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FT9. Sandwich and Iliac Branched Device for Hypogastric Preservation During EVAR: A Comparative Study
JOURNAL OF VASCULAR SURGERY June Supplement 2015
16S Abstracts
Nothing to disclose; N. Nishioka: Nothing to disclose; K. Ujihira: Nothing to disclose; Y. Iba: Nothing to disclose; E. Hatta: Nothing to disclose; A. Yamada: Nothing to disclose; M. Nojima: Nothing to disclose; K. Nakanishi: Nothing to disclose. FT7. Semiconversion for Persistent Type II Endoleak: When and How to Use the Easy Way Nicola Mangialardi, Eugenia Serrao, Sonia Ronchey, Vittorio Alberti, Stefano Fazzini, Barbara Praquin, Matteo Orrico. San Filippo Neri Hospital, Rome, Italy Objectives: This study presents our large case series of semiconversions as a feasible and safe treatment for untreatable and persistent type II endoleak and endotension. Methods: Between January 2001 and December 2014, 25 patients of 1623 endovascular aneurysm repair (EVAR) were selected as candidates for open semiconversion. The indication was persistent type II endoleak in 10, type I and II endoleak in 5, and endotension in the other 10. After preparing the infrarenal aorta (via a retroperitoneal access whenever possible), the technique consisted of performing a banding of the neck with Teflon, a sacotomy to remove the thrombus and/or the igroma, and then suturing all the feeding vessels (always present, even in cases of endotension). Proximal and distal fenestrations were left to avoid sac depressurization. Results: The semiconversion was performed after a medium period of 74 months from the EVAR. The mean aneurysm size at the time of the EVAR in these 25 patients was 6.0 cm (range, 50-95 mm), and the mean aneurysm size at the time of the semiconversion was 7.2 cm ( range, 55-100 mm). Only one patient had a stable aneurysm size; the remaining 24 had a mean percentage diameter increase of 38% and an average increasing rate of 6.4% per year. The 10 patients with endotension and the five with associated type I and II endoleak did not undergo any other treatment but the sacotomy; the 10 patients with type II endoleak had previously undergone embolization, which was unsuccessful. We had technical success in 100% of the cases, with resolution of the endoleak or endotension without perioperative mortality. Four cardiac deaths were registered at 12, 26, 30 and 60 months (mean follow-up, 42 months; range, 1-80 months). Conclusions: As shown by several authors, graft salvage appears to be a valid option if compared with open repair when considering treatment of persistent type II endoleak. This large case series shows that semiconversion is a safe and effective treatment for otherwise untreatable type II endoleak. Author Disclosures: N. Mangialardi: Nothing to disclose; E. Serrao: Nothing to disclose; S. Ronchey: Nothing to disclose; V. Alberti: Nothing to disclose; S. Fazzini: Nothing to disclose; B. Praquin: Nothing to disclose; M. Orrico: Nothing to disclose.
Setacci5, Giuseppe Galzerano6, Carlo Setacci7. 1Vascular and Endovascular Surgery, Department of Surgery “P Stefanini” - “Sapienza” University of Rome, Rome, Italy; 2 Danilo Menna, Vascula and Endovascular Surgery Division, Rome, Italy; 3“Sapienza” University of Rome, Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, Roma, Italy; 4Policlinico Umberto I, “Sapienza” University of Rome, Rome, Italy; 5 Department of Surgery, Sapienza university of Rome, Siena, Italy; 6Aous, University Hospital of Siena, Siena, Italy; 7University of Siena, University of Siena, Siena, Italy Objectives: This study evaluated the impact of iliac arteries’ anatomical features on outcome of elective endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) in a double-center experience. Methods: A retrospective study was conducted on a prospectively collected database between 2010 and 2012. Preoperative DICOM images were reviewed searching for iliac axes’ diameters and tortuosity (expressed as ratio between the centreline-assessed length and the straight distance from aortic bifurcation to femoral artery, assessed in coronal projection) and the presence of femoropopliteal