Key result
IMA-PLUS Score predicts type 2 endoleak after EVAR with ~0.77 discrimination in validation cohorts.
Why the study?
Patient selection for prophylactic embolisation of infrarenal branch vessels to prevent type 2 endoleak following endovascular repair of abdominal aortic aneurysms is poorly defined, motivating the development and validation of a CTA-based risk prediction score.
Does the CTA-based IMA-PLUS Score accurately predict type 2 endoleak after endovascular repair in patients with abdominal aortic aneurysms?
Cohort (n=502)
Yes
Does the CTA-based IMA-PLUS Score accurately predict type 2 endoleak after endovascular repair in patients with abdominal aortic aneurysms?
The CTA-based IMA-PLUS Score demonstrates good discrimination and interobserver agreement for predicting type 2 endoleak and associated reinterventions after EVAR across European and Japanese cohorts.
Answers are grounded in this paper and cite their sources.
IMA-PLUS score may aid EL2 risk stratification after EVAR; leaves open whether it should guide prophylactic embolisation.
OBJECTIVE: Prophylactic embolisation of infrarenal branch vessels has been investigated to prevent type 2 endoleak (EL2) following endovascular repair (EVAR) of abdominal aortic aneurysms (AAA), but patient selection is poorly defined. In this study, a computed tomography angiography (CTA) based risk score was developed and validated to predict EL2 after EVAR. METHODS: This multicentre, retrospective diagnostic study used prospectively collected data from the Zenith alpha for aneurysm Repair Registry (ZEPHYR) as the development cohort. Eligible patients underwent standard EVAR with pre-operative arterial phase CTA and at least one post-operative delayed phase CTA. The model was converted into a numerical score ("IMA-PLUS Score") and validated in two retrospective cohorts. Discrimination, calibration, and risk group thresholds were assessed. In validation cohorts, freedom from AAA expansion and EL2 associated reinterventions up to 5 years were analysed. RESULTS: Data from 245 patients of the ZEPHYR registry were included. EL2 occurred in 96 patients (39.2%). The IMA-PLUS Score includes inferior mesenteric artery diameter, number of infrarenal renal pole arteries, number of patent lumbar arteries, and median sacral artery patency, achieving a crossvalidated area under the curve (AUC) of 0.78. Using prespecified thresholds (low < 128, medium 128 - 200, high > 200), observed EL2 incidences in ZEPHYR were 19%, 59%, and 74%. In the Heidelberg cohort (n = 134; EL2 44%), AUC was 0.77 (95% confidence intervals [CI] 0.69 - 0.85) with EL2 incidences of 24%, 60%, and 89% across risk groups with good calibration; interobserver agreement for total score was high (intraclass correlation coefficient of 0.95). In the Tokyo cohort (n = 123; EL2 52.8%) AUC was 0.75 (95% CI 0.67 - 0.84); EL2 incidences were 36%, 76%, and 80%, with higher observed incidence than predicted. In validation cohorts, the IMA-PLUS Score was associated with AAA expansion and reduced freedom from EL2 associated reinterventions. CONCLUSION: The IMA-PLUS Score may support selection of patients for future studies on preventive management strategies.
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Hatzl et al. (2026) conducted a cohort in Abdominal aortic aneurysm (AAA) undergoing endovascular repair (EVAR) (n=502). IMA-PLUS Score (CTA-based risk score incorporating inferior mesenteric artery diameter, infrarenal renal pole arteries, patent lumbar arteries, and median sacral artery patency) vs. Risk group stratification (low <128, medium 128-200, high >200) was evaluated on Type 2 endoleak (EL2) after endovascular repair (EVAR) (AUC 0.78). The CTA-based IMA-PLUS Score predicted type 2 endoleak after EVAR with an AUC of 0.78 in development and 0.77 and 0.75 in external validation cohorts.
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