Photon Counting Computed Tomography in Rectal Cancer: Associations Between Iodine Concentration, Histopathology and Treatment Response: A Pilot Study.

RATIONALE AND OBJECTIVES: Common computed tomography (CT) investigation plays a limited role in characterizing and assessing the response of rectal cancer (RC) to neoadjuvant radiochemotherapy (NARC). Photon counting computed tomography (PCCT) improves the imaging quality and can provide multiparametric spectral image information including iodine concentration (IC). Our purpose was to analyze associations between IC and histopathology in RC and to evaluate the role of IC in response prediction to NARC. MATERIALS AND METHODS: Overall, 41 patients were included into the study, 14 women and 27 men, mean age, 65.5 years. PCCT in a portal venous phase of the abdomen was performed. In every case, a polygonal region of interest (ROI) was manually drawn on iodine maps. Normalized IC (NIC) was also calculated. Tumor stage, grade, lymphovascular invasion, circumferential resection margin, and tumor markers were analyzed. Tumor regression grade (absence/presence of tumor cells) after NARC was analyzed. NIC values in groups were compared to Mann-Whitney-U tests. Sensitivity, specificity, and area under the curve values were calculated. Intraclass correlation coefficient (ICC) was calculated. RESULTS: ICC was 0.93, 95%CI= (0.88; 0.96). Tumors with lymphovascular invasion showed higher NIC values in comparison to those without (p = 0.04). Tumors with response grade 2-4 showed higher pretreatment NIC values in comparison to lesions with response grade 0-1 (p = 0.01). A NIC value of 0.36 and higher can predict response grade 2-4 (sensitivity, 73.9%; specificity, 91.7%; area under the curve, 0.85). CONCLUSION: NIC values showed an excellent interreader agreement in RC. NIC can predict treatment response to NARC.

[Current CT developments in imaging of pancreatic diseases]. / Aktuelle CT-Entwicklungen für die Diagnostik von Erkrankungen des Pankreas.

BACKGROUND: Diseases of the pancreas are often diagnosed late and can have fatal consequences for patients. PURPOSE: Current computed tomography (CT) developments in imaging of pancreatic diseases. MATERIALS AND METHODS: Evaluation of numerous studies, especially considering modern CT techniques such as dual-energy CT and photon-counting CT but also artificial intelligence (AI) algorithms for disease detection. RESULTS: Spectral imaging using dual-energy CT and photon-counting CT offers numerous advantages in the detection of pancreatic disease and can thus improve diagnostic performance but also provide additional information on any therapeutic response. Likewise, advances in the development of AI algorithms are improving diagnostic performance. CONCLUSION: In the future, we can expect increasingly improved detection of pancreatic diseases, thereby enabling patients to be treated more quickly, which will consequently result in improved outcomes.

Dual-layer dual-energy CT-derived pulmonary perfusion for the differentiation of acute pulmonary embolism and chronic thromboembolic pulmonary hypertension.

