-enhanced CDUS (CE-CDUS) are less invasive but considered less accurate than CT.

Objectives: To determine the diagnostic accuracy of colour duplex ultrasound (CDUS) and contrast-enhanced-colour duplex ultrasound (CE-CDUS) in terms of sensitivity and specificity for endoleak detection after endoluminal abdominal aortic aneurysm repair (EVAR).

Search methods: We searched MEDLINE, Embase, LILACS, ISI Conference Proceedings, Zetoc, and trial registries in June 2016 without language restrictions and without use of filters to maximize sensitivity.

Selection criteria: Any cross-sectional diagnostic study evaluating participants who received EVAR by both ultrasound (with or without contrast) and CT scan assessed at regular intervals.

Data collection and analysis: Two pairs of review authors independently extracted data and assessed quality of included studies using the QUADAS 1 tool. A third review author resolved discrepancies. The unit of analysis was number of participants for the primary analysis and number of scans performed for the secondary analysis. We carried out a meta-analysis to estimate sensitivity and specificity of CDUS or CE-CDUS using a bivariate model. We analysed each index test separately. As potential sources of heterogeneity, we explored year of publication, characteristics of included participants (age and gender), direction of the study (retrospective, prospective), country of origin, number of CDUS operators, and ultrasound manufacturer.

Main results: We identified 42 primary studies with 4220 participants. Twenty studies provided accuracy data based on the number of individual participants (seven of which provided data with and without the use of contrast). Sixteen of these studies evaluated the accuracy of CDUS. These studies were generally of moderate to low quality: only three studies fulfilled all the QUADAS items; in six (40%) of the studies, the delay between the tests was unclear or longer than four weeks; in eight (50%), the blinding of either the index test or the reference standard was not clearly reported or was not performed; and in two studies (12%), the interpretation of the reference standard was not clearly reported. Eleven studies evaluated the accuracy of CE-CDUS. These studies were of better quality than the CDUS studies: five (45%) studies fulfilled all the QUADAS items; four (36%) did not report clearly the blinding interpretation of the reference standard; and two (18%) did not clearly report the delay between the two tests.Based on the bivariate model, the summary estimates for CDUS were 0.82 (95% confidence interval (CI) 0.66 to 0.91) for sensitivity and 0.93 (95% CI 0.87 to 0.96) for specificity whereas for CE-CDUS the estimates were 0.94 (95% CI 0.85 to 0.98) for sensitivity and 0.95 (95% CI 0.90 to 0.98) for specificity. Regression analysis showed that CE-CDUS was superior to CDUS in terms of sensitivity (LR Chi2 = 5.08, 1 degree of freedom (df); P = 0.0242 for model improvement).Seven studies provided estimates before and after administration of contrast. Sensitivity before contrast was 0.67 (95% CI 0.47 to 0.83) and after contrast was 0.97 (95% CI 0.92 to 0.99). The improvement in sensitivity with of contrast use was statistically significant (LR Chi2 = 13.47, 1 df; P = 0.0002 for model improvement).Regression testing showed evidence of statistically significant effect bias related to year of publication and study quality within individual participants based CDUS studies. Sensitivity estimates were higher in the studies published before 2006 than the estimates obtained from studies published in 2006 or later (P < 0.001); and studies judged as low/unclear quality provided higher estimates in sensitivity. When regression testing was applied to the individual based CE-CDUS studies, none of the items, namely direction of the study design, quality, and age, were identified as a source of heterogeneity.Twenty-two studies provided accuracy data based on number of scans performed (of which four provided data with and without the use of contrast). Analysis of the studies that provided scan based data showed similar results. Summary estimates for CDUS (18 studies) showed 0.72 (95% CI 0.55 to 0.85) for sensitivity and 0.95 (95% CI 0.90 to 0.96) for specificity whereas summary estimates for CE-CDUS (eight studies) were 0.91 (95% CI 0.68 to 0.98) for sensitivity and 0.89 (95% CI 0.71 to 0.96) for specificity.

Authors' conclusions: This review demonstrates that both ultrasound modalities (with or without contrast) showed high specificity. For ruling in endoleaks, CE-CDUS appears superior to CDUS. In an endoleak surveillance programme CE-CDUS can be introduced as a routine diagnostic modality followed by CT scan only when the ultrasound is positive to establish the type of endoleak and the subsequent therapeutic management.

PubMed Disclaimer

Conflict of interest statement

The review authors have no financial involvement with any organization or entity with a financial interest in, or financial conflict with, the subject matter or materials discussed in the review.

IA: none known. MLL: none known. RDF: none known. FC: none known. GC: none known. PD: none known. BP: none known. MO: none known. AG: none known. PE: none known. AM: none known.

