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MR Angiography for Patient Surveillance After Endovascular Repair of Abdominal Aortic Aneurysms

¹ All authors: Department of Interventional Radiology, Mount Sinai Medical Center, One Gustave L. Levy Pl., Box 1234, New York, NY 10029.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —AneuRx (Medtronic Medical) endovascular device designed to treat infrarenal abdominal aortic aneurysms. Photograph (courtesy of Medtronic Vascular, Santa Rosa, CA) (A), radiograph (B), and coronal maximal-intensity-projection image from contrast-enhanced MR angiography (C). Modular, self-expanding endovascular device designed to treat infrarenal abdominal aortic aneurysms. This stent-graft module consists of smooth woven polyester graft that is joined to nitinol exoskeleton.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —AneuRx (Medtronic Medical) endovascular device designed to treat infrarenal abdominal aortic aneurysms. Photograph (courtesy of Medtronic Vascular, Santa Rosa, CA) (A), radiograph (B), and coronal maximal-intensity-projection image from contrast-enhanced MR angiography (C). Modular, self-expanding endovascular device designed to treat infrarenal abdominal aortic aneurysms. This stent-graft module consists of smooth woven polyester graft that is joined to nitinol exoskeleton.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —AneuRx (Medtronic Medical) endovascular device designed to treat infrarenal abdominal aortic aneurysms. Photograph (courtesy of Medtronic Vascular, Santa Rosa, CA) (A), radiograph (B), and coronal maximal-intensity-projection image from contrast-enhanced MR angiography (C). Modular, self-expanding endovascular device designed to treat infrarenal abdominal aortic aneurysms. This stent-graft module consists of smooth woven polyester graft that is joined to nitinol exoskeleton.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —Gore Excluder (Gore Medical) abdominal aortic device. Photograph (courtesy of Gore Medical) (A), radiograph (B), and coronal maximal-intensity-projection image from contrast-enhanced MR angiography (C). Abdominal aortic device is modular bifurcated endovascular system. Skeleton is made of nitinol, which spans length of each component. Polytetrafluoroethylene (PTFE) graft material is attached to nitinol with polyethylene tape.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —Gore Excluder (Gore Medical) abdominal aortic device. Photograph (courtesy of Gore Medical) (A), radiograph (B), and coronal maximal-intensity-projection image from contrast-enhanced MR angiography (C). Abdominal aortic device is modular bifurcated endovascular system. Skeleton is made of nitinol, which spans length of each component. Polytetrafluoroethylene (PTFE) graft material is attached to nitinol with polyethylene tape.

View larger version (74K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —Gore Excluder (Gore Medical) abdominal aortic device. Photograph (courtesy of Gore Medical) (A), radiograph (B), and coronal maximal-intensity-projection image from contrast-enhanced MR angiography (C). Abdominal aortic device is modular bifurcated endovascular system. Skeleton is made of nitinol, which spans length of each component. Polytetrafluoroethylene (PTFE) graft material is attached to nitinol with polyethylene tape.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —Medtronic Talent (Medtronic Medical) stent-graft system. Photograph (courtesy of Medtronic Vascular, Santa Rosa, CA) (A), radiograph (B), and coronal maximal-intensity-projection image from contrast-enhanced MR angiography (C). Endograft is self-expanding modular stent-graft system composed of serpentine-shaped nitinol stents inlaid in woven polyester fabric.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —Medtronic Talent (Medtronic Medical) stent-graft system. Photograph (courtesy of Medtronic Vascular, Santa Rosa, CA) (A), radiograph (B), and coronal maximal-intensity-projection image from contrast-enhanced MR angiography (C). Endograft is self-expanding modular stent-graft system composed of serpentine-shaped nitinol stents inlaid in woven polyester fabric.

View larger version (56K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —Medtronic Talent (Medtronic Medical) stent-graft system. Photograph (courtesy of Medtronic Vascular, Santa Rosa, CA) (A), radiograph (B), and coronal maximal-intensity-projection image from contrast-enhanced MR angiography (C). Endograft is self-expanding modular stent-graft system composed of serpentine-shaped nitinol stents inlaid in woven polyester fabric.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 —81-year-old man with proximal type 1 endoleak 6 months after endovascular aneurysm repair with Talent (Medtronic Medical) bifurcated device. Coronal maximal-intensity-projection image from contrast-enhanced MR angiography shows large collection of contrast material to left of device, originating (arrow) from proximal seal zone.