OBJECTIVES: To evaluate dual-layer dual-energy computed tomography (dlDECT)-derived pulmonary perfusion maps for differentiation between acute pulmonary embolism (PE) and chronic thromboembolic pulmonary hypertension (CTEPH). METHODS: This retrospective study included 131 patients (57 patients with acute PE, 52 CTEPH, 22 controls), who underwent CT pulmonary angiography on a dlDECT. Normal and malperfused areas of lung parenchyma were semiautomatically contoured using iodine density overlay (IDO) maps. First-order histogram features of normal and malperfused lung tissue were extracted. Iodine density (ID) was normalized to the mean pulmonary artery (MPA) and the left atrium (LA). Furthermore, morphological imaging features for both acute and chronic PE, as well as the combination of histogram and morphological imaging features, were evaluated. RESULTS: In acute PE, normal perfused lung areas showed a higher mean and peak iodine uptake normalized to the MPA than in CTEPH (both p < 0.001). After normalizing mean ID in perfusion defects to the LA, patients with acute PE had a reduced average perfusion (IDmean,LA) compared to both CTEPH patients and controls (p < 0.001 for both). IDmean,LA allowed for a differentiation between acute PE and CTEPH with moderate accuracy (AUC: 0.72, sensitivity 74%, specificity 64%), resulting in a PPV and NPV for CTEPH of 64% and 70%. Combining IDmean,LA in the malperfused areas with the diameter of the MPA (MPAdia) significantly increased its ability to differentiate between acute PE and CTEPH (sole MPAdia: AUC: 0.76, 95%-CI: 0.68-0.85 vs. MPAdia + 256.3 * IDmean,LA - 40.0: AUC: 0.82, 95%-CI: 0.74-0.90, p = 0.04). CONCLUSION: dlDECT enables quantification and characterization of pulmonary perfusion patterns in acute PE and CTEPH. Although these lack precision when used as a standalone criterion, when combined with morphological CT parameters, they hold potential to enhance differentiation between the two diseases. CLINICAL RELEVANCE STATEMENT: Differentiating between acute PE and CTEPH based on morphological CT parameters is challenging, often leading to a delay in CTEPH diagnosis. By revealing distinct pulmonary perfusion patterns in both entities, dlDECT may facilitate timely diagnosis of CTEPH, ultimately improving clinical management. KEY POINTS: • Morphological imaging parameters derived from CT pulmonary angiography to distinguish between acute pulmonary embolism and chronic thromboembolic pulmonary hypertension lack diagnostic accuracy. • Dual-layer dual-energy CT reveals different pulmonary perfusion patterns between acute pulmonary embolism and chronic thromboembolic pulmonary hypertension. • The identified parameters yield potential to enable more timely identification of patients with chronic thromboembolic pulmonary hypertension.

Metal artifact reduction in patients with total hip replacements: evaluation of clinical photon counting CT using virtual monoenergetic images.

OBJECTIVES: To investigate photon-counting CT (PCCT)-derived virtual monoenergetic images (VMI) for artifact reduction in patients with unilateral total hip replacements (THR). METHODS: Forty-two patients with THR and portal-venous phase PCCT of the abdomen and pelvis were retrospectively included. For the quantitative analysis, region of interest (ROI)-based measurements of hypodense and hyperdense artifacts, as well as of artifact-impaired bone and the urinary bladder, were conducted, and corrected attenuation and image noise were calculated as the difference of attenuation and noise between artifact-impaired and normal tissue. Two radiologists qualitatively evaluated artifact extent, bone assessment, organ assessment, and iliac vessel assessment using 5-point Likert scales. RESULTS: VMI110keV yielded a significant reduction of hypo- and hyperdense artifacts compared to conventional polyenergetic images (CI) and the corrected attenuation closest to 0, indicating best possible artifact reduction (hypodense artifacts: CI: 237.8 ± 71.4 HU, VMI110keV: 8.5 ± 122.5 HU; p < 0.05; hyperdense artifacts: CI: 240.6 ± 40.8 HU vs. VMI110keV: 13.0 ± 110.4 HU; p < 0.05). VMI110keV concordantly provided best artifact reduction in the bone and bladder as well as the lowest corrected image noise. In the qualitative assessment, VMI110keV received the best ratings for artifact extent (CI: 2 (1-3), VMI110keV: 3 (2-4); p < 0.05) and bone assessment (CI: 3 (1-4), VMI110keV: 4 (2-5); p < 0.05), whereas organ and iliac vessel assessments were rated highest in CI and VMI70keV. CONCLUSIONS: PCCT-derived VMI effectively reduce artifacts from THR and thereby improve assessability of circumjacent bone tissue. VMI110keV yielded optimal artifact reduction without overcorrection, yet organ and vessel assessments at that energy level and higher were impaired by loss of contrast. CLINICAL RELEVANCE STATEMENT: PCCT-enabled artifact reduction is a feasible method for improving assessability of the pelvis in patients with total hip replacements at clinical routine imaging. KEY POINTS: • Photon-counting CT-derived virtual monoenergetic images at 110 keV yielded best reduction of hyper- and hypodense artifacts, whereas higher energy levels resulted in artifact overcorrection. • The qualitative artifact extent was reduced best in virtual monoenergetic images at 110 keV, facilitating an improved assessment of the circumjacent bone. • Despite significant artifact reduction, assessment of pelvic organs as well as vessels did not profit from energy levels higher than 70 keV, due to the decline in image contrast.

