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Eliminating the need for mesenteric angiography after negative CTA: negative predictive value of CTA in obscure GI bleeding
S196
Scientific e-Posters
Abstract No. 456 Arterial access site changes on CT angiography following open vs. percutaneous endovascular aortic repair P. Smith1, R. Hieb2, C. Lee3, P. Patel3; 1Medical College of Wisconsin, Milwaukee, IL; 2N/A, Pewaukee, WI; 3Medical College of Wisconsin, Milwaukee, WI Purpose: To compare the accessed artery luminal diameter on follow up CT scans in patients who underwent percutaneous endovascular aortic repair (PEVAR) vs. open endovascular aortic repair (EVAR). Materials: Angiography, operative reports, follow up CT scans, complications and demographics of all patients who underwent PEVAR or EVAR between September 2008 and April 2016 performed conjointly with vascular surgery were reviewed. The patients were divided between open vs percutaneous based on arterial access. Study outcome measures include the difference in the luminal caliber of the accessed artery prior to and following EVAR using the most recent follow up contrast enhanced CT. Patients were excluded if there was solely non-contrast CT follow up, the access site was surgically repaired during the procedure or the accessed site was obscured on follow up. Access related complications were also recorded. Results: A total of 207 patients who underwent EVAR or PEVAR within the defined interval (163 males, 399 arterial accesses, 210 of which were percutaneous), and 168 patients met inclusion criteria (339 arterial accesses, 166 of which were percutaneous.) Mean time to follow up CTA is 1.5 years (1.9 years for open and 1.1 years for percutaneous). The average decrease in luminal diameter of the accessed artery was 0.65 mm for those accessed open and 0.30 mm for those accessed percutaneously. The average diameter of the arteries accessed openly was 9.3 mm and 9.5 mm percutaneously. The delivery sheath sizes required ranged from 7-24 French. Percutaneous closure devices used were the Proglide Perclose and 8 French Angio-seal. There were 5 instances of inadequate hemostasis (3%) following percutaneous closure device deployment, which required open exposure Conclusions: Midterm follow up of arterial access imaging changes of EVAR vs PEVAR show a promising trend towards less luminal diameter narrowing at the arteriotomy and high success rate, recognizing the expectedly longer term follow up data of the open group. Further investigation is warranted as we trend toward more PEVAR.
Scientific e-Posters
Abstract No. 457 Eliminating the need for mesenteric angiography after negative CTA: negative predictive value of CTA in obscure GI bleeding P. Shukla1, A. Zybulewski1, M. Kolber1, E. Berkowitz1, J. Silberzweig1, M. Hayim1; 1Mount Sinai Beth Israel, New York, NY Purpose: To evaluate the negative predictive power of computed tomography angiography (CTA) for the identification of obscure acute gastrointestinal (GI) bleeding (GI bleeding not visualized/
’
JVIR
treated by endoscopy) on subsequent mesenteric angiography (MA) with the intention to treat. Materials: A retrospective chart review of patients was performed who underwent mesenteric angiography for the evaluation/treatment of acute GI bleeding between November 2012 and July 2016. Patients with negative CTA examinations that proceeded to MA were identified. Negative predictive value (NPV) was calculated. Results: 20 patients (14 male, 6 female; average age: 73.1 ⫾ 12.8 years) underwent 20 negative CTA examinations for the evaluation and treatment of GI bleeding followed by mesenteric angiography. Eighteen of 20 patients had negative subsequent MA (negative predictive value, NPV ¼ 90%). Both false negative cases were upper GI bleed (vs 0 lower GI bleed); this difference was significant (p o 0.05). Conclusions: The high NPV of CTA for the evaluation of GI bleeding suggests utility for excluding patients that are unlikely to benefit from MA and subsequent endovascular therapy. CTA may be considered the first line diagnostic study for the evaluation of obscure GI bleeding.
Abstract No. 458 Preoperative CTV for IPS sampling: weighing the radiation costs and benefits V. Rajpurohit1, A. Doshi1, F. Hui1; 1Johns Hopkins University, Baltimore, MD Purpose: The inferior petrosal sinus (IPS) is the main transvenous access route to sample the secretions of patients with suspected pituitary adenomas. Sampling techniques have utilized preoperative CT Venography (CTV) in addition to Digital Subtraction Angiography (DSA) and intraoperative fluoroscopy to detail venous anatomy. The goal of our study was to evaluate the need of preoperative CTV with respect to radiation exposure and anatomical guidance. Materials: We observed venous anatomy and radiation exposure in nine patients referred for IPS sampling with suspected Cushing’s syndrome. Each patient obtained a preoperative CTV, which was followed by intraoperative DSA and fluoroscopy. Venous anatomy was detailed by an experienced neuroradiologist using both CTV and DSA. Radiation exposure was obtained and comparisons made using approximate values of effective dose conversion factors. Results: All nine patients demonstrated patent IPS-IJV connections. There were four hypoplastic IPS, one IPS draining into the IJV inferiorly at the level of C3-C4 (type II), and another IPS which divided into multiple channels before draining into the IJV (type III). Each IPS was successfully catheterized. The average effective dose for CTV and DSA/Fluoroscopy was 5.4 mSv and 3.0 mSv, respectively. Conclusions: While preoperative CTV may elucidate IPS venous drainage and accelerate the performance of inferior petrosal sinus sampling, catheterization can be accomplished under DSV and fluoroscopic guidance alone in the majority of patients. Prior knowledge of venous anatomy may be helpful in altering operative planning when confronting complex aberrant venous access. In light of nearly doubled radiation dose, standard preoperative CTV should be used judiciously and with hesitation.