View larger version (62K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —76-year-old man with type 2 endoleak after endovascular aneurysm repair with Talent (Medtronic Medical) device. Selected frame from coronal contrast-enhanced MR angiography shows perfusion of aneurysm sac and patent inferior mesenteric artery (arrow).

View larger version (87K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —69-year-old man with type 2 endoleak after endovascular aneurysm repair with Gore Excluder (Gore Medical). Selected frames from coronal time-resolved MR angiography sequence show this endoleak originating from inferior mesenteric artery, which is perfused via arc of Riolan (arrow, B) to left of endograft.

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —69-year-old man with type 2 endoleak after endovascular aneurysm repair with Gore Excluder (Gore Medical). Selected frames from coronal time-resolved MR angiography sequence show this endoleak originating from inferior mesenteric artery, which is perfused via arc of Riolan (arrow, B) to left of endograft.

View larger version (88K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —69-year-old man with type 2 endoleak after endovascular aneurysm repair with Gore Excluder (Gore Medical). Selected frames from coronal time-resolved MR angiography sequence show this endoleak originating from inferior mesenteric artery, which is perfused via arc of Riolan (arrow, B) to left of endograft.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —82-year-old woman with enlarging aneurysm sac after thoracic endovascular aneurysm repair with Gore Excluder (Gore Medical). CT angiogram from July 1999 (A) shows aneurysm diameter of 7.0 cm; CT angiogram from July 2003 (B) shows aneurysm diameter of 10.0 cm.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —82-year-old woman with enlarging aneurysm sac after thoracic endovascular aneurysm repair with Gore Excluder (Gore Medical). CT angiogram from July 1999 (A) shows aneurysm diameter of 7.0 cm; CT angiogram from July 2003 (B) shows aneurysm diameter of 10.0 cm.

View larger version (170K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —82-year-old woman with enlarging aneurysm sac after thoracic endovascular aneurysm repair with Gore Excluder (Gore Medical). Axial, contrast-enhanced fat-saturated T1-weighted MR image from August 2003 (C) and axial steady-state free procession (SSFP) image from August 2003 (D). Four years after thoracic endovascular aneurysm repair, CT angiogram (B) shows no evidence of endoleak, but aneurysm sac has grown by 3.0 cm. Axial, contrast-enhanced fat-saturated T1-weighted MR image (C) also shows no endoleak, but axial SSFP image (D) shows diffuse high signal within aneurysm sac, suggesting endotension.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D —82-year-old woman with enlarging aneurysm sac after thoracic endovascular aneurysm repair with Gore Excluder (Gore Medical). Axial, contrast-enhanced fat-saturated T1-weighted MR image from August 2003 (C) and axial steady-state free procession (SSFP) image from August 2003 (D). Four years after thoracic endovascular aneurysm repair, CT angiogram (B) shows no evidence of endoleak, but aneurysm sac has grown by 3.0 cm. Axial, contrast-enhanced fat-saturated T1-weighted MR image (C) also shows no endoleak, but axial SSFP image (D) shows diffuse high signal within aneurysm sac, suggesting endotension.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7E —82-year-old woman with enlarging aneurysm sac after thoracic endovascular aneurysm repair with Gore Excluder (Gore Medical). To confirm diagnosis of endotension, patient underwent direct aneurysm sac aspiration with CT guidance (arrow, E) to sample contents of sac. Approximately 150 mL of serosanguineous fluid was sampled and is shown in photograph (F). This confirmed diagnosis of sac hygroma, which is one possible cause of endotension.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7F —82-year-old woman with enlarging aneurysm sac after thoracic endovascular aneurysm repair with Gore Excluder (Gore Medical). To confirm diagnosis of endotension, patient underwent direct aneurysm sac aspiration with CT guidance (arrow, E) to sample contents of sac. Approximately 150 mL of serosanguineous fluid was sampled and is shown in photograph (F). This confirmed diagnosis of sac hygroma, which is one possible cause of endotension.

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —82-year-old man after endovascular aneurysm repair with AneuRx endograft (Medtronic Medical). Follow-up imaging shows enlarging aneurysm sac. Any stainless steel products (coils, bare stents, and covered stents) produce significant metallic artifact on MRI, preventing evaluation of aneurysm sac with this technique, as shown in this axial, contrast-enhanced fat-saturated T1-weighted MR image (A). Patient underwent embolization of one internal iliac artery with four stainless steel coils. Patient eventually underwent MDCT angiography (B), which revealed complex type 1 endoleak. As result, many institutions have shifted to use of only platinum coils for embolization procedures.