Structured Reporting in Cross-Sectional Imaging of the Heart: Reporting Templates for CMR Imaging of Ischemia and Myocardial Viability and for Cardiac CT Imaging of Coronary Heart Disease and TAVI Planning. / Strukturierte Befundung in der Schnittbilddiagnostik des Herzens: Befundvorlagen für die Herz-MRT bezüglich Ischämie- und Vitalitätsdiagnostik sowie für die Herz-CT bezüglich Koronardiagnostik und Planung vor TAVI.

BACKGROUND: Structured reporting allows a high grade of standardization and thus a safe and unequivocal report communication. In the past years, the radiological societies have started several initiatives to base radiological reports on structured reporting rather than free text reporting. METHODS: Upon invitation of the working group for Cardiovascular Imaging of the German Society of Radiology, in 2018 an interdisciplinary group of Radiologists, Cardiologists, Pediatric Cardiologists and Cardiothoracic surgeons -all experts on the field of cardiovascular MR and CT imaging- met for interdisciplinary consensus meetings at the University Hospital Cologne. The aim of these meetings was to develop and consent templates for structured reporting in cardiac MR and CT of various cardiovascular diseases. RESULTS: Two templates for structured reporting of CMR in ischemia imaging and vitality imaging and two templates for structured reporting of CT imaging for planning Transcatheter Aortic Valve Implantation (TAVI; pre-TAVI-CT) and coronary CT were discussed, consented and transferred to a HTML 5/IHR MRRT compatible format. The templates were made available for free use on the website www.befundung.drg.de. CONCLUSION: This paper suggests consented templates in German language for the structured reporting of cross-sectional CMR imaging of ischemia and vitality as well as reporting of CT imaging pre-TAVI and coronary CT. The implementation of these templates is aimed at providing a constant level of high reporting quality and increasing the efficiency of report generation as well as a clinically based communication of imaging results. KEY POINTS: · Structured reporting offers a constant level of high reporting quality and increases the efficiency of report generation as well as a clinically based communication of imaging results.. · For the first time templates in German language for the structured reporting of CMR imaging of ischemia and vitality and CT imaging pre-TAVI and coronary CT are reported.. · These templates will be made available on the website www.befundung.drg.de and can be commented via strukturierte-befundung@drg.de.. ZITIERWEISE: · Soschynski M, Bunck AC, Beer M et al. Structured Reporting in Cross-Sectional Imaging of the Heart: Reporting Templates for CMR Imaging of Ischemia and Myocardial Viability and for Cardiac CT Imaging of Coronary Heart Disease and TAVI Planning. Fortschr Röntgenstr 2023; 195: 293 - 296.

Photon-counting CT Material Decomposition: Initial Experience in Assessing Adrenal Adenoma.

See also the editorial by Pourmorteza in this issue.

Mechanical thrombectomy using the Nimbus stent-retriever - initial experiences in a single-center observational study.

