Effect of direct oral anticoagulant therapy on pulmonary artery clot dissolution in intermediate high-risk pulmonary thromboembolism.

BACKGROUND: Direct oral anticoagulants are the established drugs for treating pulmonary thromboembolism. The advantage of direct oral anticoagulants over conventional therapy for clot lysis and right ventricular unloading in the acute phase remains unclear. This study aimed to evaluate the effect of acute treatment with direct oral anticoagulants on clot dissolution and right ventricular unloading in intermediate high-risk pulmonary thromboembolism. METHODS: Thirty patients with intermediate high-risk pulmonary thromboembolism admitted between November 2012 and December 2018 were included; 21 and 9 were treated with direct oral anticoagulants and conventional therapy, respectively. We compared the efficacy of clot dissolution and right ventricular unloading for intermediate high-risk pulmonary thromboembolism between direct oral anticoagulant and conventional therapy in the acute phase. Efficacy was assessed by computed tomography obstruction index, right/left ventricular ratio, and brain natriuretic peptide levels between baseline and at discharge. RESULTS: Computed tomography obstruction index, right ventricular/left ventricular ratio, and brain natriuretic peptide levels were significantly lower at discharge than at admission in both groups. The rate of improvement in computed tomography obstruction index was significantly higher in the direct oral anticoagulant therapy group than in the conventional therapy group (64 ± 15% vs. 47 ± 16%; p = 0.01). There were no significant differences in the rate of improvement in right ventricular/ left ventricular ratio and brain natriuretic peptide levels between the two groups. CONCLUSIONS: Compared with conventional therapy, direct oral anticoagulants significantly reduced pulmonary artery clot burden conventional therapy in the acute treatment of intermediate high-risk pulmonary thromboembolism.

Very late-onset atrial lead perforation leading to pneumopericardium.

BACKGROUND: Atrial lead perforation may lead to pneumopericardium or pneumothorax within a few days of device implantation. METHODS AND RESULTS: We report a case of atrial lead perforation 6 years after cardiac resynchronization therapy implantation, which resulted in pneumopericardium and pneumothorax. CONCLUSION: Although pneumopericardium caused by atrial lead perforation can spontaneously resolve with conservative treatment, as it did in this case, treatment should be decided based on the patient's general condition and lead performance.

Optimization of null point in Look-Locker images for myocardial late gadolinium enhancement imaging using deep learning and a smartphone.

OBJECTIVES: To determine the optimal inversion time (TI) from Look-Locker scout images using a convolutional neural network (CNN) and to investigate the feasibility of correcting TI using a smartphone. METHODS: In this retrospective study, TI-scout images were extracted using a Look-Locker approach from 1113 consecutive cardiac MR examinations performed between 2017 and 2020 with myocardial late gadolinium enhancement. Reference TI null points were independently determined visually by an experienced radiologist and an experienced cardiologist, and quantitatively measured. A CNN was developed to evaluate deviation of TI from the null point and then implemented in PC and smartphone applications. Images on 4 K or 3-megapixel monitors were captured by a smartphone, and CNN performance on each monitor was determined. Optimal, undercorrection, and overcorrection rates using deep learning on the PC and smartphone were calculated. For patient analysis, TI category differences in pre- and post-correction were evaluated using the TI null point used in late gadolinium enhancement imaging. RESULTS: For PC, 96.4% (772/749) of images were classified as optimal, with under- and overcorrection rates of 1.2% (9/749) and 2.4% (18/749), respectively. For 4 K images, 93.5% (700/749) of images were classified as optimal, with under- and overcorrection rates of 3.9% (29/749) and 2.7% (20/749), respectively. For 3-megapixel images, 89.6% (671/749) of images were classified as optimal, with under- and overcorrection rates of 3.3% (25/749) and 7.0% (53/749), respectively. On patient-based evaluations, subjects classified as within optimal range increased from 72.0% (77/107) to 91.6% (98/107) using the CNN. CONCLUSIONS: Optimizing TI on Look-Locker images was feasible using deep learning and a smartphone. KEY POINTS: • A deep learning model corrected TI-scout images to within optimal null point for LGE imaging. • By capturing the TI-scout image on the monitor with a smartphone, the deviation of the TI from the null point can be immediately determined. • Using this model, TI null points can be set to the same degree as that by an experienced radiological technologist.

Deep Learning-based Post Hoc CT Denoising for Myocardial Delayed Enhancement.

