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The safety, feasibility & utility of

3-D Rotational Angiography with


XperCT post-EVAR


Patrick Chong
Consultant Vascular and Endovascular Surgeon
The Surrey Heart, Stroke and Vascular Centre
Frimley Park Hospital NHS Foundation Trust

INDOVASCULAR SYMPOSIUM BANGALORE
March 2014
Disclosures
Travel and Study Grants
COOK Medical
Medtronic Limited UK
Sapheon Vascular B.V.

Paid speaker
Otsuka Pharmaceuticals
Background
Demonstrates 4% of patients
had an unidentified but
correctable technical error
not diagnosed by
Uniplanar Angiography
Biasi et al. 2009 J VS
Philips Allura Xper FD20 system + Xper Guide
(Philips, Best, The Netherlands)
Post EVAR Xper CT Technique
Ensure C Arm is in the lateral position
Detector is set to landscape
Raise patients arms above head
Clear rotational area of obstacles + cover
100 mls (50:50 contrast/saline) at 10mls/sec
Isocentre in AP then Lateral
Select XperCT Module Final CHECK
Acquire images via foot pedal control
STUDY OBJECTIVES
Pilot study for
Safety renal function
Feasibility time taken
Utility post-EVAR
Can additional XperCT aid quality control following
satisfactory conventional uni-planar Angiography?
Can XperCT replace routine CTA at 30-days for EVAR
surveillance?
Study post-EVAR imaging protocol
P
O
S
T

E
V
A
R

STANDARD
UNI-PLANAR
ANGIOGRAPHY

Intervene for the following
Malposition
Endoleaks 1A 1A 3
Limb kinking
Thrombus
P
O
S
T

R
O
U
T
I
N
E

A
N
G
I
O
G
R
A
P
H
Y

o
r

I
N
T
E
R
V
E
N
T
I
O
N

XperCT ANGIOGRAPHY

Exclude patients with pre-
op eGFR of <
30mls/min.1.73m2

Intervene further for
technical errors until
clinically satisfactory

ROUTINE CTA at 30-days

RESULTS
51 patients underwent conventional post-EVAR angiography
& additional XperCT between April 2010 - July 2013.
Median Age 77 (64-90) years
Median time required to perform Xper CT 11 (6-23) minutes
Median LOS 2 (1-50) days
Indication Device
Elective 47 - Anaconda 2
Urgent 3 - Cook 22
Emergency 1 - Endurant 25
- Endologix 1
- Trivascular 1

Renal Function
pre-EVAR & pre-discharge
Median eGFR (range) p = NS
Pre-EVAR 60 (30-60) mls/min/1.73m2
Pre-discharge 60 (29-60) mls/min/1.73m2

Median Serum Creatinine (range) p = NS
Pre-EVAR 87 (38-202) mol/L
Pre-discharge 92 (45-187) mol/L

Xper CT findings post satisfactory
conventional uni-planar angiography
1 Type 1A endoleak (2%) ballooned small
1A persistent but not visible at 30 days
5 new Type 2 (9.8%) not treated 2 visible
at 30 days
4 treated suboptimal limbs - all satisfactory
all patent at 30-days
3 new suboptimal limbs (6%) all stented
all patent at 30-days
Type 1A Endoleak

Conventional Angiography Xper CT
Right iliac limb thrombus
30-day Surveillance CTA findings
5 new type 2 endoleaks (9.8%) not detected
by previous XperCT
None required intervention

2 new limb occlusions (4%)
Right limb occlusion 8 days post-EVAR (Endurant)
asymptomatic
Left limb occlusion 3 days post-EVAR (Endurant)
symptomatic requiring fem-fem crossover bypass
Summary of findings
XperCT detected new findings not identified by conventional
uni-planar angiography in 9 (17.6%) patients. Of these 4
(7.8%) underwent further on-table intervention for a
correctable technical error.
Following satisfactory XperCT, 7 (13.7%) patients had new
surveillance CTA findings at 30-days.
30-day mortality was 3.9%
Emergency 73m 13.5cm ruptured AAA died Day 24 post-EVAR
Pneumonia
Elective 78m discharged Day 1 post-EVAR. Re-admitted day 10 post-
EVAR with peritonitis and died Day 14 post-EVAR of sepsis
CONCLUSIONS
It is feasible to perform XperCT post-EVAR safely for
patients with eGFR > 30mls/min/1.73m2.
XperCT may be a useful adjunct in immediate post-
EVAR quality control on table.
This study shows that at present the post-EVAR 30-
day surveillance CTA may not be replaced by on-table
XperCT.
A randomised study comparing conventional
angiography versus XperCT post-EVAR is required.

FUTURE THERAPEUTIC OPTIONS?
XperCT guided needle injection of ONYX for Type 2 Endoleak
Van Bindsbergen et al. JVIR 2010
THANK YOU
L. Everson, R.Limbu, A. Bajwa, S. Stevenson, P. Leopold, D. Gerrard, A. Hatrick, J. Taylor