Scientific e-Posters
Abstract No. 456 Arterial access site changes on CT angiography following open vs. percutaneous endovascular aortic repair P. Smith1, R. Hieb2, C. Lee3, P. Patel3; 1Medical College of Wisconsin, Milwaukee, IL; 2N/A, Pewaukee, WI; 3Medical College of Wisconsin, Milwaukee, WI Purpose: To compare the accessed artery luminal diameter on follow up CT scans in patients who underwent percutaneous endovascular aortic repair (PEVAR) vs. open endovascular aortic repair (EVAR). Materials: Angiography, operative reports, follow up CT scans, complications and demographics of all patients who underwent PEVAR or EVAR between September 2008 and April 2016 performed conjointly with vascular surgery were reviewed. The patients were divided between open vs percutaneous based on arterial access. Study outcome measures include the difference in the luminal caliber of the accessed artery prior to and following EVAR using the most recent follow up contrast enhanced CT. Patients were excluded if there was solely non-contrast CT follow up, the access site was surgically repaired during the procedure or the accessed site was obscured on follow up. Access related complications were also recorded. Results: A total of 207 patients who underwent EVAR or PEVAR within the defined interval (163 males, 399 arterial accesses, 210 of which were percutaneous), and 168 patients met inclusion criteria (339 arterial accesses, 166 of which were percutaneous.) Mean time to follow up CTA is 1.5 years (1.9 years for open and 1.1 years for percutaneous). The average decrease in luminal diameter of the accessed artery was 0.65 mm for those accessed open and 0.30 mm for those accessed percutaneously. The average diameter of the arteries accessed openly was 9.3 mm and 9.5 mm percutaneously. The delivery sheath sizes required ranged from 7-24 French. Percutaneous closure devices used were the Proglide Perclose and 8 French Angio-seal. There were 5 instances of inadequate hemostasis (3%) following percutaneous closure device deployment, which required open exposure Conclusions: Midterm follow up of arterial access imaging changes of EVAR vs PEVAR show a promising trend towards less luminal diameter narrowing at the arteriotomy and high success rate, recognizing the expectedly longer term follow up data of the open group. Further investigation is warranted as we trend toward more PEVAR.
Scientific e-Posters
Abstract No. 457 Eliminating the need for mesenteric angiography after negative CTA: negative predictive value of CTA in obscure GI bleeding P. Shukla1, A. Zybulewski1, M. Kolber1, E. Berkowitz1, J. Silberzweig1, M. Hayim1; 1Mount Sinai Beth Israel, New York, NY Purpose: To evaluate the negative predictive power of computed tomography angiography (CTA) for the identification of obscure acute gastrointestinal (GI) bleeding (GI bleeding not visualized/
’
JVIR
treated by endoscopy) on subsequent mesenteric angiography (MA) with the intention to treat. Materials: A retrospective chart review of patients was performed who underwent mesenteric angiography for the evaluation/treatment of acute GI bleeding between November 2012 and July 2016. Patients with negative CTA examinations that proceeded to MA were identified. Negative predictive value (NPV) was calculated. Results: 20 patients (14 male, 6 female; average age: 73.1 ⫾ 12.8 years) underwent 20 negative CTA examinations for the evaluation and treatment of GI bleeding followed by mesenteric angiography. Eighteen of 20 patients had negative subsequent MA (negative predictive value, NPV ¼ 90%). Both false negative cases were upper GI bleed (vs 0 lower GI bleed); this difference was significant (p o 0.05). Conclusions: The high NPV of CTA for the evaluation of GI bleeding suggests utility for excluding patients that are unlikely to benefit from MA and subsequent endovascular therapy. CTA may be considered the first line diagnostic study for the evaluation of obscure GI bleeding.
Abstract No. 458 Preoperative CTV for IPS sampling: weighing the radiation costs and benefits V. Rajpurohit1, A. Doshi1, F. Hui1; 1Johns Hopkins University, Baltimore, MD Purpose: The inferior petrosal sinus (IPS) is the main transvenous access route to sample the secretions of patients with suspected pituitary adenomas. Sampling techniques have utilized preoperative CT Venography (CTV) in addition to Digital Subtraction Angiography (DSA) and intraoperative fluoroscopy to detail venous anatomy. The goal of our study was to evaluate the need of preoperative CTV with respect to radiation exposure and anatomical guidance. Materials: We observed venous anatomy and radiation exposure in nine patients referred for IPS sampling with suspected Cushing’s syndrome. Each patient obtained a preoperative CTV, which was followed by intraoperative DSA and fluoroscopy. Venous anatomy was detailed by an experienced neuroradiologist using both CTV and DSA. Radiation exposure was obtained and comparisons made using approximate values of effective dose conversion factors. Results: All nine patients demonstrated patent IPS-IJV connections. There were four hypoplastic IPS, one IPS draining into the IJV inferiorly at the level of C3-C4 (type II), and another IPS which divided into multiple channels before draining into the IJV (type III). Each IPS was successfully catheterized. The average effective dose for CTV and DSA/Fluoroscopy was 5.4 mSv and 3.0 mSv, respectively. Conclusions: While preoperative CTV may elucidate IPS venous drainage and accelerate the performance of inferior petrosal sinus sampling, catheterization can be accomplished under DSV and fluoroscopic guidance alone in the majority of patients. Prior knowledge of venous anatomy may be helpful in altering operative planning when confronting complex aberrant venous access. In light of nearly doubled radiation dose, standard preoperative CTV should be used judiciously and with hesitation.