Background To improve myocardial delayed enhancement (MDE) CT, a deep learning (DL)-based post hoc denoising method supervised with averaged MDE CT data was developed. Purpose To assess the image quality of denoised MDE CT images and evaluate their diagnostic performance by using late gadolinium enhancement (LGE) MRI as a reference. Materials and methods MDE CT data obtained by averaging three acquisitions with a single breath hold 5 minutes after the contrast material injection in patients from July 2020 to October 2021 were retrospectively reviewed. Preaveraged images obtained in 100 patients as inputs and averaged images as ground truths were used to supervise a residual dense network (RDN). The original single-shot image, standard averaged image, RDN-denoised original (DLoriginal) image, and RDN-denoised averaged (DLave) image of holdout cases were compared. In 40 patients, the CT value and image noise in the left ventricular cavity and myocardium were assessed. The segmental presence of MDE in the remaining 40 patients who underwent reference LGE MRI was evaluated. The sensitivity, specificity, and accuracy of each type of CT image and the improvement in accuracy achieved with the RDN were assessed using odds ratios (ORs) estimated with the generalized estimation equation. Results Overall, 180 patients (median age, 66 years [IQR, 53-74 years]; 107 men) were included. The RDN reduced image noise to 28% of the original level while maintaining equivalence in the CT values (P < .001 for all). The sensitivity, specificity, and accuracy of the original images were 77.9%, 84.4%, and 82.3%, of the averaged images were 89.7%, 87.9%, and 88.5%, of the DLoriginal images were 93.1%, 87.5%, and 89.3%, and of the DLave images were 95.1%, 93.1%, and 93.8%, respectively. DLoriginal images showed improved accuracy compared with the original images (OR, 1.8 [95% CI: 1.2, 2.9]; P = .011) and DLave images showed improved accuracy compared with the averaged images (OR, 2.0 [95% CI: 1.2, 3.5]; P = .009). Conclusion The proposed denoising network supervised with averaged CT images reduced image noise and improved the diagnostic performance for myocardial delayed enhancement CT. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Vannier and Wang in this issue.

Filtered back projection revisited in low-kilovolt computed tomography angiography: sharp filter kernel enhances visualization of the artery of Adamkiewicz.

PURPOSE: The reliability of assessment of the artery of Adamkiewicz before the aortic repair is highly dependent on the display of the continuity of this artery with the aorta, mainly around the vertebral pedicle, by computed tomography angiography (CTA). We hypothesized that the sharp filter kernel can improve visualization of this continuity of the vessel structure because of its edge enhancement and high-spatial resolution. This study was performed to compare the subjective and objective image quality of spinal CTA reconstructed with sharp and smooth filter kernels. METHODS: We retrospectively reviewed 40 consecutive patients who had undergone 80-kV CTA to detect the artery of Adamkiewicz before aortic repair. We measured the CT number and the contrast-to-noise ratio of the anterior spinal artery to the spinal cord. Furthermore, the continuity of the artery of Adamkiewicz was evaluated using a 3-point scale (2 points, absolute; 0 points, undetectable). RESULTS: CTA with the sharp filter kernel showed a significantly higher CT number and contrast-to-noise ratio of the spinal artery than did CTA with the smooth filter kernel (P < .001 for both). Moreover, the sharp filter kernel showed a significantly higher continuity of the artery of Adamkiewicz with the aorta than did the smooth filter kernel (P < .001). CONCLUSIONS: The sharp filter kernel significantly improved the image quality in low-tube-voltage CTA for the assessment of the artery of Adamkiewicz. Thus, CTA with the sharp filter kernel can generate a high-confidence level in the evaluation of the artery of Adamkiewicz.

Morphological disease progression of combined pulmonary fibrosis and emphysema: comparison with emphysema alone and pulmonary fibrosis alone.

