Ultrasound-guided foam sclerotherapy as a therapeutic modality in venous ulceration.

OBJECTIVES: The objective of this systematic review and meta-analysis was to evaluate rates of ulcer healing following ultrasound-guided foam sclerotherapy (UGFS). METHODS: The MEDLINE, CENTRAL and Embase databases were used to search for relevant studies using the terms ' (sclerotherapy AND ulcer) OR (vein AND ulcer) OR (sclerotherapy AND vein)'. Heterogeneity between studies was quantified using the I2 statistic. A random effects model was used to calculate risk ratios where substantial heterogeneity was found. RESULTS: The initial search yielded 8266 articles. 8 studies were included in the qualitative synthesis and 3 in the meta-analysis. Superior complete ulcer healing rates were noted in patients treated with foam sclerotherapy versus compression therapy alone (pooled OR 6.41, 95% CI = 0.3-148.2, p = 0.246, random effects method). A marked degree of heterogeneity was observed between studies (I2 = 81%). CONCLUSION: A prospective, trial is warranted in order to determine the true merits of UGFS in the setting of venous ulceration.

Effectiveness of systemic treatments for pyoderma gangrenosum: a systematic review of observational studies and clinical trials.

BACKGROUND: Pyoderma gangrenosum (PG) is a neutrophilic dermatosis with substantial morbidity. There is no consensus on gold-standard treatments. OBJECTIVES: To review the effectiveness of systemic therapy for PG. METHODS: We searched six databases for 24 systemic therapies for PG. Primary outcomes were complete healing and clinical improvement; secondary outcomes were time to healing and adverse effects. RESULTS: We found 3326 citations and 375 articles underwent full-text review; 41 studies met the inclusion criteria. There were 704 participants in 26 retrospective cohort studies, three prospective cohort studies, seven case series, one case-control study, two open-label trials and two randomized controlled trials (RCTs). Systemic corticosteroids were the most studied (32 studies), followed by ciclosporin (21 studies), biologics (16 studies) and oral dapsone (11 studies). One RCT (STOP-GAP, n = 121) showed that prednisolone and ciclosporin were similar: 15-20% of patients showed complete healing at 6 weeks and 47% at 6 months. Another RCT (n = 30) found that infliximab was superior to placebo at 2 weeks (46% vs. 6% response), with a 21% complete healing rate at 6 weeks. Two uncontrolled trials showed 60% and 37% healing within 4 months for canakinumab and infliximab, respectively; other data suggest that patients with concurrent inflammatory bowel disease may benefit from biologics. The remaining studies were poor quality and had small sample sizes but supported the use of corticosteroids, ciclosporin and biologics. CONCLUSIONS: Systemic corticosteroids, ciclosporin, infliximab and canakinumab had the most evidence in treating PG. However, current literature is limited to small and lower-quality studies with substantial heterogeneity.

Botulinum toxin injection vs topical nitrates for chronic anal fissure: an updated systematic review and meta-analysis of randomized controlled trials.

AIM: Chronic anal fissures (CAFs) are frequently encountered in coloproctology clinics. Chemical sphincterotomy with pharmacological agents is recommended as first-line therapy. Topical nitrates (TN) heal CAF effectively but recurrences are common. An alternative treatment modality is injection of botulinum toxin (BT) into the anal sphincter. We aimed to perform an updated systematic review and meta-analysis to compare the effectiveness of BT and TN in the management of CAF. METHOD: PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until March 2017. All randomized controlled trials (RCTs) that reported direct comparisons of BT and TN were included. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates. RESULTS: Six RCTs describing 393 patients (194 BT, 199 TN) were included. There was significant heterogeneity among the trials. On random effects analysis there were no significant differences in incomplete fissure healing (OR = 0.47, 95% CI 0.13-1.68, P = 0.24) or recurrence (OR = 0.70, 95% CI 0.39-1.25, P = 0.22) between BT and TN, respectively. BT was associated with a higher rate of transient anal incontinence (OR = 2.53, 95% CI 0.98-6.57, P = 0.06) but significantly fewer total side effects (OR = 0.12, 95% CI 0.02-0.63, P = 0.01) and headache (OR = 0.10, 95% CI 0.02-0.60, P = 0.01) compared with TN. CONCLUSION: BT is associated with fewer side effects than TN but there is no difference in fissure healing or recurrence. Patients need to be warned regarding the risk of transient anal incontinence associated with BT.

Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis.

Awake fibreoptic intubation is often considered the technique of choice when a difficult airway is anticipated. However, videolaryngoscopes are being used more commonly. We searched the current literature and performed a meta-analysis to compare the use of videolaryngoscopy and fibreoptic bronchoscopy for awake tracheal intubation. Our primary outcome was the time needed to intubate the patient's trachea. Secondary outcomes included: failed intubation; the rate of successful intubation at the first attempt; patient-reported satisfaction with the technique; and any complications resulting from intubation. Eight studies examining 429 patients were included in this review. The intubation time was shorter when videolaryngoscopy was used instead of fibreoptic bronchoscopy (seven trials, 408 participants, mean difference (95%CI) -45.7 (-66.0 to -25.4) s, p < 0.0001, low-quality evidence). There was no significant difference between the two techniques in the failure rate (six studies, 355 participants, risk ratio (95%CI) 1.01 (0.24-4.35), p = 0.99, low-quality evidence) or the first-attempt success rate (six studies, 391 participants, risk ratio (95%CI) 1.01 (0.95-1.06), p = 0.8, moderate quality evidence). The level of patient satisfaction was similar between both groups. No difference was found in two reported adverse events: hoarseness/sore throat (three studies, 167 participants, risk ratio (95%CI) 1.07 (0.62-1.85), p = 0.81, low-quality evidence), and low oxygen saturation (five studies, 337 participants, risk ratio (95%CI) 0.49 (0.22-1.12), p = 0.09, low-quality evidence). In summary, videolaryngoscopy for awake tracheal intubation is associated with a shorter intubation time. It also seems to have a success rate and safety profile comparable to fibreoptic bronchoscopy.

Regional Versus Local Anaesthesia for Haemodialysis Arteriovenous Fistula Formation: A Systematic Review and Meta-Analysis.

BACKGROUND: Arteriovenous fistula (AVF) formation is the most common vascular access procedure for patients requiring haemodialysis. However, it is associated with high failure rates, influenced by vessel diameter and arterial inflow. Mode of anaesthesia may affect these factors, and subsequently AVF maturation rates. OBJECTIVE: To perform a systematic review and meta-analysis to assess the effect of anaesthesia type for autologous primary radiocephalic or brachiocephalic AVF creation on subsequent fistula failure rates. METHODS: The online databases of Medline, EMBASE, CINAHL, The Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and Google Scholar as well as vascular and anaesthesiology conference abstracts were searched on August 1, 2016. Randomised control trials (RCTs) that reported the effect of anaesthesia type on subsequent failure rates during autologous AVF creation were included. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates. A sensitivity analysis was also carried out. RESULTS: Four RCTs (286 patients) were identified with 286 autologous AVFs. There were 48 fistula failures. Most of the studies suffered from significant methodological flaws. There was a significantly lower failure rate among patients undergoing regional (12/143) compared with local (36/143) anaesthesia (OR 0.28, 95% CI 0.14-0.57). On sensitivity analysis, having excluded the most heavily weighted study, the results remained significant (OR 0.20, 95% CI 0.05-0.75). CONCLUSIONS: The use of regional anaesthesia is associated with lower AVF failure rates when compared with local anaesthesia in patients undergoing primary forearm AVF formation for haemodialysis.

DAS181 treatment of hematopoietic stem cell transplant patients with parainfluenza virus lung disease requiring mechanical ventilation.

Parainfluenza infection is a cause of significant morbidity and mortality in allogeneic hematopoietic stem cell transplant (HSCT) patients. DAS181 is a novel antiviral agent with activity against influenza and parainfluenza. We report the first 2 cases, to our knowledge, of successful DAS181 use in ventilated HSCT patients with severe parainfluenza lung disease.

Ratios derived from an array of standard haematological indices predict the oncological outcome in colon cancer.

