First experience using intraoperative contrast-enhanced ultrasound during endovascular aneurysm repair for infrarenal aortic aneurysms

Intraoperative visualization of an infrarenal aortic aneurysm using contrast enhanced ultrasonography (a) in comparison to three-dimensional reconstruction of the magnetic resonance imaging (MRI) data obtained during MR angiography (b). The red arrow shows the infrarenal aortic kinking and the yellow arrows demonstrate the distal landing zone at level of the common iliac arteries.

Visualization of the proximal infrarenal landing zone by intraoperative contrast-enhanced ultrasound (iCEUS) using an endoluminal balloon catheter dilatation (yellow arrows), giving a contrast-sparing zone within the aortic lumen. The length of the balloon catheter is measured between the white cross markers (measured length: 4.07 cm; original length of the catheter as described by the manufacturer: 4.0 cm). The red arrow shows again the kinking of the aorta. Stent graft release was planned within the straight infrarenal aortic segment just below the zone of aortic kinking.

Intraoperative contrast-enhanced ultrasound (iCEUS): proximal infrarenal landing zone. iCEUS demonstrating complete proximal sealing of the stent graft. The yellow arrows show the sealing of the stent graft along the wall of the excluded proximal aortic segment. Proximal stent graft release is just below the aortic kinking, as intended. Red arrows show contrast air bubbles within the aneurysm sac, as expected, because distal aortic stent graft extension has not yet been performed. This picture would otherwise be identical to a distal type II or III endoleak.

Intraoperative contrast-enhanced ultrasonography demonstrating the right iliac stent graft (yellow arrows) extension without a detectable endoleak.

Postinterventional type III endoleak (white arrows) at the distal connection site of the left iliac extension (red arrows) endoleak following EVAR for an infrarenal aortic aneurysm. The type III endoleak disappeared after balloon dilatation of the left iliac stent graft connection site.