Aortic imaging session at CX Aortic Vienna reveals universal preoccupation with radiation reduction, and showcases the latest in CT technology

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Clockwise from top left: Roger Greenhalgh, Martin Funovics, Rodney White, Ali Azizzadeh, and Frank Vermassen

Polling at CX Aortic Vienna points to a high level of vigilance over radiation exposure during endovascular aneurysm repair (EVAR). This was among the messages to emerge from a discussion on the optimal use of aortic imaging for diagnostic purposes and to influence operative results, with a session on the topic split between examining thoracic and EVAR imaging.

This session, and all other sessions from day three of CX Aortic Vienna, is available to view on demand. Click here to register and access the recording.

Majority of the audience would not use IVUS to diagnose complex aortic conditions

The role of thoracic imaging and planning in revealing underlying thoracic aortic pathology was the initial focus of the session, with Frank Vermassen (Ghent, Belgium) opening on the topic of intramural haematomas and penetrating aortic ulcers, “two less common aortic pathologies,” in his words. “Being pathologies of the aortic wall, they are intimately related to each other, and to aortic dissection,” he informed viewers.

Vermassen’s presentation focused on the diagnosis of both conditions, with intramural haematoma signposted by similar symptoms to those of acute aortic dissection, he said, and thoracic pain often a giveaway of a penetrating aortic ulcer. “Sometimes, even rupture can be the first sign,” Vermassen said. “Diagnosis is mostly made on CT scans, showing a focal or crater-like outpouching in the atherosclerotic wall with subintimal haematoma mostly in the descending aorta.”

Medical management and serial follow-up are indicated in uncomplicated intramural haematoma/penetrating aortic dissection, he noted, adding that thoracic endovascular aortic repair (TEVAR) is the treatment of choice in complicated cases. Following Vermassen’s talk, the audience was asked to vote upon the use of intravascular ultrasound (IVUS) for diagnosis of the condition—with 75% suggesting they would not employ this technique.

Transection must be ruled out in cases of blunt thoracic aortic injury

Ali Azizzadeh (Los Angeles, USA) then took to the online podium to discuss the medical management of blunt thoracic aortic injury, viewed through the lens of the Aortic Trauma Foundation global registry. He believes that these most recent data support the revision of the current Society for Vascular Surgery (SVS) clinical practice guidelines for the management of Grade II traumatic aortic injury.

Azzizadeh told the CX Aortic Vienna audience that medical management “appears to be safe and effective, with a low overall intervention rate and no aortic-related deaths”. Polling then revealed that 86% of attendees agreed that aortic transection must be ruled out in such cases.

Opening the EVAR-specific side of the aortic imaging session, Franco Grego (Padua, Italy) argued in favour of using a relatively new, systematic, preoperative cardiac evaluation in patients undergoing abdominal aortic aneurysm repair, as opposed to following the American Heart Association (AHA) and European Society of Cardiology (ESC)/European Society of Anaesthesiology (ESA) guidelines.

Grego relayed findings of a retrospective study on patients with infrarenal abdominal aortic aneurysm undergoing elective repair, with both endovascular and open treatments included. “I think that a systematic, preoperative cardiac consultation can improve all our patients’ follow-up, reducing late cardiac-related morbidity and mortality, and therefore improving their lives,” he concluded.

Clockwise from top left: Roger Greenhalgh, Martin Funovics, Rodney White, Maani Hakimi, Tom Carrell, and Alan Lumsden

Dynamic CT the “gold standard” for endoleak management, audience hears

“Dynamic CT should be considered the gold standard in troubleshooting endoleaks and guidance of therapy,” Alan Lumsden (Houston, USA) argued at CX Aortic Vienna. He called for a “dynamic CT for a dynamic process”. He went on to say that “the problem with magnetic resonance imaging [MRI] is that it requires a lot of expensive hardware [and] a lot of additional expertise. CT, on the other hand, is generally much more applicable and available,” he opined. “The question is; can we acquire the same kind of images using CT?”

Demonstrating through multiple videos the sorts of “images” dynamic CT is able to produce, Lumsden highlighted the improved spatial resolution made possible by this technology.

Tom Carrell (Barrington, UK) gave audience members an understanding of how physicians plan, navigate, and review EVAR cases today, and offered his insights into the future of this space, speaking as co-founder of Cydar Medical, a company that using cloud computing and Artificial Intelligence to improve image-guided surgery.

Inviting the CX Aortic Vienna audience to “watch this space”, Carrell left viewers with an idea of the things the team at Cydar Medical are currently working on. “Our vision for Intelligent Planning is bringing capabilities together such that each new case is informed by all previous similar cases globally, and each new case contributes to the planning of future cases. Review metrics will allow you to have some quantitative measures to assess the outcome of the patient to help you with risk stratification when deciding on follow-up.”

Long-term EVAR results have prompted action to reduce radiation, polling finds

Maani Hakimi (Lucerne, Switzerland) presented a Siemens Healthineers-sponsored edited case, demonstrating how to reduce radiation exposure during an EVAR, “an important goal during endovascular procedures”.

“Preoperative planning and strategy is the key to success for the implementation of dose reduction,” he informed attendees of the online conference. “It has been proven that a standardised protocol and the use of a navigation system are necessary.” Hakimi added that by using a low-dose software programme, radiation exposure can be further reduced.

Polling at the end of the session asked attendees whether 15-year EVAR follow-up results had led them to try to reduce radiation, to which 100% responded ‘yes’. The result was described as “terribly important” by chair Roger Greenhalgh. The result also prompted Lumsden to criticise current practice for monitoring radiation exposure among physicians, commenting: “Our methods of radiation monitoring are prehistoric, we need to move into the modern day.”


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