AIM: The interaction between inflammation and cancer is well established. Surrogate markers of systemic inflammation, such as the neutrophil/lymphocyte ratio (NLR), may be associated with the long-term oncological outcome. The present study aimed to characterize the relationship between several ratios derived from haematological indices using a classification and regression tree analysis. METHOD: Haematological white-cell ratios were established for all patients undergoing colonic cancer resection with curative intent (n = 436) in a regional cancer centre. The optimal ratios associated with overall survival (OS) were established in a training set (n = 386) using a classification and regression tree (CRT) technique. The association between ratios and OS was assessed in a separate test set (n = 50). Within the test set, two groups were generated based on each ratio (one group above and one group below the cut-off value identified in the training set). The association between ratios and OS was assessed using a stepwise Cox proportional-hazards regression model. RESULTS: The following ratios, identified by the CRT, were associated with adverse OS in the test set: an NLR of ≥ 3.4 [hazard ratio (HR) = 3.4, P < 0.001]; and a white-cell-count/lymphocyte ratio (WLR) of ≥ 5.28 (HR = 4.1, P = 0.03). CONCLUSION: This is the first study to apply recursive partitioning in determining the relationship between haematological ratios and OS in colon cancer. Haematological ratios were predictive of oncological outcome. What does this paper add to the literature? This study suggests an association between systemic inflammation and oncological outcome.

Diagnostic accuracy of non-radiologist performed ultrasound for abdominal aortic aneurysm: systematic review and meta-analysis.

BACKGROUND: Ultrasonography is increasingly used by clinicians to identify abdominal aortic aneurysms (AAA). We performed a systematic review and meta-analysis comparing the accuracy of non-radiologist performed ultrasound (NRPUS) for AAA disease to the 'gold standard' of radiologist performed aortic imaging (RPI), intra-operative findings or postmortem findings. METHODS: Cochrane Library, MEDLINE, EMBASE, SCOPUS-V.4, trial registries, conference proceedings, and article reference lists were searched to identify studies comparing NRPUS with RPI as the reference standard. Data abstracted from eligible studies was used to generate 2 × 2 contingency tables allowing calculation of pooled sensitivity and specificity values. RESULTS: 11 studies (944 patients) evaluated NRPUS for AAA detection. NRPUS had a pooled sensitivity of 0.975 [95% confidence interval (CI), 0.942-0.992] for AAA detection and a pooled specificity of 0.989 (95% CI, 0.979-0.995). CONCLUSIONS: Non-radiologist performed ultrasound achieves acceptable sensitivity and specificity for both detection and measurement of AAA. There was no evidence of significant heterogeneity with respect to pooled sensitivity or specificity.

Vascular access device type for systemic anti-cancer therapies in cancer patients: A scoping review.

BACKGROUND: Patients with cancer can expect to receive numerous invasive vascular access procedures for intravenous therapy and clinical diagnostics. Due to the increased incidence and prevalence of cancer globally there will be significantly more people who require first-line intravenous chemotherapy over the next ten years. METHODS: Our objective was to determine the types of evidence that exist for the vascular access device (VAD) type for the delivery of systemic anti-cancer therapy (SACT) in cancer patients. We used JBI scoping review methodology to identify the types of VADs used for SACT and with a specific search strategy included articles from 2012-2022 published in the English language. We identify (i) type of VADs used for SACT delivery (ii) the type of insertion and post-insertion complications (iii) the geographical location and clinical environment (iv) and whether VAD choice impacts on quality of life (QOL). Findings were presented using the PAGER framework. MAIN FINDINGS: Our search strategy identified 10,390 titles, of these, 5318 duplicates were removed. The remaining 5072 sources were screened for eligibility, 240 articles met the inclusion criteria. The most common design include retrospective study designs (n = 91) followed by prospective study designs (n = 31). We found 28 interventional studies with 21 registered in a clinical trial registry and identified no core outcome sets papers specific to VAD for SACT. The most prevalent publications were those that featured two or more VAD types (n = 70), followed by tunnelled intravenous VADs (n = 67). Of 38 unique complications identified, the most frequent catheter related complication was catheter related thrombosis (n = 178, 74%), followed by infection (n = 170, 71%). The county where the most publications originated from was China (n = 62) with one randomized controlled multicenter study from a comprehensive cancer centre. Of the thirty three studies that included QOL we found 4 which reported on body image. No QOL measurement tools specific to the process of SACT administration via VAD are available INTERPRETATION: Our findings suggest a systematic review and meta-analysis of VAD use for intravenous SACT can be considered. However, the development of a core outcome set for SACT should be prioritised. Funding for high quality programs of research for VAD in cancer are needed. Comprehensive cancer centres should lead this research agenda.

