IVUS Seen As Aid to Aortic Endografting

SCOTTSDALE, ARIZ. – Six years of having intravascular ultrasound guidance available during thoracic and abdominal endografting procedures for aortic pathologies has convinced one surgeon that it’s a sometimes necessary, sometimes complementary imaging modality – not an expensive, redundant novelty.

Among 449 cases of aortic endografting for aneurysmal, dissection, or traumatic pathologies, Dr. Martin R. Back chose to use intravascular ultrasound (IVUS) guidance in 194 cases (43%), he reported at the meeting. He used IVUS guidance in 76 (66%) of 115 thoracic cases and 118 (35%) of 334 abdominal cases.

IVUS guidance may replace most maneuvers that currently require contrast angiography during endovascular aneurysm repair and thoracic endovascular aortic repair, said Dr. Back, professor of surgery at the University of South Florida, Tampa.

He found IVUS guidance indispensable during treatment of acute aortic dissections, using it in all 25 cases. It also was especially helpful in 8 (57%) of 14 hybrid thoracoabdominal cases, he said at the annual meeting of the Southern Association for Vascular Surgery.

"I found it particularly useful in these cases to turn these into a single-stage procedure" with visceral branching done up front, endografting done primarily with IVUS guidance, and very-low-volume contrast used to assess completion of the repair, he said.

IVUS use reduced the volume of contrast needed during abdominal cases and significantly reduced the risk of worsening renal function after aortic endografting in patients with preexisting renal insufficiency.

Average contrast dye volume during abdominal cases was 47 mL in IVUS-guided cases and 92 mL in cases without IVUS, a significant difference. Procedural contrast dye volume was marginally lower with IVUS use compared with no IVUS in thoracic cases – 91 mL vs. 106 mL, respectively.

Among thoracic cases, 26 of 115 patients (23%) had existing chronic renal insufficiency, and he used IVUS guidance in 22 of these 26 patients (85%). Among abdominal cases, 70 of 334 patients (21%) had chronic renal insufficiency, and he used IVUS guidance in 43 of these 70 cases (62%).

Among 89 patients with preoperative chronic renal insufficiency and complete follow-up data 30 days after the procedure, renal function worsened in 7 of 60 patients (12%) who had IVUS guidance and 9 of 29 patients (31%) with no IVUS, a significant difference. Worsening renal function was defined as greater than a 50% increase in baseline creatinine or dialysis by day 30.

"IVUS use cuts down on dye use and spares kidneys in that higher-risk population," he said.

Among 331 patients without preexisting chronic renal insufficiency who had 30 days of follow-up data, renal function worsened in 9 (8%) of 107 patients who had IVUS guidance and in 12 (5%) of 224 patients without IVUS, which was not significantly different between groups.

"This is not really a diagnostic tool but can be used as an intraprocedural guidance tool with fluoroscopy to supplant the need for angiographic injections throughout the performance of an endovascular aortic intervention," he said. In general, IVUS guidance appeared to be safe and accurate for endografting, he said. In a random sample of 25 cases with IVUS guidance and 51 cases without IVUS in patients with similar-sized aneurysms and fixation lengths, measurements from the lowest renal artery to the endograft device and from the hypogastric arteries to the end of the device were similar in accuracy, Dr. Back said.

Cost is an issue, with IVUS catheters being approximately $500 each. "I’m not advocating for all these patients" to have IVUS-guided endografting, but there are "subgroups here that I think really benefit from its use," he said.

Dr. Back reported being a paid trainer and speaker for Volcano Corp., which markets the IVUS equipment that he used in his case series.

SCOTTSDALE, ARIZ. – Six years of having intravascular ultrasound guidance available during thoracic and abdominal endografting procedures for aortic pathologies has convinced one surgeon that it’s a sometimes necessary, sometimes complementary imaging modality – not an expensive, redundant novelty.

Among 449 cases of aortic endografting for aneurysmal, dissection, or traumatic pathologies, Dr. Martin R. Back chose to use intravascular ultrasound (IVUS) guidance in 194 cases (43%), he reported at the meeting. He used IVUS guidance in 76 (66%) of 115 thoracic cases and 118 (35%) of 334 abdominal cases.

IVUS guidance may replace most maneuvers that currently require contrast angiography during endovascular aneurysm repair and thoracic endovascular aortic repair, said Dr. Back, professor of surgery at the University of South Florida, Tampa.

He found IVUS guidance indispensable during treatment of acute aortic dissections, using it in all 25 cases. It also was especially helpful in 8 (57%) of 14 hybrid thoracoabdominal cases, he said at the annual meeting of the Southern Association for Vascular Surgery.

"I found it particularly useful in these cases to turn these into a single-stage procedure" with visceral branching done up front, endografting done primarily with IVUS guidance, and very-low-volume contrast used to assess completion of the repair, he said.

IVUS use reduced the volume of contrast needed during abdominal cases and significantly reduced the risk of worsening renal function after aortic endografting in patients with preexisting renal insufficiency.

Average contrast dye volume during abdominal cases was 47 mL in IVUS-guided cases and 92 mL in cases without IVUS, a significant difference. Procedural contrast dye volume was marginally lower with IVUS use compared with no IVUS in thoracic cases – 91 mL vs. 106 mL, respectively.

