Endovascular Repair of Combined Distal Arch and Extent in Thoracoabdominal Aneurysm: Landing Zone Extension into the Aortic Arch and Mesenteric Portion of the Abdominal Aorta

Abstract

Thoracic endovascular aortic repair (TEVAR) has emerged as a surgical alternative for patients at prohibitive risk for open repair. We report a series of patients at a single institution with type I thoracoabdominal aneurysms (TAAAs) who required coverage of the left subclavian (LSA) and celiac artery to achieve aneurysmal exclusion during TEVAR. Between August 2005 and April 2009, 219 patients underwent TEVAR. Patients with type I TAAAs requiring coverage of the LSA (zone 2) and celiac artery to achieve adequate proximal and distal fixation were identified. Except when contraindicated by renal failure, all patients underwent preoperative computed tomography angiography (CTA) to evaluate collateral circulation between the celiac and superior mesenteric artery (SMA). Six of 219 (2.7%) patients undergoing TEVAR had type I TAAAs that required proximal landing zone extension to zone 2 of the aortic arch and distal landing zone extension into the mesenteric abdominal aorta to include coverage of the celiac artery. There were two male and four female patients, and the mean age was 78.3 years (range, 68 to 83 years). The average maximum aneurysmal diameter was 6.8 cm. All six patients underwent elective LSA bypass prior to TEVAR with subsequent coil embolization of the LSA remnant during TEVAR. In a mean follow-up of 21.2 months, there were no reported complications of paraplegia, stroke, endoleak, visceral ischemia, spinal ischemia, conversion to open revascularization, left upper extremity ischemia, or aneurysm rupture. Although TEVAR has evolved into a viable option in the treatment of thoracic aortic aneurysms, there is little data to support distal landing zone extension into the abdominal aorta, and there are no reported series of TEVAR for type I TAAAs. This preliminary series suggests that TEVAR can be utilized in the treatment of type I TAAAs, and that coverage of the LSA and celiac artery to achieve aneurysmal exclusion is safe and viable in select patients. Elective LSA revascularization and subsequent coil embolization are useful adjuncts to reduce the risk of paraplegia and endoleak and to maintain left upper extremity perfusion. Preoperative CTA and intraoperative angiography are essential to confirm SMA to celiac collateralization prior to complete celiac interruption.TableTEVAR landing zone extension into the aortic arch and abdominal aorta: Collateral assessmentCeliac coveragePatient #Preoperative CTA findingsIntraoperative angiography: predeploymentIntraoperative angiography: postdeploymentPartial1Noncontrast CTAortogramPatent SMA, celiac2Replaced R hepatic arteryAortogramPatent SMA, celiacComplete1Collaterals poorly visualizedSelective SMA AngiogramSMA to celiac collaterals2Pancreaticoduodenal collaterals visualizedAortogramSMA to celiac collaterals3Chronic celiac occlusionAortogramSMA to celiac collaterals4Replaced R hepatic arteryAortogramPatent SMA, R hepaticCT, Computed tomography; CTA, computed tomography angiography; R, right; SMA, superior mesenteric artery. Open table in a new tab