PLANNING, EVAR AND FOLLOWUP WITHOUT CONTRAST IN CHRONIC KIDNEY DISEASE

  • Rita Soares Ferreira Serviço de Angiologia e Cirurgia Vascular, Hospital Santa Marta, CHLC, Lisboa; NOVA Medical School, Lisboa
  • Frederico Bastos Gonçalves Serviço de Angiologia e Cirurgia Vascular, Hospital Santa Marta, CHLC, Lisboa; NOVA Medical School, Lisboa
  • Anita Quintas Serviço de Angiologia e Cirurgia Vascular, Hospital Santa Marta, CHLC, Lisboa
  • Rodolfo Abreu Serviço de Angiologia e Cirurgia Vascular, Hospital Santa Marta, CHLC, Lisboa
  • Nelson Camacho Serviço de Angiologia e Cirurgia Vascular, Hospital Santa Marta, CHLC, Lisboa
  • Maria Emília Ferreira Serviço de Angiologia e Cirurgia Vascular, Hospital Santa Marta, CHLC, Lisboa
  • João Albuquerque e Castro Serviço de Angiologia e Cirurgia Vascular, Hospital Santa Marta, CHLC, Lisboa
  • Luís Mota Capitão Serviço de Angiologia e Cirurgia Vascular, Hospital Santa Marta, CHLC, Lisboa; NOVA Medical School, Lisboa
Keywords: EVAR, contrast, chronic kidney disease, contrast induced nephropathy

Abstract

Introduction: Up to 30% of patients undergoing elective EVAR have prior Chronic Kidney Disease (CKD). The contrast-induced nephropathy is a complication of EVAR. It is possible to perform EVAR without contrast or minimize its amount during the procedure, using intraoperative angiography with CO2 and/or IVUS instead of conventional angiography. However, these techniques are not available in most hospitals, unlike Dupplex ultrasound (DUS). In patients with favorable biotype and performed by an experienced professional, DUS allows the detection of endoleaks and confirms patency of the renal and hypogastric arteries during EVAR.

Objectives: show the feasibility of planning, execution and follow-up of EVAR without contrast through the presentation of the technique used in a clinical case.

Case Report: A 70-year-old man with a history of CKD due to IgA nephropathy, presented in our hospital with a 57mm asymptomatic infrarenal aortic aneurysm diagnosed on a non-contrast CT. As the patient had risk factors for contrast induced nephropathy, a favorable anatomy and a good biotype for abdominal DUS, he was proposed for EVAR. Planning was performed using centre-lumen line reconstruction and outer-to-outer measurements on non-contrast CT. Proximal neck thrombus, lumen diameter and iliac patency were evaluated by DUS. During surgery the left (lowermost) renal artery was cannulated under fluoroscopy and confirmed by DUS, and a hydrophilic guidewire was left as reference. The main body (Gore Excluder®) was advanced and subsequently deployed under DUS monitoring. Afterwards, both hypogastric arteries were cannulated and used as reference for bilateral extension. A final DUS excluded type 1 or 3 endoleaks. Before discharge he underwent DUS and non-contrast CT which demonstrated the adequate positioning of the endoprosthesis just below the lowermost renal artery, and renal and hypogastric artery permeability. There was no change in renal function during hospitalization.

Conclusion: The planning, execution and and follow-up of EVAR are feasible without contrast. This technique is justified in cases with high risk for contrast-induced nephropathy in patients with a favorable biotype for abdominal ultrasound and a favorable anatomy for EVAR.

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References

1. Saratzis A, Melas N, Mahmood A et al. Incidence of Acute Kidney
Injury (AKI) after Endovascular Abdominal Aortic Aneurysm
Repair (EVAR) and Impact on Outcome. Eur J Vasc Endovasc Surg
2015; 49: 534–540.
2. Patel VI, Lancaster RT, Mukhopadhyay et al. Impact of Chronic
kidney disease on outcomes after abdominal aortic aneurysm
repair. J Vasc Surg 2012; 56: 1206–13.
3. Krasznai AG, Sigterman TA, Bouwman LH et al. Contrast free
Dupplex-Assisted EVAR in Patients with Chronic Renal insufficiency.
Annals of Vascular Diseases 2014; (4): 426–429.
4. Canyigit M, Çetin L, Uguz E et al. Reduction of iodinated contrast
load with the renal artery catheterization technique during endovascular
aortic repair. Diagn Interv Radiol 2013; 19: 244.250.
5. Kaladji A, Dumenil A, Mahé G et al. Safety and Accuracy of Endovascular
Aneurysm Repair without Pre-operative and Intra-operative
Contrast Agent. Eur J Vasc Endovasc Surg 2015; article in press.
6. Wald R, Waikar SS, Liangos O et al. Acute renal failure after endovascular
vs open repair of abdominal aortic aneurysm. J Vasc Surg
2006; 43(3): 460–6.
7. Prinssen M, Verhoeven EL, Buth J et al. A randomizedtrial comparing
conventional and endovascular repair of abdominal aortic
aneurysms. N Engl J Med 2004; 351(16): 1607–18.
8. Moos SI, Nagan G, de Weijert RS et al. Patients at risk for contrast-
-induced nephropathy and mid-term effects after contrast administration:
a prospective cohort study. The Netherlands Journal of
Medicine 2014; 72 (7): 363–371.
9. Huang SG, Woo K, Moos JM et al. A prospective study of carbon
dioxide digital subtraction versus standard contrast arteriography
in detection of endoleaks in endovascular abdominal aortic
aneurysm repairs. Ann Vasc Surg 2013; 27(1): 38–44.
10. Sueyoshi E, Nagayama H, Sakamoto I et al. Carbon dioxide digital
subtraction angiography as an option for detection of endoleaks
in endovascular abdominal aortic aneurysm repair procedure. J
Vasc Surg 2015; 61: 298–303.
11. Hoshina K, Kato M, Miyahara T et al., A retrospective Study of
intravascular Ultrasound use in Patients undergoing Endovascular
Aneurysm Repair: Its usefulness and a Description of the
Procedure. Eur J Vasc Endovasc Surg 2010; 40: 559–563.
12. Tacher et al. Comparision of two-dimensional (2D) angiography,
three-dimensional rotational angiography and a preprocedural
CT image fusion with 2D fluoroscopy for endovascular repair of
thoracoabdominal aortic aneurysm. J Vasc interv radiol 2013; 24
(11): 1698–706.
13. Mirza TA, Karthikesalingam A, Jackson D et al. Duplex ultrasound
and Contrast-Enhanced Ultrasound versus Computed Tomography
for the detection of Endoleak after EVAR; Systematic
Review and Bivariate Meta-Analysis. Eur J Endovasc Surg 2010;
39: 418–428.
Published
2017-12-30
Section
Clinical Case