steno-obstructive disease as factors potentially influencing outcome. Measures considered for analysis were reintervention and mortality rates during follow-up. Results: Of 289 patients evaluated, 248 were male (85.9%), mean age was 75 6 7.3. Mean narrowest diameters of common iliac arteries (CIA) were 12.8 6 4 mm and 12.9 6 3.9 mm; mean right external iliac artery (EIA) 7.7 6 1.6 mm and 7.8 6 1.7 mm, respectively, on the right and left side. Mean tortuosity ratios were 0.8 6 0.1 (0.40.91) and 0.8 6 0.1 (0.49-0.99) on right and left side, respectively. Femoropopliteal steno-obstructive disease was present in 31 patients (10.7%). Technical success was achieved in all cases. No in-hospital and 30-day complications were recorded. At a mean follow-up of 26 months, 30 reinterventions were required in 26 patients (8.9%), and 22 (7.6%) non-AAA-related deaths were noted. Right EIA diameter #5 mm (odds ratio, 5.2; confidence interval, 1.73-15.57; P ¼ .0012), and femoropopliteal steno-obstructive disease (odds ratio, 3.06; confidence interval, 1.02-9.20; P ¼ .03) were significantly related to reinterventions during follow-up. Iliac tortuosity ratio was not a significant predictor of adverse events. Conclusions: Our experience suggests that diameters of access vessels and the presence of femoro-popliteal steno-obstructive disease could affect the outcome of EVAR. Author Disclosures: P. Sirignano: Nothing to disclose; F. Speziale: Nothing to disclose; D. Menna: Nothing to disclose; L. Capoccia: Nothing to disclose; W. Mansour: Nothing to disclose; F. Setacci: Trivascular, consulting fee; G. Galzerano: Nothing to disclose; C. Setacci: Nothing to disclose. FT9.
FT8. Iliac Arteries Morphological Features as Predictor of Outcome After Standard EVAR Procedures Pasqualino Sirignano1, Francesco Speziale1, Danilo Menna2, Laura Capoccia3, Wassim Mansour4, Francesco
Sandwich and Iliac Branched Device for Hypogastric Preservation During EVAR: A Comparative Study Maxime Raux1, Dominique Fabre2, Marek Majewski, Claude-Yves Angel, Pascal Desgranges3, Jean-Pierre Becquemin4. 1Henri Mondor Hospital, Paris, France;
JOURNAL OF VASCULAR SURGERY Volume 61, Number 6S
2
Marie Lannelongue Hospital, Le Plessis Robinson, France; Vascular Surgery Unit, Henri Mondor Hospital, Creteil, France; 4AP/HP Paris, University Paris XII, Creteil, France 3
Objectives: This study compared outcomes of an iliacbranched device (IBD) and the sandwich technique (ST) for preservation of hypogastric flow in the setting of aortoiliac aneurysm repair. Methods: Between 2010 and 2014, patients of two high-volume vascular centers referred for elective repair of abdominal aortic aneurysms (AAAs) involving iliac bifurcation or isolated common iliac artery (CIA) aneurysms underwent IBD placement or ST. Clinical and anatomic data, operative intervention, and outcomes were collected prospectively and analyzed retrospectively. Results: Thirty-seven patients underwent 40 procedures: 20 IBD and 20 ST, with placement of aortic endograft in 28 patients (70%). Technical success rate were comparable in both groups (95% vs 100%, P ¼ 1). Three external iliac artery (EIA) limbs and one internal iliac artery (IIA) stent thrombosed in the ST group. Early and late patency rates were not statistically different in the IBD group (100% and 94.7%) and in the ST group (90% and 80%; P > .05). There was no statistical difference between both groups regarding endoleaks onset (P ¼ .2). One patient suffered of transient buttock claudication after branched device IIA stent thrombosis. Reintervention rates were comparable in both groups (P ¼ .1). Both techniques permitted comparable aneurysm sac shrinkage (P ¼ .7). No rupture, colonic ischemia, or arterial access complication was noticed. Conclusions: In this retrospective study, IBD and ST provided similar outcomes for aortoiliac aneurysm treatment with hypogastric preservation. The sandwich technique represents a reliable alternative to IBD when the latter is not feasible, making patients more eligible for endovascular treatment. Further larger cohort studies are warranted to confirm these encouraging results. Author Disclosures: M. Raux: Nothing to disclose; D. Fabre: Nothing to disclose; M. Majewski: Nothing to disclose; C. Y. Angel: Nothing to disclose; P. Desgranges: Nothing to disclose; J. Becquemin: Nothing to disclose. FT10. Mid-term Outcomes of EVAR Performed in AAA With Large Infrarenal Necks Mauro Gargiulo1, Enrico Gallitto1, Helene Wattez2, Fabio Verzini3, Claudio Bianchini Massoni4, Stéphan Haulon2, Diletta Loschi3, Antonio Freyrie1. 