BACKGROUND: The Nimbus stent-retriever (NSR) was developed for mechanical thrombectomy of wall-adherent thrombi in cerebral arteries. It features a novel geometry with a proximal spiral section and a distal barrel section. The new device is designed to retrieve tough clots with a micro-clamping technique. In the first case series reporting on the NSR, we share our initial experience about the first 12 treated cases. METHODS: In total, 12 patients (5 men, 7 women; mean age 78 years) with occlusion of the internal carotid artery or the middle cerebral artery (M1 or M2 segment) were treated with the NSR, 11 after unsuccessful recanalization attempts with conventional stent-retrievers or aspiration thrombectomy. RESULTS: Retrieving maneuvers with the NSR recovered a thrombus in 7 patients (58%), of which 6 resulted in vessel recanalization mTICI ≥ 2b. Successful recanalization improved the mTICI score by a median of 3 points. In 5 of 7 cases, this required only one thrombectomy maneuver. In 5 cases, no improvement of recanalization could be achieved with the NSR (1-3 attempts). No NSR-related complications occurred in this case series. CONCLUSIONS: In our initial experience, the NSR appeared to be a safe and effective second-line stent-retriever after unsuccessful MT with conventional stent-retrievers or aspiration thrombectomy allowing for mTICI ≥ 2b rescue thrombectomy in ab 50% of cases. No NSR associated complications occurred in our case series.

[Complications and Management of Complications After Resection and Reconstruction of the Esophagus]. / Komplikationen und Komplikationsmanagement nach Resektion und Rekonstruktion der Speiseröhre.

Complications and Management of Complications After Resection and Reconstruction of the Esophagus Abstract. A curative therapy of advanced esophagus carcinoma is primarily made possible by radical esophagectomy with lymphadenectomy. Impressive advances in the surgical techniques of esophageal surgery through minimally invasive and robotic oesophagectomy have been made in the last two decades. The perioperative management with prehabilitation, PDK application, early mobilization and early food intake also contributed significantly to a reduction in complications. However, esophageal surgery is fraught with complications. Anastomotic leakage is the most common technical-surgical complication. The rate is approximately 10-16%, independent of the technique and procedure. In addition to an experienced, subtle, atraumatic and rapid surgical technique, early detection (clinical, endoscopic, radiological) and adequate, interdisciplinary management of perioperative complications in resecting esophageal surgery are the key to increasing the safety of these complex interventions. The treatment of the complications includes conservative, interventional and surgical measures. In the last few decades, there has been a radical change from once exclusively surgical revisions with a high degree of invasiveness and a poor outcome to today's mostly conservative-interventional management with little patient burden and - in centers with the appropriate expertise - good results.

[State of the Art Diagnostics of the Esophagus]. / State of the Art Diagnostik des Ösophagus.

State of the Art Diagnostics of the Esophagus Abstract. Modern diagnostics of the esophagus is highly technical. It mainly includes endoscopic, radiological, nuclear medicine, functional and electrochemical examinations. Diagnostic tools for esophageal disorders involve esophagogastroduodenoscopies with chromoendoscopy, manometric and pH-impedance catheters as well as radiological techniques, such as CT, MRI or PET-CTs. The patient's history including the main clinical symptoms such as heartburn or dysphagia, and the physical examination will determine the choice and order of subsequent examinations. The esophagogastroduodenoscopy is one of the most important diagnostic tools and has a very low complication rate. During esophagogastroduodenoscopy biopsies, chromoendoscopy or therapeutic interventions can be performed. Endosonography is essential for the staging of esophageal cancer and accuracy can be improved by endosonographically guided biopsies. A CT scan completes the tumor staging and is essential to search for metastases. For motility disorders high resolution manometry is the gold standard which can be supplemented with esophagus barium swallow exams. pH-impedance catheters can be used for diagnosis of reflux. MRI swallow exams are predominantly applied in clinical studies but may be more frequently used in the future.

[Peracute Diseases of the Esophagus - Bleeding from Esophageal Varices, Esophageal Varices]. / Perakute Erkrankungen des Ösophagus.