OBJECTIVES: The purpose of this study was to evaluate the differences in 5-year morphological changes among the patients with combined pulmonary fibrosis and emphysema (CPFE), emphysema alone, and fibrosis alone using quantitative computed tomography evaluation. METHODS: This study involved 42 patients with CPFE, 45 patients with emphysema alone, and 35 patients with fibrosis alone who underwent computed tomography scans twice (initial and 5 years after the initial scan). The extent of emphysematous lesions was obtained by calculating the percentage of low attenuation area (%LAA) lower than -950 Hounsfield units. Fibrotic lesion was defined as a high attenuation area (HAA) using thresholds with pixels between 0 and -700 Hounsfield units, and the extent of fibrosis was obtained by calculating the mean percentage of HAA (%HAA). For the quantitative evaluation of the total area of emphysematous change and fibrosis, the percentage of destructed lung area (%DA) was obtained by summing %LAA and %HAA. The 5-year changes of %LAA, %HAA, and %DA were calculated. Differences were evaluated by 1-way analysis of variance, which was followed by the Tukey-Kramer test. RESULTS: The mean change of %LAA was significantly higher in CPFE (7.4% ± 3.8%) than in emphysema alone (P < 0.05). The mean change of %DA was significantly higher in CPFE (12.9% ± 5.8%) than in emphysema alone (4.9% ± 2.8%) and fibrosis alone (7.1% ± 5.7%). CONCLUSIONS: Morphological disease progression in CPFE differed from that in emphysema alone or fibrosis alone. In particular, the increase in emphysematous low-attenuation lesions was significantly higher in CPFE.

Changes in the superior vena cava area during inspiration and expiration in relation to emphysema.

BACKGROUND: In patients with emphysema, increased intrathoracic pressure is closely related to hyperinflation and leads to hemodynamic impairments. Both intrathoracic pressure and hemodynamics such as venous return are affected by the respiratory phase. Therefore, respiratory variations in hemodynamics may be associated with the extent of emphysema that causes increased intrathoracic pressure. The current study was designed to evaluate the relationship between respiratory phasic variations in the area of the superior vena cava (SVC) and the extent of emphysema. METHODS: We measured the SVC area and calculated the ratio of the SVC area in inspiratory and expiratory scans (i/e-SVC ratio) in 101 patients with emphysema who underwent both inspiratory and expiratory CT. The correlation of the i/e-SVC ratio with the extent of emphysema (%LAA) obtained by CT images was evaluated. Multiple linear regression analysis using i/e-SVC ratio as the dependent variable was performed. RESULTS: The i/e-SVC ratio had a significant positive correlation with%LAA (ρ = 0.582, p <0.0001). The i/e-SVC ratio was significantly higher in patients with severe emphysema (0.86 ± 0.13) than in patients with mild-moderate emphysema (0.69 ± 0.13) (p <0.0001). Multiple linear regression analysis showed that%LAA was the only independent predictors of the i/e-SVC ratio (r(2) = 0.471, p = 0.0006). CONCLUSION: Respiratory phasic variations in the SVC area are significantly correlated with the extent of emphysema.

Usefulness of Transesophageal Echocardiography in Diagnosing the Cause of Circulatory Collapse During Reoperation for an Inferior Vena Cava-Left Atrium Shunt After Atrial Septal Defect Closure: A Case Report.

Iatrogenic inferior vena cava (IVC)-left atrium (LA) shunt is a rare complication in atrial septal defect (ASD) surgery, caused by mistaking the Eustachian valve for the lower margin of the ASD. In this report, we describe the case of a 45-year-old woman who experienced circulatory collapse at termination of cardiopulmonary bypass during surgical IVC-LA shunt repair. Transesophageal echocardiography helped identify stenosis between the IVC and the right atrium, caused by a residual original incorrectly placed ASD patch. Removal of most of the patch led to improvement in circulatory failure.

Balloon pulmonary angioplasty for chronic thromboembolic pulmonary disease without pulmonary hypertension.

Balloon pulmonary angioplasty (BPA) is beneficial for patients with chronic thromboembolic pulmonary disease (CTEPD) with pulmonary hypertension (PH). However, the clinical benefit of BPA for the patients with CTEPD without PH remains unknown. In this study, we aimed to evaluate the efficacy, safety, and long-term outcomes of BPA in patients with CTEPD without PH. We retrospectively analyzed the data from 84 CTEPD patients with mean pulmonary artery pressure (mPAP) < 25 mmHg and 39 CTEPD patients with mPAP ≤ 20 mmHg (without PH). Among the 39 patients with CTEPD without PH, 14 underwent BPA (BPA-treated group), and the remaining 25 received no treatment (untreated group). In the patients with CTEPD without PH, BPA led to improvements in symptoms, pulmonary vascular resistance (3.6 ± 1.6 to 2.6 ± 1.1 Wood units, p < 0.001), peak oxygen consumption (16.1 ± 4.0 to 18.8 ± 4.3 mL/kg/min, p = 0.033), minute ventilation versus carbon dioxide production slope (41.4 ± 12.2 to 35.1 ± 6.7, p = 0.026), and mPAP/cardiac output slope (7.0 ± 2.6 to 4.4 ± 2.0 mmHg/L/min, p = 0.004) and facilitated the discontinuation of home oxygenation therapy, with no serious complications. Kaplan-Meier analysis showed no significant difference in all-cause mortality between the untreated and BPA-treated groups. BPA may be a safe treatment option for the patients with CTEPD without PH that can alleviate symptoms, improve exercise capacity, and facilitate weaning from home oxygen therapy. Further prospective randomized trials are needed to confirm these findings.