1University Bologna, University Bologna, Bologna, Italy; 2CHRU Lille, France; 3 Section of Vascular Surgery, University of Perugia, Perugia, Italy; 4Vascular Surgery, Policlinico S.OrsolaMalpighi, Bologna, Italia Objectives: This study evaluated the progression of the infrarenal and suprarenal aortic diameters and the midterm clinical outcomes following EVAR in AAA with large ($28 mm) infrarenal neck (WN-AAA). Methods: From 2009 to 2012, we prospectively collected and retrospectively analyzed clinical, morphological, intraoperative and postoperative data of patients undergoing EVAR for WN-AAA at three European vascular surgery units. All patients had a computed tomography angiography (CTA) follow-up $24 months. Primary end
Abstracts 17S
point was the progression of midterm infrarenal/suprarenal aortic diameters. Secondary end points were midterm survival (S), type Ia endoleak (ELIa), and freedom from reintervention (FFR). The aortic diameters were measured on the center lumen-line reconstruction, 1 cm below the lowest renal artery (D1), at the level of renal arteries (D2, D3), superior mesenteric artery (D4), and celiac trunk (D5). Preoperative (T0) and 24-month (T1) aortic diameters were compared by paired t-test. S and FFR were evaluated by Kaplan-Meier. Results: A total of 118 patients (age, 74 6 8 years) were enrolled. The mean aneurysm diameter was 61 6 10 mm. Suprarenal and infrarenal fixation endograft were implanted in 102 (86%) and 16 (14%) cases, respectively. The mean main body oversizing was 12% 6 6%. Technical success rate was 98% (3 ELIa). The mean follow-up was 38612 months. Fourteen ELIa (12%) were detected during follow-up. S at 12, 24 and 36 months was 95%, 93% and 89%, respectively. Four deaths (3.4%) were ELIa-related. FFR at 12, 24 and 36 months was 96%, 92% and 83%, respectively. Eight reinterventions (6.8%) were proximal neck related. All diameters increased at 24 months. The mean increase was 10.9% for D1 (T0: 29.1 6 1.1 mm vs T1: 32.3 6 4.5 mm; P < .001), 3% to 5% for D2 and D3, and <3% for D4 and D5. Conclusions: EVAR performed in AAA with large necks is associated with a significant infrarenal aortic neck enlargement at 24 months, as well as an increased risk of proximal type 1 endoleak and of proximal neck reinterventions. In this subgroup of patients, main body oversizing >15% or suprarenal sealing (FEVAR) following aortic morphology assessment should be discussed. Author Disclosures: M. Gargiulo: Cook, consulting fee; Medtronic, speakers bureau; E. Gallitto: Nothing to disclose; H. Wattez: Nothing to disclose; F. Verzini: Gore, Cook, consulting fee; C. Bianchini Massoni: Nothing to disclose; S. Haulon: Cook Medical, consulting fee; D. Loschi: Nothing to disclose; A. Freyrie: Nothing to disclose. FT11. The Effects of Combining Fusion Imaging, Low-Pulse Fluoroscopy, and LowConcentration Contrast Agent During EVAR Nuno V. Dias, Helen Billberg, Björn Sonesson, Pelle Törnqvist, Julien Hasselmann, Timothy Resch, Thorarinn Kristmundsson. Vascular Center Malmö, Skånes University Hospital, Malmö, Sweden Objectives: Several methods have been attempted to reduce radiation and contrast exposure during endovascular aneurysm repair (EVAR). However, most approaches have focused on a single factor. This study aims at evaluating the implications of a combined protocol with low-frequency pulsed fluoroscopy, fusion imaging, and low concentration iodine contrast for EVAR of aortic aneurysms of varying complexity. Methods: A total of 103 patients treated between May 2013 and November 2014 with a combined protocol (group A) with low-dose fluoroscopy at 4 frames/s, fusion imaging and iodine contrast of 140 mg I/mL were identified and retrospectively reviewed. A control group (n ¼ 123) was identified from the consecutive patients performed before the introduction of the protocol by
