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Application of Duplex US for Characterization of Endoleaks in Abdominal Aortic Stent-Grafts: Report of Five Cases¹

¹ From the Departments of Radiology (A.L.G., E.J.H., J.B., R.J.W.) and Surgery (M.B.K.), Thomas Jefferson University Hospital, Philadelphia, Pa. Received November 8, 2001; revision requested December 27; revision received April 12, 2002; accepted May 24. Address correspondence to A.L.G., 923 Mill Creek Rd, Gladwyne, PA 19035 (e-mail: antje.greenfield@mail.tju.edu).

View larger version (138K): [in a new window]   Figure 1a. Images in a 70-year-old man with a bifurcated aortic stent-graft placed for treatment of an infrarenal AAA and a separate left common iliac artery aneurysm. (a) Transverse CT angiogram at the level of the origin of the patent enhancing IMA (open arrowhead). Extravasation of contrast material within the native aorta (solid arrowheads) is seen anterior to the patent limbs (arrows) of the stent-graft. The graft attachment sites (not shown) were normal. (b) Conventional aortogram in an anterior oblique projection shows double intensity of contrast enhancement, with contrast material visible inside and outside of the graft. A type I leak is depicted at the distal left iliac graft attachment site (open arrowheads); the leak extends along the aorta (solid arrowheads). (c) Sagittal duplex US image of the distal left common iliac attachment site shows retrograde flow from the distal iliac graft limb (solid arrowheads) into the native common iliac artery outside the graft (open arrowheads); these findings are suggestive of a type I leak (arrow). (d) Transverse duplex US image at the same level as c shows a patent IMA (arrow) with antegrade flow (above baseline) on the spectral Doppler waveform.

View larger version (100K): [in a new window]   Figure 1b. Images in a 70-year-old man with a bifurcated aortic stent-graft placed for treatment of an infrarenal AAA and a separate left common iliac artery aneurysm. (a) Transverse CT angiogram at the level of the origin of the patent enhancing IMA (open arrowhead). Extravasation of contrast material within the native aorta (solid arrowheads) is seen anterior to the patent limbs (arrows) of the stent-graft. The graft attachment sites (not shown) were normal. (b) Conventional aortogram in an anterior oblique projection shows double intensity of contrast enhancement, with contrast material visible inside and outside of the graft. A type I leak is depicted at the distal left iliac graft attachment site (open arrowheads); the leak extends along the aorta (solid arrowheads). (c) Sagittal duplex US image of the distal left common iliac attachment site shows retrograde flow from the distal iliac graft limb (solid arrowheads) into the native common iliac artery outside the graft (open arrowheads); these findings are suggestive of a type I leak (arrow). (d) Transverse duplex US image at the same level as c shows a patent IMA (arrow) with antegrade flow (above baseline) on the spectral Doppler waveform.

View larger version (107K): [in a new window]   Figure 1c. Images in a 70-year-old man with a bifurcated aortic stent-graft placed for treatment of an infrarenal AAA and a separate left common iliac artery aneurysm. (a) Transverse CT angiogram at the level of the origin of the patent enhancing IMA (open arrowhead). Extravasation of contrast material within the native aorta (solid arrowheads) is seen anterior to the patent limbs (arrows) of the stent-graft. The graft attachment sites (not shown) were normal. (b) Conventional aortogram in an anterior oblique projection shows double intensity of contrast enhancement, with contrast material visible inside and outside of the graft. A type I leak is depicted at the distal left iliac graft attachment site (open arrowheads); the leak extends along the aorta (solid arrowheads). (c) Sagittal duplex US image of the distal left common iliac attachment site shows retrograde flow from the distal iliac graft limb (solid arrowheads) into the native common iliac artery outside the graft (open arrowheads); these findings are suggestive of a type I leak (arrow). (d) Transverse duplex US image at the same level as c shows a patent IMA (arrow) with antegrade flow (above baseline) on the spectral Doppler waveform.

