Asciutto Giuseppe, Ibrahim Abdulhakim, Leone Nicola, Gennai Stefano, Piazza Michele, Antonello Michele, Wanhainen Anders, Mani Kevin, Lindström David, Struk Lisa, Oberhuber Alexander
Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany.
Eur J Vasc Endovasc Surg. 2024 Jan;67(1):99-104. doi: 10.1016/j.ejvs.2023.09.009. Epub 2023 Sep 12.
The use of intravascular ultrasound (IVUS) reduces contrast medium use and radiation exposure during conventional endovascular aneurysm repair (EVAR). The aim of this study was to evaluate the safety and efficacy of IVUS in detecting bridging stent graft (bSG) instability during fenestrated and branched EVAR (F/B-EVAR).
This was a prospective observational multicentre study. The following outcomes were evaluated: (1) technical success of the IVUS in each bSG, (2) IVUS findings compared with intra-operative angiography, (3) incidence of post-operative computed tomography angiography (CTA) findings not detected with IVUS, and (4) absence of IVUS related adverse events. Target visceral vessel (TVV) instability was defined as any branch or fenestration issues requiring an additional manoeuvre or re-intervention. Any IVUS assessment that detected stenosis, kinking, or any geometric TVV issue was considered to be branch instability. All procedures were performed in ad hoc hybrid rooms.
Eighty patients (69% males; median age 72 years; interquartile range 59, 77 years) from four aortic centres treated with F/B-EVAR between January 2019 and September 2021 were included: 70 BEVAR (21 off the shelf; 49 custom made), eight FEVAR (custom made), and two F/B-EVAR (custom made), for a total of 300 potential TVVs. Two TVVs (0.7%) were left unstented and excluded from the analysis. The TVVs could not be accessed with the IVUS catheter in seven cases (2.3%). Furthermore, 17 (5.7%) TVVs could not be examined due to a malfunction of the IVUS catheter. The technical success of the IVUS assessment was 91.9% (274/298), with no IVUS related adverse events. Seven TVVs (2.5%) showed signs of bSG instability by means of IVUS, leading to immediate revisions. The first post-operative CTA at least 30 days after the index procedure was available in 268 of the 274 TVVs originally assessed by IVUS. In seven of the 268 TVVs (2.6%) a re-intervention became necessary due to bSG instability.
This study suggests that IVUS is a safe and potentially valuable adjunctive imaging technology for intra-operative detection of TVV instability. Further long term investigations on larger cohorts are required to validate these promising results and to compare IVUS with alternative technologies in terms of efficiency, radiation exposure, procedure time, and costs.
血管内超声（IVUS）的应用可减少传统血管内动脉瘤修复术（EVAR）期间的造影剂使用和辐射暴露。本研究的目的是评估IVUS在检测开窗和分支型EVAR（F/B-EVAR）期间桥接支架移植物（bSG）不稳定性方面的安全性和有效性。
这是一项前瞻性观察性多中心研究。评估了以下结果：（1）IVUS在每个bSG中的技术成功率；（2）IVUS结果与术中血管造影的比较；（3）IVUS未检测到的术后计算机断层扫描血管造影（CTA）结果的发生率；（4）无IVUS相关不良事件。目标内脏血管（TVV）不稳定性定义为任何需要额外操作或再次干预的分支或开窗问题。任何检测到狭窄、扭结或任何TVV几何问题的IVUS评估都被视为分支不稳定性。所有手术均在临时杂交手术室进行。
纳入了2019年1月至2021年9月期间在四个主动脉中心接受F/B-EVAR治疗的80例患者（69%为男性；中位年龄72岁；四分位间距59，77岁）：70例分支型EVAR（21例为现成产品；49例为定制），8例开窗型EVAR（定制），2例F/B-EVAR（定制），共300个潜在TVV。两个TVV（0.7%）未植入支架并被排除在分析之外。7例（2.3%）TVV无法通过IVUS导管进入。此外，17例（5.7%）TVV因IVUS导管故障无法检查。IVUS评估的技术成功率为91.9%（274/298），无IVUS相关不良事件。7个TVV（2.5%）通过IVUS显示出bSG不稳定的迹象，导致立即进行修正。最初由IVUS评估的274个TVV中的268个在索引手术后至少30天进行了首次术后CTA检查。在268个TVV中的7个（2.6%）中，由于bSG不稳定需要再次干预。
本研究表明，IVUS是一种安全且可能有价值的辅助成像技术，用于术中检测TVV不稳定性。需要对更大队列进行进一步的长期研究，以验证这些有前景的结果，并在效率、辐射暴露、手术时间和成本方面将IVUS与替代技术进行比较。
