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Aortic Aneurysmal Disease: Assessment of Stent-Graft Treatment-CT versus Conventional Angiography¹

¹ From the Department of Radiology, Stanford University School of Medicine, Stanford University Medical Center, Rm S-072B, Stanford, CA 94305-5105. From the 1997 RSNA scientific assembly. Received December 16, 1998; revision requested February 11, 1999; final revision received August 3; accepted August 5. Address reprint requests to G.D.R. (e-mail: grubin@stanford.edu).

View larger version (123K): [in a new window]   Figure 1a. In a-d, L = perigraft leak, S = stent-graft, T = thrombus. (a, b) Serial transverse CT scans demonstrate a large aortic arch aneurysm that is partially thrombosed following deployment of a stent-graft. All three CT angiography readers identified a large perigraft leak. (c) Anterior 60° left oblique screen-film angiogram was read as positive for perigraft leakage by none of the three conventional angiography readers. (d) Oblique curved planar reformation image shows leakage from a perspective similar to that in the conventional angiogram in c and also demonstrates the stent-graft occluding the origin of the left subclavian artery, where a thrombus (thick arrow) has formed.

View larger version (120K): [in a new window]   Figure 1b. In a-d, L = perigraft leak, S = stent-graft, T = thrombus. (a, b) Serial transverse CT scans demonstrate a large aortic arch aneurysm that is partially thrombosed following deployment of a stent-graft. All three CT angiography readers identified a large perigraft leak. (c) Anterior 60° left oblique screen-film angiogram was read as positive for perigraft leakage by none of the three conventional angiography readers. (d) Oblique curved planar reformation image shows leakage from a perspective similar to that in the conventional angiogram in c and also demonstrates the stent-graft occluding the origin of the left subclavian artery, where a thrombus (thick arrow) has formed.

View larger version (127K): [in a new window]   Figure 1c. In a-d, L = perigraft leak, S = stent-graft, T = thrombus. (a, b) Serial transverse CT scans demonstrate a large aortic arch aneurysm that is partially thrombosed following deployment of a stent-graft. All three CT angiography readers identified a large perigraft leak. (c) Anterior 60° left oblique screen-film angiogram was read as positive for perigraft leakage by none of the three conventional angiography readers. (d) Oblique curved planar reformation image shows leakage from a perspective similar to that in the conventional angiogram in c and also demonstrates the stent-graft occluding the origin of the left subclavian artery, where a thrombus (thick arrow) has formed.

View larger version (138K): [in a new window]   Figure 1d. In a-d, L = perigraft leak, S = stent-graft, T = thrombus. (a, b) Serial transverse CT scans demonstrate a large aortic arch aneurysm that is partially thrombosed following deployment of a stent-graft. All three CT angiography readers identified a large perigraft leak. (c) Anterior 60° left oblique screen-film angiogram was read as positive for perigraft leakage by none of the three conventional angiography readers. (d) Oblique curved planar reformation image shows leakage from a perspective similar to that in the conventional angiogram in c and also demonstrates the stent-graft occluding the origin of the left subclavian artery, where a thrombus (thick arrow) has formed.

View larger version (126K): [in a new window]   Figure 2. Top images: Transverse sections from a CT angiogram interpreted with three of three true-positive results for perigraft leakage (L). Middle and bottom images: Early and late phases of aortic conventional angiographic and corresponding CT angiographic maximum intensity projection images obtained through anteroposterior and 60° left anterior oblique projections, respectively. The perigraft leak (L) is demonstrated on the CT angiographic images but is not visible on either early- or late-phase aortic injection images. Conventional angiograms were interpreted with three of three false-negative results. The mean confidence level for the three true-positive CT angiographic interpretations was 4.7, whereas the mean confidence level for the three false-negative conventional angiographic interpretations was 4.3. T = thrombus in aneurysm.

View larger version (158K): [in a new window]   Figure 3. Top images (left to right): Anterior 60° left oblique, anterior shallow right oblique, and anteroposterior conventional angiograms interpreted as false-positive by two of three reviewers. Bottom images: Transverse CT scans interpreted as true-negative by three of three reviewers. The black arrows indicate a suspicious region on the conventional angiograms, and the white arrow indicates the corresponding region on a CT scan; this appearance was secondary to billowing of the graft material between two suture tethers.

View larger version (129K): [in a new window]   Figure 4. CT angiograms interpreted as false-positive for perigraft leakage by one of three CT interpreters (confidence level, 3.0). Two transverse sections (top images) and an oblique curved planar reformation image (bottom image) demonstrate the characteristic appearance of billowing graft material (arrows) between two suture tethers.

View larger version (94K): [in a new window]   Figure 5a. Aortic dissection with large pseudoaneurysm from the false lumen and stent-graft deployment into the false lumen to occlude the pseudoaneurysm. T = true lumen. (a) Anterior 60° left oblique screen-film arteriogram demonstrates the difficulty in assessing the adequacy of stent-graft deployment on a projectional image. This study, which was composed of three runs with differing degrees of obliquity, was interpreted as demonstrating complete deployment by all three conventional angiography interpreters (mean confidence level, 4.3). (b) Transverse CT section (top) and curved planar reformation image (bottom) demonstrate complete collapse of one of two stent-grafts (thick arrows). The collapse was identified by all three CT readers with a mean confidence level of 4.7.

View larger version (93K): [in a new window]   Figure 5b. Aortic dissection with large pseudoaneurysm from the false lumen and stent-graft deployment into the false lumen to occlude the pseudoaneurysm. T = true lumen. (a) Anterior 60° left oblique screen-film arteriogram demonstrates the difficulty in assessing the adequacy of stent-graft deployment on a projectional image. This study, which was composed of three runs with differing degrees of obliquity, was interpreted as demonstrating complete deployment by all three conventional angiography interpreters (mean confidence level, 4.3). (b) Transverse CT section (top) and curved planar reformation image (bottom) demonstrate complete collapse of one of two stent-grafts (thick arrows). The collapse was identified by all three CT readers with a mean confidence level of 4.7.