Endoleak Detection after Endovascular Aortic Repair via Coded-Excitation Ultrasound—A Feasibility Study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Abdominal aortic aneurysm treated with endovascular aortic repair (EVAR) (n=34). Intervention: B-Flow coded-excitation ultrasound vs. Contrast-enhanced ultrasound (CEUS), computed tomography angiography (CTA), and Duplex ultrasound (DUS). Primary outcome: Endoleak detection agreement between B-Flow and established imaging modalities (CEUS, CTA, DUS).

Q: What does this research mean for the field?

B-Flow coded-excitation ultrasound achieves high agreement (>80%) with CEUS, CTA, and DUS for endoleak detection after EVAR and 100% accuracy in identifying endoleaks requiring intervention without requiring contrast enhancement or radiation. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

G Hofmann; Fabian Klosz; Irene Mlekusch; Georg Wickenhauser; Corinna Walter; Afshin Assadian; Fadi Taher

doi:10.3390/jcm12113775

May 31, 2023Journal of Clinical MedicineOpen Access

Endoleak Detection after Endovascular Aortic Repair via Coded-Excitation Ultrasound—A Feasibility Study

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Key result

B-Flow ultrasound matches standard imaging for endoleak detection with ~88% CTA agreement during EVAR surveillance.

n=34

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Why the study?

CTA and CEUS are reference standards for endoleak surveillance after EVAR, but both require contrast enhancement and CTA exposes patients to ionizing radiation. The performance of B-Flow coded-excitation ultrasound for endoleak detection compared with CEUS, CTA, and DUS needed evaluation.

Does B-Flow coded-excitation ultrasound accurately detect and classify endoleaks compared to CEUS, CTA, and DUS in patients undergoing surveillance after endovascular aortic repair (EVAR)?

Key Points

To assess the feasibility and diagnostic performance of B-Flow coded-excitation ultrasound for detecting and classifying endoleaks following endovascular aortic repair compared with established imaging modalities.
Retrospective single-center study analyzing a prospectively maintained database of 34 patients (31 men, 3 women; mean age 75.4 years) undergoing post-EVAR surveillance between January 2021 and December 2022.
A total of 43 follow-up appointments and 132 imaging studies were evaluated, comparing B-Flow against contrast-enhanced ultrasound (CEUS, n=41), duplex ultrasound (DUS, n=40), and computed tomography angiography (CTA, n=18).
Endoleak detection and classification concordance were evaluated using agreement percentages and inter-method reliability assessed via Cohen's kappa coefficient.
B-Flow demonstrated overall agreement rates for endoleak detection of 82.1% with CEUS, 87.5% with CTA, and 85.0% with DUS, yielding good inter-method reliability across all comparisons.
B-Flow missed 1 out of 12 endoleaks compared with CTA (a type I endoleak in a combined type I/type II case) and 6 out of 22 endoleaks compared with CEUS (seven type II endoleaks overall, including one where B-Flow identified a concurrent type III endoleak).
In a sensitivity analysis cross-validated against interventional angiography, B-Flow achieved 100% accuracy for both identifying and classifying endoleaks that required secondary intervention.

Study Design

Type

Cohort (n=34)

Multicenter

No

Structured PICO

Does B-Flow coded-excitation ultrasound accurately detect and classify endoleaks compared to CEUS, CTA, and DUS in patients undergoing surveillance after endovascular aortic repair (EVAR)?

P

Population

34 adults (mean age 75.4 years, 8.8% female) who underwent EVAR for abdominal aortic aneurysm and received 43 follow-up B-Flow ultrasound investigations at a single center in Austria between January 2021 and December 2022.

I

Intervention

B-Flow digitally encoded excitation ultrasound (Logiq S8 device, GE Healthcare) performed during outpatient EVAR surveillance.

C

Comparator

Established surveillance imaging modalities including contrast-enhanced ultrasound (CEUS with intravenous Sonovue bolus, n=41 studies), triple-phase computed tomography angiography (CTA, n=18 studies), and Duplex ultrasound (DUS, n=40 studies).

O

Outcome

Endoleak detection (binary outcome: detected vs. no detected endoleak) evaluated by percent agreement and inter-method reliability (Cohen's kappa coefficient).surrogate

Limitations

Observational feasibility trial design (hypothesis-generating)
Small sample size limiting statistical power and subgroup conclusions (e.g., branched/fenestrated grafts)
Single-center setting limiting generalizability
Absence of proof-investigator independence
Small sample size limiting statistical power and conclusions for complex grafts (branched/fenestrated EVAR)
Absent proof of investigator independence

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Implication

B-Flow coded-excitation ultrasound provides high agreement with CTA and CEUS for post-EVAR endoleak surveillance and 100% accuracy for clinically actionable endoleaks without requiring intravenous contrast or ionizing radiation.

Abstract

Endoleaks are the most common complication after endovascular aortic repair (EVAR). Their correct identification is one of the main objectives of surveillance protocols after EVAR. So far, computed tomography angiography (CTA), contrast-enhanced (CEUS) and Duplex ultrasound (DUS), as well as magnetic resonance angiography, have been investigated for their ability to detect endoleaks. In general, all technologies have distinct benefits and disadvantages, with CTA and CEUS emerging as the reference standard for surveillance after EVAR. However, they are both contrast-enhancer-dependent, and CTA additionally exposes patients to ionizing radiation. In the present study, we investigated B-Flow, a type of coded-excitation ultrasound that was specifically designed to optimize the visualization of blood flow, for its ability to detect endoleaks, and compared its performance to CEUS, CTA, and DUS. In total, 34 patients were included in the analysis that accumulated in 43 distinct B-Flow investigations. They underwent a total of 132 imaging investigations. Agreement between B-Flow and other imaging modalities was high (>80.0%), while inter-method reliability can be interpreted as good. However, with B-Flow, six and one endoleaks would have been missed compared to CEUS and CTA, respectively. Regarding endoleak classification, all metrics were lower but retained an adequate level of comparison. In a subset of patients requiring intervention, B-Flow had 100% accuracy regarding both endoleak detection and classification. Ultrasonography enables endoleak detection and classification without the need for pharmaceutical contrast enhancement or radiation. Ultrasound coded-excitation imaging in the application of B-Flow could further simplify surveillance after EVAR by offering adequate accuracy without requiring intravenous contrast enhancement. Our findings may promote subsequent investigations of coded-excitation imaging for endoleak detection and classification in the surveillance after EVAR.

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Cite This Study

Hofmann et al. (2023) conducted a cohort in Abdominal aortic aneurysm treated with endovascular aortic repair (EVAR) (n=34). B-Flow coded-excitation ultrasound vs. Contrast-enhanced ultrasound (CEUS), computed tomography angiography (CTA), and Duplex ultrasound (DUS) was evaluated on Endoleak detection agreement between B-Flow and established imaging modalities (CEUS, CTA, DUS). B-Flow ultrasound demonstrated high agreement for endoleak detection with CEUS, CTA, and DUS, with 100% accuracy in patients requiring secondary intervention.

synapsesocial.com/papers/6a946ad35e49303b6c31aa38 https://doi.org/10.3390/jcm12113775

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Endoleak Detection after Endovascular Aortic Repair via Coded-Excitation Ultrasound—A Feasibility Study

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Endoleak Detection after Endovascular Aortic Repair via Coded-Excitation Ultrasound—A Feasibility Study

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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