Dynamic magnetic resonance angiography of the aneurysm neck: Conformational changes during the cardiac cycle with possible consequences for endograft sizing and future design

van Herwaarden, Joost A., Bartels, Lambertus W., Muhs, Bart E., Vincken, Koen L., Lindeboom, Maud Y.A., Teutelink, Arno, Moll, Frans L., Verhagen, Hence J.M.


Journal of Vascular Surgery 44 (1), p. 22-28


Objective: Proper proximal fixation and stent-graft sealing within the aneurysm neck are critical for endovascular aneurysm repair (EVAR) durability. Computed tomography angiography (CTA) is the gold standard for preoperative sizing of endograft diameters, but the accuracy of these measurements is uncertain because they rely on static images of a dynamic process. The aortic configuration and diameter may change during the cardiac cycle. We studied these phenomena using dynamic electrocardiograph-triggered magnetic resonance angiography (MRA). Methods: Eleven consecutive EVAR patients were included. Dynamic MRA was used to perform preoperative and postoperative measurements. Changes were measured in transverse aortic sections 10 mm below the lowest renal artery (level A), at the level of the renal arteries (level B), and 3 cm above the lowest renal artery (level C). Data were analyzed using image segmentation software. Aortic area and diameter changes along 256 axes were determined. Results: Dynamic MRA demonstrated significant aortic area changes during the cardiac cycle before and after EVAR at all three measured levels. Pre-EVAR aortic area significantly increased per cardiac cycle: 8.4% at level A; 9.3% at level B; and 13.3% at level C (P < .001 for all levels). Post-EVAR aortic area increased 9.7% at level A, 9.6% at level B, and 15.8% at level C per cardiac cycle (P < .001 for all levels). Significant diameter changes during cardiac cycles were also observed at all three levels. Pre-EVAR mean diameter changed up to 8.9% (P < .001) compared with post-EVAR aortic changes of up to 11.5% (P < .001). EVAR had no effect on change in aortic area and diameter. Dynamic MRA also demonstrated that pulsatile aortic distension was not equal in all axes, but rather occurred as an asymmetrical expansion and contraction. Conclusion: In patients with (atherosclerotic) aneurysm disease, the aortic dimensions at the level of and proximal to the aneurysm neck change during the cardiac cycle. This phenomenon is preserved after EVAR. Therefore, maximum diameter using dynamic MRA may not be similar to the maximum diameter with static CTA in all patients, and a standard regimen of 10% to 15% oversizing of an endograft based on static CTA images may be inadequate for some patients. Further studies using dynamic MRA to evaluate effects of different endografts are anticipated, with possible consequences for endograft designs.