16S Abstracts
Nothing to disclose; N. Nishioka: Nothing to disclose; K. Ujihira: Nothing to disclose; Y. Iba: Nothing to disclose; E. Hatta: Nothing to disclose; A. Yamada: Nothing to disclose; M. Nojima: Nothing to disclose; K. Nakanishi: Nothing to disclose. FT7. Semiconversion for Persistent Type II Endoleak: When and How to Use the Easy Way Nicola Mangialardi, Eugenia Serrao, Sonia Ronchey, Vittorio Alberti, Stefano Fazzini, Barbara Praquin, Matteo Orrico. San Filippo Neri Hospital, Rome, Italy Objectives: This study presents our large case series of semiconversions as a feasible and safe treatment for untreatable and persistent type II endoleak and endotension. Methods: Between January 2001 and December 2014, 25 patients of 1623 endovascular aneurysm repair (EVAR) were selected as candidates for open semiconversion. The indication was persistent type II endoleak in 10, type I and II endoleak in 5, and endotension in the other 10. After preparing the infrarenal aorta (via a retroperitoneal access whenever possible), the technique consisted of performing a banding of the neck with Teflon, a sacotomy to remove the thrombus and/or the igroma, and then suturing all the feeding vessels (always present, even in cases of endotension). Proximal and distal fenestrations were left to avoid sac depressurization. Results: The semiconversion was performed after a medium period of 74 months from the EVAR. The mean aneurysm size at the time of the EVAR in these 25 patients was 6.0 cm (range, 50-95 mm), and the mean aneurysm size at the time of the semiconversion was 7.2 cm ( range, 55-100 mm). Only one patient had a stable aneurysm size; the remaining 24 had a mean percentage diameter increase of 38% and an average increasing rate of 6.4% per year. The 10 patients with endotension and the five with associated type I and II endoleak did not undergo any other treatment but the sacotomy; the 10 patients with type II endoleak had previously undergone embolization, which was unsuccessful. We had technical success in 100% of the cases, with resolution of the endoleak or endotension without perioperative mortality. Four cardiac deaths were registered at 12, 26, 30 and 60 months (mean follow-up, 42 months; range, 1-80 months). Conclusions: As shown by several authors, graft salvage appears to be a valid option if compared with open repair when considering treatment of persistent type II endoleak. This large case series shows that semiconversion is a safe and effective treatment for otherwise untreatable type II endoleak. Author Disclosures: N. Mangialardi: Nothing to disclose; E. Serrao: Nothing to disclose; S. Ronchey: Nothing to disclose; V. Alberti: Nothing to disclose; S. Fazzini: Nothing to disclose; B. Praquin: Nothing to disclose; M. Orrico: Nothing to disclose.
Setacci5, Giuseppe Galzerano6, Carlo Setacci7. 1Vascular and Endovascular Surgery, Department of Surgery “P Stefanini” - “Sapienza” University of Rome, Rome, Italy; 2 Danilo Menna, Vascula and Endovascular Surgery Division, Rome, Italy; 3“Sapienza” University of Rome, Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, Roma, Italy; 4Policlinico Umberto I, “Sapienza” University of Rome, Rome, Italy; 5 Department of Surgery, Sapienza university of Rome, Siena, Italy; 6Aous, University Hospital of Siena, Siena, Italy; 7University of Siena, University of Siena, Siena, Italy Objectives: This study evaluated the impact of iliac arteries’ anatomical features on outcome of elective endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) in a double-center experience. Methods: A retrospective study was conducted on a prospectively collected database between 2010 and 2012. Preoperative DICOM images were reviewed searching for iliac axes’ diameters and tortuosity (expressed as ratio between the centreline-assessed length and the straight distance from aortic bifurcation to femoral artery, assessed in coronal projection) and the presence of femoropopliteal steno-obstructive disease as factors potentially influencing outcome. Measures considered for analysis