Feasibility of revascularization after gelatin sponge embolization for hemoptysis during balloon pulmonary angioplasty.

BACKGROUND: Vessel injury is a common complication during balloon pulmonary angioplasty (BPA). For persistent hemoptysis, gelatin sponge embolization (GSE) is considered, but its impact on subsequent perfusion in embolized vessels remains unknown. This study explores the feasibility of revascularization in vessels post-GSE. METHODS: We included 64 vessels from 50 patients with chronic thromboembolic pulmonary hypertension who experienced hemoptysis during BPA in 2012-2023. Twenty-four vessels were treated conservatively (conservative group), while 40 were treated with GSE for persistent hemoptysis or desaturation despite conservative treatment (GSE group). We assessed hemoptysis-related parameters, perfusion of injured vessels pre- and post-treatment, and hemodynamic parameters through multiple BPA sessions. RESULTS: Hemoptysis resolved immediately after the procedure in 67% of patients, including 70% of those in the GSE group, and all cases resolved by the next day. Of 37 embolized vessels, 41% showed spontaneous perfusion improvement in subsequent sessions. BPA was reperformed in 22 embolized vessels, with 86% showing further improvement, resulting in 70% of all embolized vessels finally showing improvement in perfusion. In both groups, clinical and hemodynamic parameters significantly improved after BPA. CONCLUSIONS: Perfusion of embolized vessels improved after GSE, suggesting that GSE is safe for the treatment of severe persistent hemoptysis after conservative treatment.

Laterality of CT-measured hepatic extracellular volume fraction in patients with chronic thromboembolic pulmonary hypertension.

PURPOSE: This study examines the hepatic extracellular volume fraction (ECV) disparity between the left and right lobes (ECV_left and ECV_right) in patients with chronic thromboembolic pulmonary hypertension (CTEPH), its association with right heart catheterization (RHC) metrics, and with intolerance to increased pulmonary hypertension (PH)-targeted medication dosages. METHODS: We retrospectively analyzed 72 CTEPH-diagnosed patients who underwent equilibrium-phase abdominal dual-energy CT (DECT) and RHC. Hepatic ECVs, derived from DECT's iodine maps using circular regions of interest in the liver and aorta, were correlated with RHC parameters via Spearman's rank correlation and lobe differences through the Wilcoxon signed-rank test. Logistic regression assessed cases with ECV_left exceeding ECV_right by > 0.05, while receiver operating characteristic curve analysis gauged ECVs' predictive power for medication intolerance. RESULTS: Of the 72 patients (57 females; median age 69), ECV_total (0.24, IQR 0.20-0.27) moderately correlated with RHC parameters (rs = 0.28, -0.24, 0.3 for mean pulmonary arterial pressure, cardiac index [CI], and pulmonary vascular resistance index, respectively). ECV_left significantly surpassed ECV_right (0.25 vs. 0.22, p < 0.001), with a greater ECV_left by > 0.05 indicating notably lower CI (p < 0.001). In 27 patients on PH medication, ECV_left effectively predicted medication intolerance (AUC = 0.84). CONCLUSION: In CTEPH patients, hepatic ECV correlated with RHC metrics, where elevated left lobe ECV suggested reduced CI and potential medication intolerance.

Deep Learning-based Post Hoc CT Denoising for the Coronary Perivascular Fat Attenuation Index.

