EJVES Vascular Forum (2020) 47, 35e37 CASE REPORT Feasibility of Intraoperative Fusion Imaging Using Non-Contrast CT Scan for EVAR in Ruptured Abdominal Aortic Aneurysm Marc Masana Llimona, Pere Altés Mas *, Lucía Martínez Carnovale, Secundino Llagostera Pujol Department of Angiology and Vascular Surgery, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain WHAT THIS PAPER ADDS Fusion imaging often requires contrast computed tomography (CT) as guidance for aortic endovascular treat- ment. Endovascular aneurysm repair (EVAR) was successfully achieved under image fusion guidance using non- contrast CT with VesselNavigatorÒ in a patient with ruptured abdominal aneurysm and simultaneous acute renal failure. Introduction: Acute renal failure is a frequent major complication (24%) of endovascular repair for ruptured abdominal aneurysm (rAAA). Iodinated contrast media is known to be nephrotoxic. This report describes a case of endovascular aneurysm repair (EVAR) under fusion imaging guidance in a patient diagnosed with a rAAA after non-contrast CT. Written consent was obtained from the patient. Report: A 73 year old patient with stage IV chronic kidney failure and contrast-induced nephropathy was diagnosed with rAAA using non-contrast CT. Subsequently, the patient was treated with EVAR using fusion imaging. Discussion: EVAR with fusion imaging after non-contrast CT was safe in a patient with rAAA. It could represent an option for patients with acute renal failure in emergency settings. Ó 2020 The Author(s). Published by Elsevier Ltd on behalf of European Society for Vascular Surgery. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Article history: Received 22 November 2019, Revised 3 March 2020, Accepted 9 March 2020, Keywords: Acute renal failure, Contrast induced nephropathy, Endovascular aortic repair, Fusion imaging, Ruptured abdominal aortic aneurysm INTRODUCTION history included a mild dementia, high blood pressure, Acute renal failure is a common major complication (24%) dyslipidaemia, and stage IV chronic kidney failure. The first of endovascular repair for ruptured abdominal aneurysm blood test in the emergency room showed haemoglobin of (rAAA).1 Nephrotoxicity of iodinated contrast media re- 12.6 g/dL, creatinine of 1.95 mg/dL, and d-dimer of 18473 mains a limitation for endovascular procedures. Fusion ng/mL. The patient was haemodynamically stable. imaging has already been used in elective endovascular He was admitted in the internal medicine ward and a aneurysm repair (EVAR) in patients with non-contrast CT- thoracic contrast CT scan was performed to rule out pul- scan AAA diagnosis.2 This report describes an EVAR with monary thromboembolism, because this was the first fusion imaging in a patient diagnosed with rAAA after non- diagnostic consideration. CT revealed a left ventricular hy- contrast CT. pertrophy and an aortic arch of 47-mm diameter; never- theless, there were no signs of pulmonary embolism. Two days later the patient’s overall condition worsened; a CASE REPORT painful abdominal palpation was noted, he suffered a A 73 year old man presented to the emergency room with contrast-induced nephropathy, and acute anaemia was diarrhoea and syncope while standing. His past medical detected in blood tests (creatinine of 2.45 mg/dL and haemoglobin of 9.1 g/dL). An abdominal non-contrast CT * Corresponding author. Department of Angiology and Vascular Surgery, scan was performed. Given the renal failure, contrast media Hospital Universitari Germans Trias i Pujol, Badalona, Universitat Autònoma was avoided. A rAAA with an extensive retroperitoneal de Barcelona, Spain. collection was found (Fig. 1). E-mail address: paltesmas@gmail.com (Pere Altés Mas). 2666-688X/Ó 2020 The Author(s). Published by Elsevier Ltd on behalf of The patient was taken immediately to the operating European Society for Vascular Surgery. This is an open access article under the room. The non-contrast CT scan was analysed using HorosÔ CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). (Horos software ver. 2.0.2, Horos Project, Annapolis, MD, https://doi.org/10.1016/j.ejvsvf.2020.03.001 36 Marc Masana Llimona et al. Fig. 1. Non-contrast CT scan showing a ruptured abdominal aortic aneurysm and a right retroperitoneal haematoma. USA), an open source medical viewer, for aortic measure- ments and endograft preselection. Then, fusion imaging was prepared using VesselNavigator of Azurion (Philips, Amsterdam, Netherlands). Segmentation of the infrarenal aorta (the process of selection of the pixels corresponding to the region of interest) in this case, because of a lack of contrast media, had to be corrected manually (Fig. 2).3 The endograft implantation was performed in a hybrid operating room. Live fluoroscopic images were matched Fig. 2. Manually achieved fusion images using VesselNavigator of with previous aortic segmentation images. After locating Azurion platform (PhilipsÒ). renal arteries with 10 mL of contrast media, a 36 mm Endurant IIs (Medtronic, Santa Rosa, CA, USA) was DISCUSSION implanted. The bifurcated graft was completed with a 16  An aortic abdominal aneurysm rupture is a life-threatening 16  124 mm limb for the left common iliac artery, and surgical emergency. A quick process from diagnosis to 16  13  124 mm and 16  13  93 mm limbs for the treatment is essential; nevertheless, an atypical presenta- right external iliac artery. Manual injections