UOTW #35 Answer

Answer: Leaking aortic graft 

This bedside ultrasound reveals a 6 cm aortic anuerysm (AAA) with centrally located endograft in place.  Additionally, there is a second pulsatile lumen noted inferior-lateral to the endograft consistent with flow around the graft.  CTA imaging noted active extravasation of contrast around the graft confirming the diagnosis of endoleak.

• Patients with a previously repaired AAA via endograft are at risk of leaking around the graft for various reasons, putting the patient at continued risk of aneurysm expansion and rupture.¹
• While CTA is typically considered the surveillance study of choice, doppler ultrasound has shown promise as its AAA measurements correlate closely with CTA.^2,3
• On ultrasound, “Endoleaks appear as pulsatile color-flow within or adjacent to the aneurysm sac.”¹
• Contrast enhancement has been shown to increase ultrasound’s sensitivity for endograft leak.  In fact, some studies show that contrast enhanced u/s is even more sensitive for endoleak than CTA. However, the use of ultrasound contrast agents is typically outside the purview of point of care sonographers.^4,5,6
• Traditional, non-contrasted ultrasound should be considered very specific but insensitive for an aortic endoleak.^4,5,6

1. Picel AC, Kansal N. Essentials of endovascular abdominal aortic aneurysm repair imaging: postprocedure surveillance and complications. AJR Am J Roentgenol. 2014;203:(4)W358-72. [pubmed]
2. Wolf YG, Johnson BL, Hill BB, Rubin GD, Fogarty TJ, Zarins CK. Duplex ultrasound scanning versus computed tomographic angiography for postoperative evaluation of endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2000;32:(6)1142-8. [pubmed]
3. Raman KG, Missig-Carroll N, Richardson T, Muluk SC, Makaroun MS. Color-flow duplex ultrasound scan versus computed tomographic scan in the surveillance of endovascular aneurysm repair. J Vasc Surg. 2003;38:(4)645-51. [pubmed]
4. Gürtler VM, Sommer WH, Meimarakis G, et al. A comparison between contrast-enhanced ultrasound imaging and multislice computed tomography in detecting and classifying endoleaks in the follow-up after endovascular aneurysm repair. J Vasc Surg. 2013;58:(2)340-5. [pubmed]
5. Cantisani V, Ricci P, Grazhdani H, et al. Prospective comparative analysis of colour-Doppler ultrasound, contrast-enhanced ultrasound, computed tomography and magnetic resonance in detecting endoleak after endovascular abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2011;41:(2)186-92. [pubmed]
6. Ten Bosch JA, Rouwet EV, Peters CT, et al. Contrast-enhanced ultrasound versus computed tomographic angiography for surveillance of endovascular abdominal aortic aneurysm repair. J Vasc Interv Radiol. 2010;21:(5)638-43. [pubmed]