Purse-string approximation is superior to primary skin closure following stoma reversal: a systematic review and meta-analysis.

BACKGROUND: The incidence of surgical site infection (SSI) following stoma reversal can reach 40 %. A recent variation on primary linear closure (PLC) is purse-string approximation (PSA), where the skin is approximated via a purse-string suture but not closed. The optimal technique remains to be determined. The objective of this review was to compare outcomes with PLC versus PSA for skin closure following stoma reversal. METHODS: A literature search of Embase and Medline was performed to identify studies comparing PLC with PSA published between 1966 and 2012. Reviews of each study were conducted and data extracted. Random-effects methods were used to combine data, and between-study heterogeneity was assessed. RESULTS: Six out of 47 identified studies met the inclusion criteria: 2 randomized controlled trials and 4 case controlled series. For the primary outcome of SSI rate, 233 patients in the PLC and 170 patients in the PSA group were available for comparison. PSA resulted in a reduced rate of SSI (2.4 % PSA vs. 29.6 % PLC; OR 0.083, 95 % CI = 0.03-0.21, p < 0.001). No differences were noted in length of hospital stay. Three studies assessed self-reported cosmetic results at a minimum of 7 months post-operatively. Patients who underwent PSA reported greater satisfaction with the cosmetic outcome (Standard mean difference = 0.47 on ten-point scale, 95 % CI 0.15-0.79, p = 0.005). CONCLUSIONS: Purse-string approximation of stoma wounds is associated with an 80 % reduction in SSI with no negative effect on length of hospital stay or long-term cosmetic outcome.

Mid-term outcomes following emergency endovascular aortic aneurysm repair for ruptured abdominal aortic aneurysms.

OBJECTIVE: Emergency Endovascular Aortic Aneurysm Repair (eEVAR) is a rapidly evolving approach to ruptured Abdominal Aortic Aneurysms (rAAA). Yet longer-term outcomes following eEVAR remain unclear. This study compares mid-term outcomes of eEVAR and open rAAA. METHODS: A prospective database for all patients undergoing eEVAR and open rAAA from January 2006 to April 2010 was analysed. Patients were offered eEVAR if anatomically suitable. RESULTS: 52 patients (45 male, median age 78 years (62-92 years), underwent eEVAR, 50 patients (44 male, median age = 71 (62-95 years) underwent open rAAA repair. In-hospital mortalities were 12% (6/52) for eEVAR, 32% (16/50) for open repair. There were five re-interventions (10%) in the eEVAR group. The peri-operative survival benefits of eEVAR over open rAAA repair were maintained at 1 and 2 years post-operatively with open repair demonstrating a two-fold increased risk of mortality (Hazard ratio 2.2, Fisher Exact test, 95% Confidence Interval (CI) 1.108-4.62, p = 0.0122). Overall survival was 81% at 1 year, 73% at 2 years for eEVAR, and 62% at 1 year and 52% at 2 years for open rAAA repair. CONCLUSION: EEVAR is associated with excellent mid-term survival in this cohort. We would recommend eEVAR as the management of choice for rAAA in anatomically suitable patients where local facilities and expertise exist.

Axial ablation versus terminal interruption of the reflux source (AAVTIRS): a randomised controlled trial.