View larger version (86K): [in a new window]   Figure 1d. Images in a 70-year-old man with a bifurcated aortic stent-graft placed for treatment of an infrarenal AAA and a separate left common iliac artery aneurysm. (a) Transverse CT angiogram at the level of the origin of the patent enhancing IMA (open arrowhead). Extravasation of contrast material within the native aorta (solid arrowheads) is seen anterior to the patent limbs (arrows) of the stent-graft. The graft attachment sites (not shown) were normal. (b) Conventional aortogram in an anterior oblique projection shows double intensity of contrast enhancement, with contrast material visible inside and outside of the graft. A type I leak is depicted at the distal left iliac graft attachment site (open arrowheads); the leak extends along the aorta (solid arrowheads). (c) Sagittal duplex US image of the distal left common iliac attachment site shows retrograde flow from the distal iliac graft limb (solid arrowheads) into the native common iliac artery outside the graft (open arrowheads); these findings are suggestive of a type I leak (arrow). (d) Transverse duplex US image at the same level as c shows a patent IMA (arrow) with antegrade flow (above baseline) on the spectral Doppler waveform.

View larger version (147K): [in a new window]   Figure 2a. Follow-up images obtained in the same patient as in Figure 1 after repair of the type I leak. (a) Transverse CT angiogram at the level of the origin of the small, patent, and enhancing IMA (open arrowhead). A recurrent small endoleak (solid arrowheads) appears as an area of faint contrast enhancement within the native aorta, anterior to the patent limbs of the stent-graft (arrows). (b) Conventional aortogram in an anterior oblique projection shows retrograde reconstitution of the IMA (open arrowhead) through the arc of Riolan; a focal, small collection of contrast material (solid arrowhead) is seen outside the graft and inside the aneurysm in the native aorta. (c) Transverse duplex US image shows a patent IMA (arrowheads) with a complex flow pattern on the spectral waveform. There is a short segment of early systolic antegrade flow (below baseline) followed by a dominant late systolic retrograde flow component (represented by an above-baseline component directed toward the transducer, but reversing to the direction of blood flow expected in a normal IMA). The early antegrade component may be related to transmitted pulsations from the endograft. The graft expands during systole and thus creates a propulsive effect on residual blood pooling in the native aorta adjacent to the graft. Once the collateral vessels fill the IMA in retrograde fashion in late systole, the dominant retrograde flow becomes apparent. The late retrograde component of the spectral waveform represents the endoleak flow entering back into the aorta. (d) Transverse duplex US image at the level of the origin of the IMA (arrowhead) demonstrates retrograde flow (the below-baseline component of the spectral waveform) into the aneurysm in the native aorta.

View larger version (205K): [in a new window]   Figure 2b. Follow-up images obtained in the same patient as in Figure 1 after repair of the type I leak. (a) Transverse CT angiogram at the level of the origin of the small, patent, and enhancing IMA (open arrowhead). A recurrent small endoleak (solid arrowheads) appears as an area of faint contrast enhancement within the native aorta, anterior to the patent limbs of the stent-graft (arrows). (b) Conventional aortogram in an anterior oblique projection shows retrograde reconstitution of the IMA (open arrowhead) through the arc of Riolan; a focal, small collection of contrast material (solid arrowhead) is seen outside the graft and inside the aneurysm in the native aorta. (c) Transverse duplex US image shows a patent IMA (arrowheads) with a complex flow pattern on the spectral waveform. There is a short segment of early systolic antegrade flow (below baseline) followed by a dominant late systolic retrograde flow component (represented by an above-baseline component directed toward the transducer, but reversing to the direction of blood flow expected in a normal IMA). The early antegrade component may be related to transmitted pulsations from the endograft. The graft expands during systole and thus creates a propulsive effect on residual blood pooling in the native aorta adjacent to the graft. Once the collateral vessels fill the IMA in retrograde fashion in late systole, the dominant retrograde flow becomes apparent. The late retrograde component of the spectral waveform represents the endoleak flow entering back into the aorta. (d) Transverse duplex US image at the level of the origin of the IMA (arrowhead) demonstrates retrograde flow (the below-baseline component of the spectral waveform) into the aneurysm in the native aorta.