Peracute Diseases of the Esophagus - Bleeding from Esophageal Varices, Esophageal Varices Abstract. Due to a permanently increased portal venous pressure - usually due to infectious or ethyltoxic liver cirrhosis - varices can form in the lower esophagus due to expansion of the submucosal venous plexus. Acute bleeding from the esophageal varices is a life-threatening situation. In therapy, a distinction is made between primary prophylaxis of bleeding, control of acute bleeding and prevention of recurrent bleeding. In addition to non-selective betablockers, the transjugular intrahepatic portosystemic shunt (TIPS), which is introduced radiologically, plays a decisive role today, especially in the prophylaxis of recurrent bleeding. Apart from special indications, surgical shunt procedures are only of historical value. In liver cirrhosis patients, liver transplantation represents a causal treatment and lasting cure for esophageal varices.

Spectral Detector CT-Derived Pulmonary Perfusion Maps and Pulmonary Parenchyma Characteristics for the Semiautomated Classification of Pulmonary Hypertension.

Objectives: To evaluate the usefulness of spectral detector CT (SDCT)-derived pulmonary perfusion maps and pulmonary parenchyma characteristics for the semiautomated classification of pulmonary hypertension (PH). Methods: A total of 162 consecutive patients with right heart catheter (RHC)-proven PH of different aetiologies as defined by the current ESC/ERS guidelines who underwent CT pulmonary angiography (CTPA) on SDCT and 20 patients with an invasive rule-out of PH were included in this retrospective study. Semiautomatic lung segmentation into normal and malperfused areas based on iodine density (ID) as well as automatic, virtual non-contrast-based emphysema quantification were performed. Corresponding volumes, histogram features and the ID SkewnessPerfDef-Emphysema-Index (δ-index) accounting for the ratio of ID distribution in malperfused lung areas and the proportion of emphysematous lung parenchyma were computed and compared between groups. Results: Patients with PH showed a significantly greater extent of malperfused lung areas as well as stronger and more homogenous perfusion defects. In group 3 and 4 patients, ID skewness revealed a significantly more homogenous ID distribution in perfusion defects than in all other subgroups. The δ-index allowed for further subclassification of subgroups 3 and 4 (p < 0.001), identifying patients with chronic thromboembolic PH (CTEPH, subgroup 4) with high accuracy (AUC: 0.92, 95%-CI, 0.85-0.99). Conclusion: Abnormal pulmonary perfusion in PH can be detected and quantified by semiautomated SDCT-based pulmonary perfusion maps. ID skewness in malperfused lung areas, and the δ-index allow for a classification of PH subgroups, identifying groups 3 and 4 patients with high accuracy, independent of reader expertise.

Vacuum-Assisted Suction Drainage as a Successful Treatment Option for Postoperative Symptomatic Lymphoceles.

PURPOSE: Lymphoceles often occur within several weeks or even months after surgery. Mostly asymptomatic and therefore undiagnosed, they may be self-healing without any treatment. A small percentage of postoperative lymphoceles are symptomatic with significant pain, infection, or compression of vital structures, thus requiring intervention. Many different treatment options are described in the literature, like drainage with or without sclerotherapy, embolization of lymph vessels, and surgical approaches with laparoscopy or laparotomy. Inspired by reports stating that postoperative suction drainage can prevent the formation of lymphoceles, we developed a simple protocol for vacuum-assisted drainage of symptomatic lymphoceles, which proved to be successful and which we would therefore like to present. MATERIALS AND METHOD: Between 2008 and 2020, 35 patients with symptomatic postoperative lymphoceles were treated with vacuum-assisted suction drainage (in total 39 lymphoceles). The surgery that caused lymphocele formation had been performed between 8 and 572 days before. All lymphoceles were diagnosed based on biochemical and cytologic findings in aspirated fluid. The clinical and imaging data were collected and retrospectively analyzed. RESULTS: In total, 43 suction drainage catheters were inserted under CT guidance. The technical success rate was 100 %. One patient died of severe preexisting pulmonary embolism, sepsis, and poor conditions (non-procedure-related death). In 94.8 % of symptomatic lymphoceles, healing and total disappearance could be achieved. 4 lymphoceles had a relapse or dislocation of the drainage catheter and needed a second drainage procedure. Two lymphoceles needed further surgery. The complication rate of the procedure was 4.6 % (2/43, minor complications). The median indwelling time of a suction drainage catheter was 8-9 days (range: 1-30 days). CONCLUSION: The positive effects of negative pressure therapy in local wound therapy have been investigated for a long time. These positive effects also seem to have an impact on suction drainage of symptomatic lymphoceles with a high cure rate. KEY POINTS: · Suction drainage of lymphoceles is an easy and successful method to cure symptomatic lymphoceles at various locations.. · We believe this to be due to the induction of cavity collapse and surface adherence.. · In most cases rapid clinical improvement could be obtained.. CITATION FORMAT: · Franke M, Saager C, Kröger J et al. Vacuum-Assisted Suction Drainage as a Successful Treatment Option for Postoperative Symptomatic Lymphoceles. Fortschr Röntgenstr 2022; 194: 384 - 390.