Figures

1
1
Study flow diagram.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for all included study (42 participants).
3
3
Risk of bias according to QUADAS 1: review authors' judgements about each domain presented as percentages for colour duplex ultrasound (CDUS) (n = 16) and contrast‐enhanced colour duplex ultrasound (CE‐CDUS) (n = 11) that were included in primary analysis. The unit of analysis was number of individuals (not number of scans).
4
4
A forest plot of colour duplex ultrasound (CDUS) (n = 16) and contrast‐enhanced colour duplex ultrasound (CE‐CDUS) (n = 11) that were included in primary analysis.
5
5
Summary receiver operating characteristic plot of studies assessing the accuracy of colour duplex ultrasound (CDUS) and contrast‐enhanced colour duplex ultrasound (CE‐CDUS) in discriminating endoleak (primary analysis). Each value of sensitivity and specificity is represented by a circle. The filled circle represents the summary point. Dotted closed line represent 95% confidence region of the summary point.
6
6
Fagan plot estimating changes in the probability that a person has an endoleak given a pre‐test probability: a presumed pre‐test probability at low (5.4%), median (24.5%) and high (47.6%) prevalence of endoleak for CDUS and CE‐CDUS. Left vertical axis represents the pre‐test probability, axis in the middle represents the likelihood ratio, and right vertical axis represents the post‐test probability (LR‐: negative likelihood ratio; LR+: positive likelihood ratio).
7
7
Likelihood ratio scatterplot matrix. Circles represent individual studies. The filled square circle shows the weighted summary likelihood ratios. Error bars represent 95% confidence intervals. The likelihood ratio profile shows that contrast‐enhanced colour duplex ultrasound (CE‐CDUS) is a potent tool for endoleak conformation or exclusion in people who received endovascular aneurysm repair (EVAR).
8
8
Summary Receiver Operating Characteristic Plot of studies (n = 7) that assessed accuracy measures for endoleak detection before and after administration of contrast. Studies used individual based analysis. The filled circle represents the summary point. Dotted closed line represent 95% confidence region of the summary point. CDUS: colour duplex ultrasound; CE‐CDUS: contrast‐enhanced colour duplex ultrasound.
9
9
Figure A. Indirect comparison of summary estimates of studies assessing the accuracy of CDUS (colour duplex ultrasound) and CE‐CDUS (contrast‐enhanced colour duplex ultrasound) in discriminating endoleak (secondary analysis). Figure B. Summary Receiver Operating Characteristic plots of CDUS and CE‐CDUS (indirect) estimates excluding two outliers. The confidence region was significantly reduced when the outliers were excluded.
1
1. Test
All colour duplex ultrasound (CDUS).
2
2. Test
CDUS (unit of analysis: number of individuals).
3
3. Test
Contrast‐enhanced colour duplex ultrasound (CE‐CDUS) (unit of analysis: number of individuals).
4
4. Test
CE‐CDUS endoleak types I and III.
5
5. Test
Subgroup CDUS (unit of analysis: number of individuals).
6
6. Test
Subgroup CE‐CDUS (unit of analysis: number of individuals).
7
7. Test
CDUS (unit of analysis: number of scans).
8
8. Test
CE‐CDUS (unit of analysis: number of scans).
9
9. Test
CDUS (excluding outliers; unit of analysis: number of scans).
10
10. Test
CE‐CDUS (excluding outliers; unit of analysis: number of scans).
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Giannoni 2007 {published data only}
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Golzarian 2002 {published data only}
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Gray 2012 {published data only}
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Gurtler 2013 {published data only}
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Heilberger 1997 {published data only}
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Henao 2006 {published data only}
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McLafferty 2002 {published data only}
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McWilliams 2002 {published data only}
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Motta 2012 {published data only}
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Nagre 2011 {published data only}
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Nerlekar 2006 {published data only}
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Oikonomou 2012 {published data only}
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Pages 2001 {published data only}
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Parent 2002 {published data only}
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Perini 2011 {published data only}
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Perini 2012 {published data only}
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Raman 2003 {published data only}
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Sandford 2006 {published data only}
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Sato 1998 {published data only}
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Ten Bosch 2010 {published data only}
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Thompson 1998 {published data only}
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Wolf 2000 {published data only}
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Zannetti 2000 {published data only}
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References to studies excluded from this review

Almaroof 2013 {published data only}
    1. Almaroof BH, Ahanchi SS, Chen BL, Day JD, Nelms CR, Panneton JM. Comparison of duplex ultrasound and computed tomography surveillance after endovascular aneurysm repair in determining proximal endograft location. Journal for Vascular Ultrasound 2013;37(1):9‐13.
Beeman 2009 {published data only}
    1. Beeman BR, Doctor LM, Doerr K, McAfee‐Bennett S, Dougherty MJ, Calligaro KD. Duplex ultrasound imaging alone is sufficient for midterm endovascular aneurysm repair surveillance: a cost analysis study and prospective comparison with computed tomography scan. Journal of Vascular Surgery 2009;50(5):1019‐24. [PUBMED: 19656651] - PubMed
Bredahl 2013 {published data only}
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Clevert 2008a {published data only}
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Clevert 2013 {published data only}
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Greenfield 2002 {published data only}
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Han 2010 {published data only}
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Harrison 2011 {published data only}
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Hertault 2015 {published data only}
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Manning 2009 {published data only}
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Millen 2013 {published data only}
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Napoli 2004 {published data only}
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Nyheim 2013 {published data only}
    1. Nyheim T, Staxrud LE, Rosen L, Slagsvold CE, Sandbaek G, Jorgensen JJ. Review of postoperative CT and ultrasound for endovascular aneurysm repair using Talent stent graft: can we simplify the surveillance protocol and reduce the number of CT scans?. Acta Radiologica (Stockholm, Sweden: 1987) 2013;54(1):54‐8. [PUBMED: 23377874] - PubMed
Ormesher 2014 {published data only}
    1. Ormesher DC, Lowe C, Sedgwick N, McCollum CN, Ghosh J. Use of three‐dimensional contrast‐enhanced duplex ultrasound imaging during endovascular aneurysm repair. Journal of Vascular Surgery. Mosby Inc., 2014; Vol. 60, issue 6:1468‐72. - PubMed
Pfister 2009 {published data only}
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Sommer 2012 {published data only}
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References to other published versions of this review

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Publication types