Chaer Rabih A, Gushchin Anna, Rhee Robert, Marone Luke, Cho Jae S, Leers Steven, Makaroun Michel S
Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
J Vasc Surg. 2009 Apr;49(4):845-9; discussion 849-50. doi: 10.1016/j.jvs.2008.10.073.
Long-term surveillance with computed tomography (CT) after endovascular aneurysm repair (EVAR) increases both cost and risk. The purpose of this study was to evaluate the safety of an alternative follow-up modality with color flow duplex ultrasound scanning (CDU) as the sole method of imaging.
In 2003, we initiated a new follow-up (FU) schedule with yearly CDU as the sole imaging method for selected patients. Indications included a residual sac of less than 4 cm, expanded later to stable sac size for more than 2 years. A stable type II endoleak was not a contraindication. CT scans were obtained selectively-based on suspicious findings of a new endoleak or enlarging sac on CDU. The records of all patients with at least 1 year FU under this schedule were reviewed.
One hundred eighty-four patients were followed with CDU only for 1 to 4 years for a mean of 24 +/- 13 months. The new schedule was initiated at a mean of 34 +/- 24 months after EVAR (range 1-112 months). Twenty-three patients had previous endoleaks that had resolved spontaneously or had been treated. During CDU FU, three new endoleaks were detected, one with sac enlargement. All prompted CT evaluation: one type II endoleak with stable sac size could not be identified on CT 3 months later, and two distal type I endoleaks that required limb extension. All three had a prior Ancure endograft. No ruptures or graft occlusions were noted. One abdominal aortic aneurysm (AAA) related death followed graft explantation for infection. There were two additional deaths from malignancy and two from cardiac causes. After the FU switch, freedom from endoleaks was 96%, and from secondary interventions 95% at 48 months by life table method. Mean AAA diameter at baseline was 54 +/- 8 mm and decreased to 40 +/- 11 mm before the switch to CDU only FU. At last FU mean aneurysm diameter was 39 +/- 11 mm. When the current switch criteria were applied to a consecutive series of 200 EVAR patients, 97% would have been eligible for CDU only surveillance by 3 years postoperatively.
CDU only surveillance post-EVAR is safe and can be initiated early after treatment in patients with shrinking or stable aneurysms. This policy should result in cost savings advantage and avoid the complications associated with CT.
血管内动脉瘤修复术（EVAR）后采用计算机断层扫描（CT）进行长期监测会增加成本和风险。本研究的目的是评估将彩色血流双功超声扫描（CDU）作为唯一成像方法的替代随访方式的安全性。
2003年，我们启动了一项新的随访（FU）计划，将每年一次的CDU作为选定患者的唯一成像方法。入选标准包括残余瘤腔小于4 cm，后来扩大为瘤腔大小稳定超过2年。稳定的II型内漏不是禁忌证。根据CDU上发现的新内漏或瘤腔扩大的可疑结果选择性地进行CT扫描。回顾了在此计划下至少随访1年的所有患者的记录。
184例患者仅接受CDU随访1至4年，平均随访时间为24±13个月。新计划在EVAR术后平均34±24个月（范围1 - 112个月）开始实施。23例患者既往有内漏，已自行缓解或已接受治疗。在CDU随访期间，检测到3例新的内漏，其中1例伴有瘤腔扩大。所有这些情况均促使进行CT评估：3个月后CT未发现1例瘤腔大小稳定的II型内漏，2例远端I型内漏需要延长肢体。这3例患者均曾使用过Ancure血管内移植物。未发现破裂或移植物闭塞情况。1例腹主动脉瘤（AAA）相关死亡发生在因感染进行移植物切除术后。另外有2例死于恶性肿瘤，2例死于心脏疾病。在改用CDU随访后，采用生命表法计算，48个月时无内漏发生率为96%，无二次干预发生率为95%。基线时AAA平均直径为54±8 mm，在改用仅CDU随访之前降至40±11 mm。在最后一次随访时，动脉瘤平均直径为39±11 mm。当将当前的转换标准应用于连续的200例EVAR患者系列时，97%的患者在术后3年时符合仅采用CDU监测的条件。
EVAR术后仅采用CDU监测是安全的，对于动脉瘤缩小或稳定的患者，可在治疗后早期开始。该策略应具有节省成本的优势，并避免与CT相关的并发症。