Structured Reporting of Solid and Cystic Pancreatic Lesions in CT and MRI: Consensus-Based Structured Report Templates of the German Society of Radiology (DRG). / Strukturierte Befundung von soliden und zystischen Pankreasläsionen im CT und MRT: Konsensus-basierte Befundvorlagen der Deutschen Röntgengesellschaft (DRG).

BACKGROUND: Radiological reports of pancreatic lesions are currently widely formulated as free texts. However, for optimal characterization, staging and operation planning, a wide range of information is required but is sometimes not captured comprehensively. Structured reporting offers the potential for improvement in terms of completeness, reproducibility and clarity of interdisciplinary communication. METHOD: Interdisciplinary consensus finding of structured report templates for solid and cystic pancreatic tumors in computed tomography (CT) and magnetic resonance imaging (MRI) with representatives of the German Society of Radiology (DRG), German Society for General and Visceral Surgery (DGAV), working group Oncological Imaging (ABO) of the German Cancer Society (DKG) and other radiologists, oncologists and surgeons. RESULTS: Among experts in the field of pancreatic imaging, oncology and pancreatic surgery, as well as in a public online survey, structured report templates were developed by consensus. These templates are available on the DRG homepage under www.befundung.drg.de and will be regularly revised to the current state of scientific knowledge by the participating specialist societies and responsible working groups. CONCLUSION: This article presents structured report templates for solid and cystic pancreatic tumors to improve clinical staging (cTNM, ycTNM) in everyday radiology. KEY POINTS: · Structured report templates offer the potential of optimized radiological reporting with regard to completeness, reproducibility and differential diagnosis.. · This article presents consensus-based, structured reports for solid and cystic pancreatic lesions in CT and MRI.. · These structured reports are available open source on the homepage of the German Society of Radiology (DRG) under www.befundung.drg.de.. CITATION FORMAT: · Persigehl T, Baumhauer M, Baeßler B et al. Structured Reporting of Solid and Cystic Pancreatic Lesions in CT and MRI: Consensus-Based Structured Report Templates of the German Society of Radiology (DRG). Fortschr Röntgenstr 2020; 192: 641 - 655.

Structured Reporting in Cross-Sectional Imaging of the Heart: Reporting Templates for CMR Imaging of Cardiomyopathies (Myocarditis, Dilated Cardiomyopathy, Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Siderosis). / Strukturierte Befundung in der Schnittbilddiagnostik des Herzens: Befundvorlagen für die MRT bei Kardiomyopathien (Myokarditis, dilatative Kardiomyopathie, hypertrophe Kardiomyopathie, arrhythmogene rechtsventrikuläre Kardiomyopathie und Siderose).