RATIONALE AND OBJECTIVES: Coronary inflammation related to high-risk hemorrhagic plaques can be captured by the perivascular fat attenuation index (FAI) using coronary computed tomography angiography (CCTA). Since the FAI is susceptible to image noise, we believe deep learning (DL)-based post hoc noise reduction can improve diagnostic capability. We aimed to assess the diagnostic performance of the FAI in DL-based denoised high-fidelity CCTA images compared with coronary plaque magnetic resonance imaging (MRI) delivered high-intensity hemorrhagic plaques (HIPs). MATERIALS AND METHODS: We retrospectively reviewed 43 patients who underwent CCTA and coronary plaque MRI. We generated high-fidelity CCTA images by denoising the standard CCTA images using a residual dense network that supervised the denoising task by averaging three cardiac phases with nonrigid registration. We measured the FAIs as the mean CT value of all voxels (range of -190 to -30 HU) located within a radial distance from the outer proximal right coronary artery wall. The diagnostic reference standard was defined as HIPs (high-risk hemorrhagic plaques) using MRI. The diagnostic performance of the FAI in the original and denoised images was assessed using receiver operating characteristic curves. RESULTS: Of 43 patients, 13 had HIPs. The denoised CCTA improved the area under the curve (0.89 [95% confidence interval (CI) 0.78-0.99]) of the FAI compared with that in the original image (0.77 [95% CI, 0.62-0.91], p = 0.008). The optimal cutoff value for predicting HIPs in denoised CCTA was -69 HU with 0.85 (11/13) sensitivity, 0.79 (25/30) specificity, and 0.80 (36/43) accuracy. CONCLUSION: DL-based denoised high-fidelity CCTA improved the AUC and specificity of the FAI for predicting HIPs.

Image Quality of Submillimeter High-Spatial-Resolution 2D Late Gadolinium-enhanced Images in Cardiac MRI: A Feasibility Study.

Purpose: To evaluate the image quality of high-spatial-resolution two-dimensional (2D) late gadolinium enhancement (LGE) cardiac MRI compared with conventional normal-resolution LGE MRI. Materials and Methods: This prospective study included participants suspected of having cardiomyopathy who underwent cardiac MRI between March 2021 and December 2021. Normal-resolution and high-resolution 2D LGE sequences (inversion recovery [IR] and phase-sensitive inversion recovery [PSIR]) were performed at 3 T. Resolution was compared between normal-resolution and high-resolution images obtained in a quality assurance phantom. In vivo image quality and resolution were evaluated qualitatively using a five-point scoring system. Receiver operating characteristic curve analysis was used for LGE detection performance. Border sharpness was assessed with profile curve measurement. The contrast-to-noise ratio (CNR) between hyperenhancement and remote myocardium and LGE detection performance were calculated using normal-resolution IR images as the reference. Results: In total, 120 participants were evaluated (mean age, 56 years ± 17 [SD]; 72 men). Features smaller than 1 mm were detectable only on high-resolution images of the phantom. In vivo, the image resolution score with high-resolution LGE was 4.14-4.24, which was higher than the normal-resolution LGE reference score of 2.99 (P < .05). Border sharpness was higher in high-resolution images (P < .001). Receiver operating characteristic curve analysis revealed no evidence of a difference in LGE detection between normal-resolution and high-resolution images. There was also no evidence of a change in CNR of LGE in IR and PSIR magnitude compared with reference images. Conclusion: Comparison of image quality in 2D high-resolution and normal-resolution LGE cardiac MRI demonstrated the highest resolution for high-resolution IR and high-resolution PSIR magnitude sequences.Keywords: Cartilage Imaging, MRI, Cardiac, Heart, Imaging Sequences, Comparative Studies Supplemental material is available for this article. © RSNA, 2022.

Three-dimensional computed tomography is effective in diagnosing uterine arterial pseudoaneurysm, a cause of secondary postpartum hemorrhage: A case report.

Uterine artery pseudoaneurysm is a rare cause of secondary postpartum hemorrhage. Herein, we report a case of uterine artery pseudoaneurysm, with postpartum hemorrhage commencing 22 days after uncomplicated vaginal delivery. Intermittent bleeding occurred during conservative observation. Transvaginal ultrasound color Doppler imaging revealed swollen vascular structures that suggested arteriovenous malformations, and a saccular dilatation of blood vessels. However, it was insufficient to definitively diagnose the condition as pseudoaneurysm. Meanwhile, the three-dimensional computed tomography angiogram was effective in demonstrating a pseudoaneurysm in the uterus, and an absent early venous return sign, leading to the final diagnosis of a pseudoaneurysm. The patient was successfully treated with transarterial embolization using gelatin sponge pledgets. No bleeding or recurrence of the pseudoaneurysm was observed 2 months after embolization.