were reintervention and mortality rates during follow-up. Results: Of 289 patients evaluated, 248 were male (85.9%), mean age was 75 6 7.3. Mean narrowest diameters of common iliac arteries (CIA) were 12.8 6 4 mm and 12.9 6 3.9 mm; mean right external iliac artery (EIA) 7.7 6 1.6 mm and 7.8 6 1.7 mm, respectively, on the right and left side. Mean tortuosity ratios were 0.8 6 0.1 (0.40.91) and 0.8 6 0.1 (0.49-0.99) on right and left side, respectively. Femoropopliteal steno-obstructive disease was present in 31 patients (10.7%). Technical success was achieved in all cases. No in-hospital and 30-day complications were recorded. At a mean follow-up of 26 months, 30 reinterventions were required in 26 patients (8.9%), and 22 (7.6%) non-AAA-related deaths were noted. Right EIA diameter #5 mm (odds ratio, 5.2; confidence interval, 1.73-15.57; P ¼ .0012), and femoropopliteal steno-obstructive disease (odds ratio, 3.06; confidence interval, 1.02-9.20; P ¼ .03) were significantly related to reinterventions during follow-up. Iliac tortuosity ratio was not a significant predictor of adverse events. Conclusions: Our experience suggests that diameters of access vessels and the presence of femoro-popliteal steno-obstructive disease could affect the outcome of EVAR. Author Disclosures: P. Sirignano: Nothing to disclose; F. Speziale: Nothing to disclose; D. Menna: Nothing to disclose; L. Capoccia: Nothing to disclose; W. Mansour: Nothing to disclose; F. Setacci: Trivascular, consulting fee; G. Galzerano: Nothing to disclose; C. Setacci: Nothing to disclose. FT9.
FT8. Iliac Arteries Morphological Features as Predictor of Outcome After Standard EVAR Procedures Pasqualino Sirignano1, Francesco Speziale1, Danilo Menna2, Laura Capoccia3, Wassim Mansour4, Francesco
Sandwich and Iliac Branched Device for Hypogastric Preservation During EVAR: A Comparative Study Maxime Raux1, Dominique Fabre2, Marek Majewski, Claude-Yves Angel, Pascal Desgranges3, Jean-Pierre Becquemin4. 1Henri Mondor Hospital, Paris, France;
JOURNAL OF VASCULAR SURGERY Volume 61, Number 6S
2
Marie Lannelongue Hospital, Le Plessis Robinson, France; Vascular Surgery Unit, Henri Mondor Hospital, Creteil, France; 4AP/HP Paris, University Paris XII, Creteil, France 3
Objectives: This study compared outcomes of an iliacbranched device (IBD) and the sandwich technique (ST) for preservation of hypogastric flow in the setting of aortoiliac aneurysm repair. Methods: Between 2010 and 2014, patients of two high-volume vascular centers referred for elective repair of abdominal aortic aneurysms (AAAs) involving iliac bifurcation or isolated common iliac artery (CIA) aneurysms underwent IBD placement or ST. Clinical and anatomic data, operative intervention, and outcomes were collected prospectively and analyzed retrospectively. Results: Thirty-seven patients underwent 40 procedures: 20 IBD and 20 ST, with placement of aortic endograft in 28 patients (70%). Technical success rate were comparable in both groups (95% vs 100%, P ¼ 1). Three external iliac artery (EIA) limbs and one internal iliac artery (IIA) stent thrombosed in the ST group. Early and late patency rates were not statistically different in the IBD group (100% and 94.7%) and in the ST group (90% and 80%; P > .05). There was no statistical difference between both groups regarding endoleaks onset (P ¼ .2). One patient suffered of transient buttock claudication after branched device IIA stent thrombosis. Reintervention rates were comparable in both groups (P ¼ .1). Both techniques permitted comparable aneurysm sac shrinkage (P ¼ .7). No rupture, colonic ischemia, or arterial access complication was noticed. Conclusions: In this retrospective study, IBD and ST provided similar outcomes for aortoiliac aneurysm treatment with hypogastric preservation. The sandwich technique represents a reliable alternative to IBD when the latter is not feasible, making patients more eligible for endovascular treatment. Further larger cohort studies are warranted to confirm these encouraging results. Author Disclosures: M. Raux: Nothing to disclose; D. Fabre: Nothing to disclose; M. Majewski: Nothing to disclose; C. Y. Angel: Nothing to disclose; P. Desgranges: Nothing to disclose; J. Becquemin: Nothing to disclose. FT10. Mid-term Outcomes of EVAR Performed in AAA With Large Infrarenal Necks Mauro Gargiulo1, Enrico Gallitto1, Helene Wattez2, Fabio Verzini3, Claudio Bianchini Massoni4, Stéphan Haulon2, Diletta Loschi3, Antonio Freyrie1. 