of 5 mL of tion may result in diagnostic delay.4 Currently, EVAR is the contrast media were employed to locate internal iliac ar- first-line treatment for these patients, when feasible.5 teries. A left internal iliac occlusion and a right common High-resolution contrast CT scan provides a reliable iliac aneurysm were found. Nester coils (Cook Medical, diagnosis as well as providing anatomical requirements for Bloomington, IN, USA) were deployed in the aortic aneu- EVAR (neck length and diameter, suprarenal and infrarenal rysm sac and right iliac aneurysm through a parallel cath- angulations, distal fixation site length and diameter, and eter. This procedure required 7 mL of contrast media. circumferential calcification and thrombus). Although some Remodelling of the endograft was done using a Reliant thrombus could appear to have higher density than blood balloon (Medtronic). Postprocedural control was verified (especially in patients with anaemia), a non-contrast CT is using 15 mL of contrast media: no endoleaks were found limited in this regard. and both renal arteries remained patent. A residual It is not uncommon to deal with rAAA diagnosed using dissection was fixed in the left external iliac artery with an non-contrast CT in an emergency setting. In the present Astron Pulsar 8  60 mm stent (Biotronik, Berlin, Ger- case, internists were reluctant to use iodinated contrast many). A total amount of 47 mL of contrast media was because the patient suffered from contrast-induced ne- used for the whole procedure. The patient remained in the phropathy. It was decided to use fusion imaging to reduce hospital for two weeks because of social concerns; finally the iodinated contrast dose during the procedure. Non- he was discharged with a creatinine of 2.05 mg/dL and a contrast CT was used for this purpose in an attempt to haemoglobin of 8.9 g/dL. avoid another time-consuming contrast CT in a patient with One month later, the patient had already recovered his a rAAA and a renal failure.6e9 basal renal function (creatinine of 1.85 mg/dL) and from the The use of CO2 instead of iodinated contrast agents for anaemia (haemoglobin of 11.4 g/dL). Under neph- arterial and venous angiography has been reported in many roprotection, a surveillance contrast CT revealed complete studies.10,11 CO2-EVAR is technically feasible and demon- aneurysm exclusion with partial resolution of the retro- strates a prominent protective effect on renal function.12 peritoneal collection (Fig. 3). Intraoperative Fusion Imaging Using Non-Contrast CT Scan for EVAR in Ruptured AAA 37 Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of chest physicians evidence-based clinical practice guidelines. Chest 2012;141: 7Se47S. 2 Martin-Gonzalez T, Hertault A, Maurel B, Midulla M, Kilani MS, Haulon S. Image fusion performed with noncontrast computed tomography scans during endovascular aneurysm repair. J Vasc Surg Cases 2015;1:53e6. 3 Wan T, Shang X, Yang W, Chen J, Li D, Qin Z. Automated cor- onary artery tree segmentation in x-ray angiography using improved hessian based enhancement and statistical region merging. Comput Methods Programs Biomed 2018;157:179e 90. 4 Azhar B, Patel SR, Holt PJ, Hinchliffe RJ, Thompson MM, Karthikesalingam A. Misdiagnosis of ruptured abdominal aortic aneurysm: systematic review and meta-analysis. J Endovasc Ther 2014;21:568e75. 5 Ali MM, Flahive J, Schanzer A, Simons JP, Aiello FA, Doucet DR, et al. In patients stratified by preoperative risk, endovascular repair of ruptured abdominal aortic aneurysms has a lower in- hospital mortality and morbidity than open repair. J Vasc Surg 2015;61:1399e407. 6 Tacher V, Lin M, Desgranges P, Deux JF, Grünhagen T, Becquemin JP, et al. Image guidance for endovascular repair of complex aortic aneurysms: comparison of two-dimensional and three-dimensional angiography and image fusion. J Vasc Interv Radiol 2013;24:1698e706. 7 McNally MM, Scali ST, Feezor RJ, Neal D, Huber TS, Beck AW. Fig. 3. Surveillance contrast CT scan. Three-dimensional fusion computed tomography decreases radiation exposure, procedure time, and contrast use during fenestrated endovascular aortic repair. J Vasc Surg 2015;61: However, it demands careful consideration of the status of 309e16. the aortic lumen, which cannot be determined by CO2 8 Hertault A, Maurel B, Sobocinski J, Martin Gonzalez T, Le angiography and simple CT alone. Also, IVUS can be Roux M, Azzaoui R, et al. Impact of hybrid rooms with image employed, during aneurysmal aorta procedures, not only to fusion on radiation exposure during endovascular aortic repair. properly size the aortic stent graft but also to reduce the Eur J Vasc Endovasc Surg 2014;48:382e90. amount of medium contrast and radiation exposure.13 9 Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Regrettably, these tools are not available at the study Cohnert T, et al. Editor’s choice e European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the centre. management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg 2019;57:8e93. Conclusion 10 Patel BN, Kapoor BS, Borghei P, Shah NA, Lockhart ME. Carbon EVAR with fusion imaging after non-contrast CT was safe in dioxide as an intravascular imaging agent: Review. Curr Probl a patient with a rAAA. It could be an option in the emer- Diagn Radiol 2011;40:208e17. gency setting. 11 Kerns SR, E Hawkins IF. 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