CEUS in Vascular Imaging—EVAR Follow-Up and Beyond
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Northwell Health, Manhasset, New York
John S. Pellerito, MD, Vice Chairman of the Department of Radiology as well as the Program Director for the Diagnostic Radiology Residency Program and Director of the Peripheral Vascular Laboratory at Northwell Health in Manhasset, New York, began his Monday morning session at ISET 2026 with a pragmatic message for vascular specialists: contrast-enhanced ultrasound (CEUS) is no longer a niche add-on in the vascular lab. Instead, it’s becoming a reliable, everyday problem-solver, particularly when the clinical question is about flow behavior rather than anatomy alone.
A big part of the appeal comes down to what CEUS actually is. The contrast agent discussed (Lumason/SonoVue) uses microbubbles that remain in the bloodstream and clear quickly through the lungs. That matters clinically because it is built to illuminate real-time hemodynamics and subtle flow, often without the radiation exposure or iodinated contrast concerns that come with computed-tomography (CT)-based surveillance strategies.
The centerpiece of Dr Pellerito’s presentation was endovascular aortic repair (EVAR) follow-up. Endoleaks remain a frequent post-EVAR issue, occurring in roughly 15% to 45% of cases. While CT angiography (CTA) is often treated as the default reference test, the presentation made a strong case that CEUS can be a better fit for many real-world surveillance decisions because it can pick up low-flow leaks, help classify endoleak type, and show flow dynamics as they happen.
In one comparison, sensitivity improved from 77% with non-contrast ultrasound to 98% with CEUS. A larger meta-analysis (26 studies, 2217 patients) reported sensitivity and specificity of 94% and 93% vs CTA, with particularly strong performance for Types I and III endoleaks.
Dr Pellerito reviewed the standard endoleak categories (Types I–V) and emphasized that CEUS helps the team get closer to the questions that actually influence management: What type of endoleak is this? Is it brisk or sluggish? Does it look like something that warrants escalation now, or something that can be followed with confidence?
The session walked through a broader set of vascular applications for CEUS. On the cerebrovascular side, CEUS was presented as a way to clarify difficult carotid studies (particularly near-occlusion vs total occlusion) when standard Doppler signals or windows leave too much ambiguity. It also touched on plaque characterization, including ulceration and intraplaque vascularity, which many clinicians think about in the context of plaque vulnerability.
The discussion then moved into tissue perfusion and microcirculation assessment. CEUS was positioned alongside other perfusion approaches, with an example showing measurable improvement in perfusion parameters after intervention.
In the abdominal and transplant realm, Dr Pellerito underscored CEUS’s utility for answering flow and perfusion questions, such as renal/mesenteric evaluation, portal vein patency, and transplant complications (eg, infarct or hepatic artery occlusion).
In conclusion, Dr Pellerito emphasized that adoption is as much operational as it is clinical. CEUS works best when programs standardize when they order it, how they document it, and how they report the findings in a way that drives consistent decisions, especially for endoleak type and behavior. CEUS includes off-label applications of ultrasound contrast, a reminder that teams should align internal policies and documentation as they broaden its use.