1University Bologna, University Bologna, Bologna, Italy; 2CHRU Lille, France; 3 Section of Vascular Surgery, University of Perugia, Perugia, Italy; 4Vascular Surgery, Policlinico S.OrsolaMalpighi, Bologna, Italia Objectives: This study evaluated the progression of the infrarenal and suprarenal aortic diameters and the midterm clinical outcomes following EVAR in AAA with large ($28 mm) infrarenal neck (WN-AAA). Methods: From 2009 to 2012, we prospectively collected and retrospectively analyzed clinical, morphological, intraoperative and postoperative data of patients undergoing EVAR for WN-AAA at three European vascular surgery units. All patients had a computed tomography angiography (CTA) follow-up $24 months. Primary end
Abstracts 17S
point was the progression of midterm infrarenal/suprarenal aortic diameters. Secondary end points were midterm survival (S), type Ia endoleak (ELIa), and freedom from reintervention (FFR). The aortic diameters were measured on the center lumen-line reconstruction, 1 cm below the lowest renal artery (D1), at the level of renal arteries (D2, D3), superior mesenteric artery (D4), and celiac trunk (D5). Preoperative (T0) and 24-month (T1) aortic diameters were compared by paired t-test. S and FFR were evaluated by Kaplan-Meier. Results: A total of 118 patients (age, 74 6 8 years) were enrolled. The mean aneurysm diameter was 61 6 10 mm. Suprarenal and infrarenal fixation endograft were implanted in 102 (86%) and 16 (14%) cases, respectively. The mean main body oversizing was 12% 6 6%. Technical success rate was 98% (3 ELIa). The mean follow-up was 38612 months. Fourteen ELIa (12%) were detected during follow-up. S at 12, 24 and 36 months was 95%, 93% and 89%, respectively. Four deaths (3.4%) were ELIa-related. FFR at 12, 24 and 36 months was 96%, 92% and 83%, respectively. Eight reinterventions (6.8%) were proximal neck related. All diameters increased at 24 months. The mean increase was 10.9% for D1 (T0: 29.1 6 1.1 mm vs T1: 32.3 6 4.5 mm; P < .001), 3% to 5% for D2 and D3, and <3% for D4 and D5. Conclusions: EVAR performed in AAA with large necks is associated with a significant infrarenal aortic neck enlargement at 24 months, as well as an increased risk of proximal type 1 endoleak and of proximal neck reinterventions. In this subgroup of patients, main body oversizing >15% or suprarenal sealing (FEVAR) following aortic morphology assessment should be discussed. Author Disclosures: M. Gargiulo: Cook, consulting fee; Medtronic, speakers bureau; E. Gallitto: Nothing to disclose; H. Wattez: Nothing to disclose; F. Verzini: Gore, Cook, consulting fee; C. Bianchini Massoni: Nothing to disclose; S. Haulon: Cook Medical, consulting fee; D. Loschi: Nothing to disclose; A. Freyrie: Nothing to disclose. FT11. The Effects of Combining Fusion Imaging, Low-Pulse Fluoroscopy, and LowConcentration Contrast Agent During EVAR Nuno V. Dias, Helen Billberg, Björn Sonesson, Pelle Törnqvist, Julien Hasselmann, Timothy Resch, Thorarinn Kristmundsson. Vascular Center Malmö, Skånes University Hospital, Malmö, Sweden Objectives: Several methods have been attempted to reduce radiation and contrast exposure during endovascular aneurysm repair (EVAR). However, most approaches have focused on a single factor. This study aims at evaluating the implications of a combined protocol with low-frequency pulsed fluoroscopy, fusion imaging, and low concentration iodine contrast for EVAR of aortic aneurysms of varying complexity. Methods: A total of 103 patients treated between May 2013 and November 2014 with a combined protocol (group A) with low-dose fluoroscopy at 4 frames/s, fusion imaging and iodine contrast of 140 mg I/mL were identified and retrospectively reviewed. A control group (n ¼ 123) was identified from the consecutive patients performed before the introduction of the protocol by