BACKGROUND: Treatment of superficial venous reflux has been shown to improve ulcer healing time and reduce the risk of ulcer recurrence. Terminal ablation of the reflux source (TIRS) is an alternative to formal endovenous ablation or surgery which can be performed by injecting sclerosant foam into the peri-ulcer plexus of the veins. TIRS has been shown to be successful and in our experience is the option preferred by many patients, when offered as an alternative to axial ablation (AA). AIM: To determine if the proportion of ulcers healed within 6 months of endovenous treatment differs between patients undergoing AA of varicose veins or TIRS by peri-ulcer foam sclerotherapy. METHODS: AAVTIRS is an assessor-blinded randomised controlled trial. Patients will be recruited from a dedicated ulcer clinic in Roscommon University Hospital and from the vascular surgical clinics in University Hospital Galway. All patients attending the ulcer clinic will be screened for eligibility. RANDOMISATION: Random computer-generated sequence is stratified by ulcer size. Allocation will be concealed using sealed opaque envelopes. BLINDING: Assessors reviewing wounds at follow -p visits will be blinded to patient allocation. PRIMARY ENDPOINT: The proportion of ulcers healed within 6 months of enrolment. DISCUSSION: This will be the first time that TIRS has been evaluated with a properly powered randomised trial in the setting of venous ulcer management. Streamlining the management of venous ulcers has broad health economic benefits. If it is found that TIRS is superior or non-inferior to AA, then a less expensive, less invasive injection can be offered as an alternative to AA in an attempt to encourage the healing of venous ulcers. If AA is found to be superior to TIRS, then this would suggest that all patients undergoing ablation in the management of venous ulcers should have their superficial reflux fully treated, building on the evidence of the EVRA trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT04484168. Registered on 23 July 2020.

Predicting outcome following colorectal cancer surgery using a colorectal biochemical and haematological outcome model (Colorectal BHOM).

AIM: To present a new biochemistry and haematology outcome model which uses a minimum dataset to model outcome following colorectal cancer surgery, a concept previously shown to be feasible with arterial operations. METHOD: Predictive binary logistic regression models (a mortality and morbidity model) were developed for 704 patients who underwent colorectal cancer surgery over a 6-year period in one hospital. The variables measured included 30-day mortality and morbidity. Hosmer-Lemeshow goodness of fit statistics and frequency tables compared the predicted vs the reported number of deaths. Discrimination was quantified using the c-index. RESULTS: There were 573 elective and 131 nonelective interventional cases. The overall mean predicted risk of death was 7.79% (50 patients). The actual number of reported deaths was also 50 patients (χ(2) = 1.331, df = 4, P-value = 0.856; no evidence of lack of fit). For the mortality model, the predictive c-index was = 0.810. The morbidity model had less discriminative power but there was no evidence of lack of fit (χ(2) = 4.198, df = 4, P-value = 0.380, c-index = 0.697). CONCLUSIONS: The Colorectal Biochemistry and Haematology Outcome mortality model suggests good discrimination (c-index > 0.8) and uses only a minimal number of variables. However, it needs to be tested on independent datasets in different geographical locations.

Long-term effects of EVAR. Suprarenal versus infrarenal fixation.

Endovascular aortic aneurysm repair (EVAR) is the first line management of abdominal aortic aneurysms in many institutions. The relationship between EVAR and renal impairment, especially in the longer term remains unclear. Suprarenal graft fixation is widely used in order to achieve stable graft anchorage. Numerous studies have tried to answer the question about whether suprarenal fixation affects renal outcome. We reviewed the literature to investigate the relationship between endograft fixation and post-operative renal function.

Systematic review and meta-analysis of preoperative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery.

BACKGROUND: Surgical-site infection increases morbidity, mortality and financial burden. The preferred topical antiseptic agent (chlorhexidine or povidone-iodine) for preoperative skin cleansing is unclear. METHODS: A meta-analysis of clinical trials was conducted to determine whether preoperative antisepsis with chlorhexidine or povidone-iodine reduced surgical-site infection in clean-contaminated surgery. RESULTS: The systematic review identified six eligible studies, containing 5031 patients. Chlorhexidine reduced postoperative surgical-site infection compared with povidone-iodine (pooled odds ratio 0.68, 95 per cent confidence interval 0.50 to 0.94; P = 0.019) . CONCLUSION: Chlorhexidine should be used preferentially for preoperative antisepsis in clean-contaminated surgery.

Role of ultrasonography in the diagnosis of temporal arteritis.