Among thoracic cases, 26 of 115 patients (23%) had existing chronic renal insufficiency, and he used IVUS guidance in 22 of these 26 patients (85%). Among abdominal cases, 70 of 334 patients (21%) had chronic renal insufficiency, and he used IVUS guidance in 43 of these 70 cases (62%).

Among 89 patients with preoperative chronic renal insufficiency and complete follow-up data 30 days after the procedure, renal function worsened in 7 of 60 patients (12%) who had IVUS guidance and 9 of 29 patients (31%) with no IVUS, a significant difference. Worsening renal function was defined as greater than a 50% increase in baseline creatinine or dialysis by day 30.

"IVUS use cuts down on dye use and spares kidneys in that higher-risk population," he said.

Among 331 patients without preexisting chronic renal insufficiency who had 30 days of follow-up data, renal function worsened in 9 (8%) of 107 patients who had IVUS guidance and in 12 (5%) of 224 patients without IVUS, which was not significantly different between groups.

"This is not really a diagnostic tool but can be used as an intraprocedural guidance tool with fluoroscopy to supplant the need for angiographic injections throughout the performance of an endovascular aortic intervention," he said. In general, IVUS guidance appeared to be safe and accurate for endografting, he said. In a random sample of 25 cases with IVUS guidance and 51 cases without IVUS in patients with similar-sized aneurysms and fixation lengths, measurements from the lowest renal artery to the endograft device and from the hypogastric arteries to the end of the device were similar in accuracy, Dr. Back said.

Cost is an issue, with IVUS catheters being approximately $500 each. "I’m not advocating for all these patients" to have IVUS-guided endografting, but there are "subgroups here that I think really benefit from its use," he said.

Dr. Back reported being a paid trainer and speaker for Volcano Corp., which markets the IVUS equipment that he used in his case series.

SCOTTSDALE, ARIZ. – Six years of having intravascular ultrasound guidance available during thoracic and abdominal endografting procedures for aortic pathologies has convinced one surgeon that it’s a sometimes necessary, sometimes complementary imaging modality – not an expensive, redundant novelty.

Among 449 cases of aortic endografting for aneurysmal, dissection, or traumatic pathologies, Dr. Martin R. Back chose to use intravascular ultrasound (IVUS) guidance in 194 cases (43%), he reported at the meeting. He used IVUS guidance in 76 (66%) of 115 thoracic cases and 118 (35%) of 334 abdominal cases.

IVUS guidance may replace most maneuvers that currently require contrast angiography during endovascular aneurysm repair and thoracic endovascular aortic repair, said Dr. Back, professor of surgery at the University of South Florida, Tampa.

He found IVUS guidance indispensable during treatment of acute aortic dissections, using it in all 25 cases. It also was especially helpful in 8 (57%) of 14 hybrid thoracoabdominal cases, he said at the annual meeting of the Southern Association for Vascular Surgery.

"I found it particularly useful in these cases to turn these into a single-stage procedure" with visceral branching done up front, endografting done primarily with IVUS guidance, and very-low-volume contrast used to assess completion of the repair, he said.

IVUS use reduced the volume of contrast needed during abdominal cases and significantly reduced the risk of worsening renal function after aortic endografting in patients with preexisting renal insufficiency.

Average contrast dye volume during abdominal cases was 47 mL in IVUS-guided cases and 92 mL in cases without IVUS, a significant difference. Procedural contrast dye volume was marginally lower with IVUS use compared with no IVUS in thoracic cases – 91 mL vs. 106 mL, respectively.

Among thoracic cases, 26 of 115 patients (23%) had existing chronic renal insufficiency, and he used IVUS guidance in 22 of these 26 patients (85%). Among abdominal cases, 70 of 334 patients (21%) had chronic renal insufficiency, and he used IVUS guidance in 43 of these 70 cases (62%).

Among 89 patients with preoperative chronic renal insufficiency and complete follow-up data 30 days after the procedure, renal function worsened in 7 of 60 patients (12%) who had IVUS guidance and 9 of 29 patients (31%) with no IVUS, a significant difference. Worsening renal function was defined as greater than a 50% increase in baseline creatinine or dialysis by day 30.

"IVUS use cuts down on dye use and spares kidneys in that higher-risk population," he said.

Among 331 patients without preexisting chronic renal insufficiency who had 30 days of follow-up data, renal function worsened in 9 (8%) of 107 patients who had IVUS guidance and in 12 (5%) of 224 patients without IVUS, which was not significantly different between groups.

"This is not really a diagnostic tool but can be used as an intraprocedural guidance tool with fluoroscopy to supplant the need for angiographic injections throughout the performance of an endovascular aortic intervention," he said. In general, IVUS guidance appeared to be safe and accurate for endografting, he said. In a random sample of 25 cases with IVUS guidance and 51 cases without IVUS in patients with similar-sized aneurysms and fixation lengths, measurements from the lowest renal artery to the endograft device and from the hypogastric arteries to the end of the device were similar in accuracy, Dr. Back said.

Cost is an issue, with IVUS catheters being approximately $500 each. "I’m not advocating for all these patients" to have IVUS-guided endografting, but there are "subgroups here that I think really benefit from its use," he said.

Dr. Back reported being a paid trainer and speaker for Volcano Corp., which markets the IVUS equipment that he used in his case series.