View larger version (89K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —82-year-old man after endovascular aneurysm repair with AneuRx endograft (Medtronic Medical). Follow-up imaging shows enlarging aneurysm sac. Any stainless steel products (coils, bare stents, and covered stents) produce significant metallic artifact on MRI, preventing evaluation of aneurysm sac with this technique, as shown in this axial, contrast-enhanced fat-saturated T1-weighted MR image (A). Patient underwent embolization of one internal iliac artery with four stainless steel coils. Patient eventually underwent MDCT angiography (B), which revealed complex type 1 endoleak. As result, many institutions have shifted to use of only platinum coils for embolization procedures.

View larger version (179K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —72-year-old man after endovascular aneurysm repair with Talent (Medtronic Medical) device and embolization of type 2 endoleak with platinum coils. MDCT angiography follow-up shows significant metallic artifact, preventing detailed visualization and analysis of aneurysm sac to determine if there is persistent endoleak.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —72-year-old man after endovascular aneurysm repair with Talent (Medtronic Medical) device and embolization of type 2 endoleak with platinum coils. Axial, contrast-enhanced, fat-saturated T1-weighted MR image provides optimal visualization of the aneurysm sac because platinum coils produce little or no artifact on MRI. No endoleak is noted.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —77-year-old man with sudden onset of left leg pain 3 months after endovascular aneurysm repair with AneuRx endograft (Medtronic Medical). Coronal maximal-intensity-projection image from contrast-enhanced MR angiography (A) and axial contrast-enhanced fat-saturated T1-weighted MR image (B) show occluded left iliac limb (arrow, B). Patient underwent urgent femoral-femoral bypass to treat acute limb ischemia.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —77-year-old man with sudden onset of left leg pain 3 months after endovascular aneurysm repair with AneuRx endograft (Medtronic Medical). Coronal maximal-intensity-projection image from contrast-enhanced MR angiography (A) and axial contrast-enhanced fat-saturated T1-weighted MR image (B) show occluded left iliac limb (arrow, B). Patient underwent urgent femoral-femoral bypass to treat acute limb ischemia.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —Three different patients (72-year-old woman [A], 68-year-old man [B], and 73-year-old man [C]) who underwent endovascular aneurysm repair. Steady-state free procession (SSFP) images of AneuRx (Medtronic Medical) (A), Talent (Medtronic Medical) (B), and Gore (Gore Medical) (C) endografts show aneurysm sac and characterize its contents without artifact from stent-graft. Sac contents appear as low signal when there is no endoleak and thrombus has begun to involute (A). When there is endoleak, there is heterogeneous signal within aneurysm sac, with focal areas of high signal (B). When aneurysm sac contents are uniformly bright in signal (C) and sac either is stable in diameter or has started to expand, endotension is thought to be present. In this scenario, there is typically no enhancement of sac contents after contrast administration.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —Three different patients (72-year-old woman [A], 68-year-old man [B], and 73-year-old man [C]) who underwent endovascular aneurysm repair. Steady-state free procession (SSFP) images of AneuRx (Medtronic Medical) (A), Talent (Medtronic Medical) (B), and Gore (Gore Medical) (C) endografts show aneurysm sac and characterize its contents without artifact from stent-graft. Sac contents appear as low signal when there is no endoleak and thrombus has begun to involute (A). When there is endoleak, there is heterogeneous signal within aneurysm sac, with focal areas of high signal (B). When aneurysm sac contents are uniformly bright in signal (C) and sac either is stable in diameter or has started to expand, endotension is thought to be present. In this scenario, there is typically no enhancement of sac contents after contrast administration.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —Three different patients (72-year-old woman [A], 68-year-old man [B], and 73-year-old man [C]) who underwent endovascular aneurysm repair. Steady-state free procession (SSFP) images of AneuRx (Medtronic Medical) (A), Talent (Medtronic Medical) (B), and Gore (Gore Medical) (C) endografts show aneurysm sac and characterize its contents without artifact from stent-graft. Sac contents appear as low signal when there is no endoleak and thrombus has begun to involute (A). When there is endoleak, there is heterogeneous signal within aneurysm sac, with focal areas of high signal (B). When aneurysm sac contents are uniformly bright in signal (C) and sac either is stable in diameter or has started to expand, endotension is thought to be present. In this scenario, there is typically no enhancement of sac contents after contrast administration.

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