BACKROUND: Structured reports have numerous benefits through standardizing the way imaging findings are reported and communicated. Nevertheless, the adoption of structured reports in everyday radiological practice is still limited. In view of the irrefutable benefits, various national and international radiological societies have started initiatives which aim at promoting a broader use of structured reports. Up to now, no consented templates in German language existed for the reporting of cross-sectional imaging studies of the heart. METHOD: Upon invitation of the working group for Cardiovascular Imaging of the German Society of Radiology a panel of radiologists, cardiologists, pediatric cardiologists and cardiothoracic surgeons, experts on the field of cardiovascular imaging and structured reporting, met for two interdisciplinary consensus meetings at the University Hospital Cologne in 2018. The aim of these meetings was to develop and agree on templates for the reporting of MR and CT studies of various cardiovascular disease entities. RESULTS: During the meetings the panel of experts developed and reached consensus on 11 different templates for the structured reporting of the following: myocarditis, dilated cardiomyopathy, hypertrophic (obstructive) cardiomyopathy, arrythmogenic right ventricular cardiomyopathy, siderosis, ischemia and vitality imaging, tetralogy of Fallot, aortic coarctation, coronary CT and CT for Transcatheter Aortic Valve Implantation (TAVI) planning. The first five templates are presented in this publication and are currently being transferred to a HTML 5/IHR MRRT compatible format. Subsequently, the templates will be made available for free use on the website www.befundung.drg.de. CONCLUSION: For the first time, consented templates in German language for the structured reporting of cross-sectional imaging studies of the heart are presented. These templates are aimed at providing a constant level of high reporting quality and increasing the efficiency of the generation and communication of imaging reports. KEY POINTS: · Structured reporting offers numerous benefits by standardizing generation and communication of imaging reports.. · For the first time templates in German language for the structured reporting of CMR imaging studies of cardiomyopathies are presented. · These templates will be made available on the website www.befundung.drg.de and can be commented via agit-sr@googlegroups.com.. CITATION FORMAT: · Bunck AC, Baeßler B, Ritter C et al. Structured Reporting in Cross-Sectional Imaging of the Heart: Reporting Templates for CMR Imaging of Cardiomyopathies (Myocarditis, Dilated Cardiomyopathy, Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular cardiomyopathy and Siderosis). Fortschr Röntgenstr 2020; 192: 27 - 37.

A Shorter Aortic Arch Sealing Ring (< 10 mm) Distal to the Most Distal Chimney Seems to Be an Additional Important Factor Contributing to a Gutter Endoleak in Aortic Arch TEVAR.

BACKGROUND: The aim of the present study was to define the possible anatomical and technical parameter that might predict the occurrence of gutter endoleak or type Ia endoleak (EL Ia) in patients treated with the chimney graft (CG) technique for the brachiocephalic trunk (BCT) and left common carotid artery (LCCA) due to aortic arch pathologies. METHODS: We reviewed our institutional endovascular aortic database of patients, who between 2010 and 2018 had undergone thoracic endovascular aortic repair (TEVAR) with chimney graft technique (ChTEVAR) as a debranching method of the supraaortic arteries. RESULTS: ChTEVAR was performed in 45 patients of whom a chimney in both the LCCA and the BCT was used in 32 patients, only in the LCCA in twelve patients, and only in the BCT in one patient. Eight patients (17.8%) had an EL Ia (based on postoperative computed tomography angiography). No late EL Ia was detected during the follow-up period. All patients with a postoperative EL Ia received 2 CGs with one each for the BCT, and LCCA had either no or a sealing ring distal to the most distal chimney of less than 10 mm versus patients with a longer sealing zone (P = 0.043). Patients with an endoleak did not differ from those without endoleak with respect to stent-graft oversizing, the diameter of the proximal and distal landing zones, or the aortic diameter directly proximal to the pathology. CONCLUSIONS: A sealing ring distal to the most distal chimney of more than 10 mm seems to be associated with a reduced risk of an EL Ia. The relatively few patients and the single-center nature require larger studies to verify the present results.