View larger version (99K): [in a new window]   Figure 2c. Follow-up images obtained in the same patient as in Figure 1 after repair of the type I leak. (a) Transverse CT angiogram at the level of the origin of the small, patent, and enhancing IMA (open arrowhead). A recurrent small endoleak (solid arrowheads) appears as an area of faint contrast enhancement within the native aorta, anterior to the patent limbs of the stent-graft (arrows). (b) Conventional aortogram in an anterior oblique projection shows retrograde reconstitution of the IMA (open arrowhead) through the arc of Riolan; a focal, small collection of contrast material (solid arrowhead) is seen outside the graft and inside the aneurysm in the native aorta. (c) Transverse duplex US image shows a patent IMA (arrowheads) with a complex flow pattern on the spectral waveform. There is a short segment of early systolic antegrade flow (below baseline) followed by a dominant late systolic retrograde flow component (represented by an above-baseline component directed toward the transducer, but reversing to the direction of blood flow expected in a normal IMA). The early antegrade component may be related to transmitted pulsations from the endograft. The graft expands during systole and thus creates a propulsive effect on residual blood pooling in the native aorta adjacent to the graft. Once the collateral vessels fill the IMA in retrograde fashion in late systole, the dominant retrograde flow becomes apparent. The late retrograde component of the spectral waveform represents the endoleak flow entering back into the aorta. (d) Transverse duplex US image at the level of the origin of the IMA (arrowhead) demonstrates retrograde flow (the below-baseline component of the spectral waveform) into the aneurysm in the native aorta.

View larger version (97K): [in a new window]   Figure 2d. Follow-up images obtained in the same patient as in Figure 1 after repair of the type I leak. (a) Transverse CT angiogram at the level of the origin of the small, patent, and enhancing IMA (open arrowhead). A recurrent small endoleak (solid arrowheads) appears as an area of faint contrast enhancement within the native aorta, anterior to the patent limbs of the stent-graft (arrows). (b) Conventional aortogram in an anterior oblique projection shows retrograde reconstitution of the IMA (open arrowhead) through the arc of Riolan; a focal, small collection of contrast material (solid arrowhead) is seen outside the graft and inside the aneurysm in the native aorta. (c) Transverse duplex US image shows a patent IMA (arrowheads) with a complex flow pattern on the spectral waveform. There is a short segment of early systolic antegrade flow (below baseline) followed by a dominant late systolic retrograde flow component (represented by an above-baseline component directed toward the transducer, but reversing to the direction of blood flow expected in a normal IMA). The early antegrade component may be related to transmitted pulsations from the endograft. The graft expands during systole and thus creates a propulsive effect on residual blood pooling in the native aorta adjacent to the graft. Once the collateral vessels fill the IMA in retrograde fashion in late systole, the dominant retrograde flow becomes apparent. The late retrograde component of the spectral waveform represents the endoleak flow entering back into the aorta. (d) Transverse duplex US image at the level of the origin of the IMA (arrowhead) demonstrates retrograde flow (the below-baseline component of the spectral waveform) into the aneurysm in the native aorta.

View larger version (137K): [in a new window]   Figure 3a. Images in a 78-year-old man with a bifurcated aortic stent-graft placed for treatment of an infrarenal AAA. (a) Transverse CT angiogram of the distal portion of the abdominal aorta demonstrates extravasation of contrast material (arrowhead) within the native aorta posterior to the patent limbs (arrows) of the stent-graft. The graft attachment sites (not shown) were normal. (b) Conventional aortogram with selective contrast material injection into the left iliac limb demonstrates double intensity of contrast enhancement. The thicker column of contrast material (arrows) outlines the graft. Lighter contrast intensity is seen outside the graft within the native common iliac artery; this finding confirms the presence of a type I leak (arrowheads). (c) Transverse US image in a superior angle along the left common iliac artery (arrowheads) with a Doppler gate (double lines) placed inside the distal iliac graft limb demonstrates normal antegrade flow (the above-baseline component in the spectral waveform) toward the transducer in the patent graft limb. (d) Transverse US image in a superior angle along the left common iliac artery (arrowheads); a Doppler gate (double lines) has been placed in the native iliac artery outside the distal iliac graft limb. Doppler tracing demonstrates abnormal retrograde flow (a below-baseline component) in the native vessel away from the transducer; this finding is suggestive of a type I attachment site leak. The flow component seen above baseline in this tracing represents artifact from the adjacent antegrade flow within the graft.