A Successful Endovascular Technique for Complete False Lumen Thrombosis in Chronic Abdominal Aortic Dissection.

A 66-year-old man presented with an enlarging abdominal aorta false lumen, after type A aortic dissection repair. Residual entries were located at the left renal artery, abdominal aorta, and left external iliac artery. The patient underwent endovascular aortic repair with left renal artery stenting to close the entries. Completion aortography showed no false lumen flow without an endoleak, and contrast-enhanced computed tomography 1 month after the procedure demonstrated complete false lumen thrombosis. A total endovascular approach is possible for abdominal aneurysmal dilation in chronic aortic dissection when all entries can be closed using a one-stage procedure with stent grafts and/or branch stenting.

Prognostic value of right ventricular native T1 mapping in pulmonary arterial hypertension.

BACKGROUND: Right ventricular function is an important prognostic marker for pulmonary arterial hypertension. Native T1 mapping using cardiovascular magnetic resonance imaging can characterize the myocardium, but accumulating evidence indicates that T1 values of the septum or ventricular insertion points do not have predictive potential in pulmonary arterial hypertension. We aimed to elucidate whether native T1 values of the right ventricular free wall (RVT1) can predict poor outcomes in patients with pulmonary arterial hypertension. METHODS: This retrospective study included 30 patients with pulmonary arterial hypertension (median age, 45 years; mean pulmonary artery pressure, 41±13 mmHg) and 16 healthy controls (median age, 43 years) who underwent native T1 mapping. RVT1 was obtained from the inferior right ventricular free wall during end systole. RESULTS: Patients with pulmonary arterial hypertension had significantly higher native RVT1 than did controls (1384±74 vs. 1217±57 ms, p<0.001). Compared with T1 values of the septum or ventricular insertion points, RVT1 correlated better with the effective right ventricular elastance index (R = -0.53, p = 0.003), ventricular-arterial uncoupling (R = 0.46, p = 0.013), and serum brain natriuretic peptide levels (R = 0.65, p<0.001). Moreover, the baseline RVT1 was an accurate predictor of the reduced right ventricular ejection fraction at the 12-month follow-up (delta -3%). RVT1 was independently associated with composite events of death or hospitalization from any cause (hazard ratio = 1.02, p = 0.002). CONCLUSIONS: RVT1 was predictive of right ventricular performance and outcomes in patients with pulmonary arterial hypertension. Thus, native T1 mapping in the right ventricular free wall may be an effective prognostic method for pulmonary arterial hypertension.

Clinical Utility of Coil in Plug Method (CIP) for Internal Iliac Artery Embolization during Endovascular Aortic Aneurysm Repair.

Objective: To evaluate the clinical utility of the coil in plug (CIP) method in internal iliac artery (IIA) embolization during endovascular aortic aneurysm repair (EVAR) compared to conventional coil embolization (CCE). Material and Methods: From July to December 2018, 10 patients who underwent IIA embolization during EVAR were divided into CIP (n=5) and CCE (n=5) groups. In the CIP technique, the AVP-1 with a size more than 30%-50% of that of the embolized IIA diameter was used. The AVP-1 was deployed in the IIA. Before detachment of the AVP-1, a 2.2-F micro catheter was inserted through the 6-F delivery guiding sheath, and entered the plug. The AVP-1 was then packed with hydrogel micro coils. We compared number of coils used, embolization length, embolization time, volume embolization ratio, and embolic material cost between the groups. Results: The CIP method achieved shorter embolization length with fewer coils used compared to CCE. The CIP method decreased the cost of total embolic materials. Conclusion: The CIP method can achieve shorter embolization length with fewer coils used compared to CCE.

Stent-Graft Relining by Combined Aortic Cuff with Double-D Technique for Type IIIb or V Endoleak after Endovascular Aneurysm Repair: A Case Report.

We report the case of a 83-year-old man with aneurysmal sac enlargement after endovascular aneurysm repair for an abdominal aortic aneurysm, despite no overt endoleak (EL) detected on imaging. Occult type II EL was suspected, and treatment was performed. However, the aneurysm continued to enlarge. Thus, we diagnose with type V EL as exclusion diagnosis. We combined an aortic cuff and stent-graft leg to cover the initially inserted stent graft, as a diagnostic treatment for unrefined type IIIb EL. Subsequently, the aneurysm diameter decreased. This technique and concept may be effective for type V EL, which may include another type occult EL.