The patient is a 73 year old female with a history of remote aortic aneurysm repair who presents with complaints of dizziness, near syncope and a fall one hour PTA. The patient has mild dementia and is unable to give further history.
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
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]
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]
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]
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]
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]
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]