View larger version (144K): [in a new window]   Figure 3b. Images in a 78-year-old man with a bifurcated aortic stent-graft placed for treatment of an infrarenal AAA. (a) Transverse CT angiogram of the distal portion of the abdominal aorta demonstrates extravasation of contrast material (arrowhead) within the native aorta posterior to the patent limbs (arrows) of the stent-graft. The graft attachment sites (not shown) were normal. (b) Conventional aortogram with selective contrast material injection into the left iliac limb demonstrates double intensity of contrast enhancement. The thicker column of contrast material (arrows) outlines the graft. Lighter contrast intensity is seen outside the graft within the native common iliac artery; this finding confirms the presence of a type I leak (arrowheads). (c) Transverse US image in a superior angle along the left common iliac artery (arrowheads) with a Doppler gate (double lines) placed inside the distal iliac graft limb demonstrates normal antegrade flow (the above-baseline component in the spectral waveform) toward the transducer in the patent graft limb. (d) Transverse US image in a superior angle along the left common iliac artery (arrowheads); a Doppler gate (double lines) has been placed in the native iliac artery outside the distal iliac graft limb. Doppler tracing demonstrates abnormal retrograde flow (a below-baseline component) in the native vessel away from the transducer; this finding is suggestive of a type I attachment site leak. The flow component seen above baseline in this tracing represents artifact from the adjacent antegrade flow within the graft.

View larger version (92K): [in a new window]   Figure 3c. Images in a 78-year-old man with a bifurcated aortic stent-graft placed for treatment of an infrarenal AAA. (a) Transverse CT angiogram of the distal portion of the abdominal aorta demonstrates extravasation of contrast material (arrowhead) within the native aorta posterior to the patent limbs (arrows) of the stent-graft. The graft attachment sites (not shown) were normal. (b) Conventional aortogram with selective contrast material injection into the left iliac limb demonstrates double intensity of contrast enhancement. The thicker column of contrast material (arrows) outlines the graft. Lighter contrast intensity is seen outside the graft within the native common iliac artery; this finding confirms the presence of a type I leak (arrowheads). (c) Transverse US image in a superior angle along the left common iliac artery (arrowheads) with a Doppler gate (double lines) placed inside the distal iliac graft limb demonstrates normal antegrade flow (the above-baseline component in the spectral waveform) toward the transducer in the patent graft limb. (d) Transverse US image in a superior angle along the left common iliac artery (arrowheads); a Doppler gate (double lines) has been placed in the native iliac artery outside the distal iliac graft limb. Doppler tracing demonstrates abnormal retrograde flow (a below-baseline component) in the native vessel away from the transducer; this finding is suggestive of a type I attachment site leak. The flow component seen above baseline in this tracing represents artifact from the adjacent antegrade flow within the graft.

View larger version (100K): [in a new window]   Figure 3d. Images in a 78-year-old man with a bifurcated aortic stent-graft placed for treatment of an infrarenal AAA. (a) Transverse CT angiogram of the distal portion of the abdominal aorta demonstrates extravasation of contrast material (arrowhead) within the native aorta posterior to the patent limbs (arrows) of the stent-graft. The graft attachment sites (not shown) were normal. (b) Conventional aortogram with selective contrast material injection into the left iliac limb demonstrates double intensity of contrast enhancement. The thicker column of contrast material (arrows) outlines the graft. Lighter contrast intensity is seen outside the graft within the native common iliac artery; this finding confirms the presence of a type I leak (arrowheads). (c) Transverse US image in a superior angle along the left common iliac artery (arrowheads) with a Doppler gate (double lines) placed inside the distal iliac graft limb demonstrates normal antegrade flow (the above-baseline component in the spectral waveform) toward the transducer in the patent graft limb. (d) Transverse US image in a superior angle along the left common iliac artery (arrowheads); a Doppler gate (double lines) has been placed in the native iliac artery outside the distal iliac graft limb. Doppler tracing demonstrates abnormal retrograde flow (a below-baseline component) in the native vessel away from the transducer; this finding is suggestive of a type I attachment site leak. The flow component seen above baseline in this tracing represents artifact from the adjacent antegrade flow within the graft.