BACKGROUND: Temporal artery (TA) biopsy is the current standard for diagnosing temporal arteritis, but has limited sensitivity. Colour duplex ultrasonography is a newer, non-invasive method of diagnosing temporal arteritis. METHODS: A systematic review was performed of trials comparing TA biopsy with duplex ultrasonography. Duplex results (halo sign, stenosis or vessel occlusion) were compared with either TA biospy findings or the American College of Rheumatology research criteria for diagnosing temporal arteritis. Trials were identified from MEDLINE, Embase and the Cochrane Library trials register. The performance of duplex ultrasonography was assessed with weighted independent sensitivity and specificity values, and summary receiver operating characteristic curve analysis. RESULTS: There were 17 eligible studies containing 998 patients. When the halo sign on duplex imaging was compared with TA biopsy, the sensitivity was 75 (95 per cent confidence interval 67 to 82) per cent and the specificity was 83 (78 to 88) per cent. There was no heterogeneity across the eligible studies. CONCLUSION: Duplex ultrasonography was relatively accurate for diagnosing temporal arteritis. It should become the first-line investigation, with biopsy reserved for patients with a negative scan.

Association between biomechanical structural stresses of atherosclerotic carotid plaques and subsequent ischaemic cerebrovascular events--a longitudinal in vivo magnetic resonance imaging-based finite element study.

BACKGROUND: High-resolution magnetic resonance (MR) imaging has been used for MR imaging-based structural stress analysis of atherosclerotic plaques. The biomechanical stress profile of stable plaques has been observed to differ from that of unstable plaques; however, the role that structural stresses play in determining plaque vulnerability remains speculative. METHODS: A total of 61 patients with previous history of symptomatic carotid artery disease underwent carotid plaque MR imaging. Plaque components of the index artery such as fibrous tissue, lipid content and plaque haemorrhage (PH) were delineated and used for finite element analysis-based maximum structural stress (M-C Stress) quantification. These patients were followed up for 2 years. The clinical end point was occurrence of an ischaemic cerebrovascular event. The association of the time to the clinical end point with plaque morphology and M-C Stress was analysed. RESULTS: During a median follow-up duration of 514 days, 20% of patients (n = 12) experienced an ischaemic event in the territory of the index carotid artery. Cox regression analysis indicated that M-C Stress (hazard ratio (HR): 12.98 (95% confidence interval (CI): 1.32-26.67, p = 0.02), fibrous cap (FC) disruption (HR: 7.39 (95% CI: 1.61-33.82), p = 0.009) and PH (HR: 5.85 (95% CI: 1.27-26.77), p = 0.02) are associated with the development of subsequent cerebrovascular events. Plaques associated with future events had higher M-C Stress than those which had remained asymptomatic (median (interquartile range, IQR): 330 kPa (229-494) vs. 254 kPa (166-290), p = 0.04). CONCLUSIONS: High biomechanical structural stresses, in addition to FC rupture and PH, are associated with subsequent cerebrovascular events.

Duplex ultrasound and contrast-enhanced ultrasound versus computed tomography for the detection of endoleak after EVAR: systematic review and bivariate meta-analysis.

INTRODUCTION: Contrast-enhanced computed tomography (CT) has become the 'gold-standard' imaging modality for surveillance following EVAR. However repeated CT causes cumulative contrast related renal injury. Duplex ultrasound (USS) and contrast-enhanced (non-nephrotoxic) duplex scanning (CEUS) are less invasive but considered less accurate than CT. The aim of this study was to determine the diagnostic accuracy of imaging modalities used to detect endoleak. Accordingly, we undertook a systematic review and meta-analysis of the evidence base for USS and CEUS compared to CT following EVAR. METHODS: Medline, Embase, trial registries, conference proceedings and article reference lists were searched to identify trials comparing USS or CEUS with CT following EVAR. Contrast-enhanced computed tomography was taken as the 'gold-standard' investigation. USS and CEUS were compared to CT in separate meta-analyses. RESULTS: Twenty-one studies in 2601 patients compared USS with CT. The sensitivity of USS at detecting endoleak was 0.77 (95% CI 0.64-0.86; I(2)=0.82) and pooled specificity 0.94 (95% CI 0.88-0.97; I(2)=0.90). Seven studies (288 patients) compared CEUS vs CT. The pooled sensitivity was 0.98 (95% CI 0.90-0.99; I(2)=0.32) and specificity 0.88 (95% CI 0.78-0.94; I(2)=0.67). CONCLUSION: This study confirms that unenhanced USS has poor sensitivity for endoleak detection; however CEUS is a highly sensitive modality. These results should be interpreted with some caution due to heterogeneity in analysed trials and further research is needed to evaluate the efficacy of CEUS before it can be utilised as the primary imaging modality for EVAR surveillance.