Risk of Mesenteric Ischemia Following Branched Endovascular Repair for Thoracoabdominal Aortic Aneurysm

Abstract

Introduction - Branched endovascular aortic repair (BEVAR) has become an accepted option for treatment of thoracoabdominal aortic aneurysms (TAAA). Staged procedures with temporary aneurysm sac perfusion (TASP) were shown to reduce the risk of spinal cord ischemia in patients with extended aortic aneurysmal disease. However, only few data about the risk of perioperative mesenteric ischemia are available. Methods - Patients with TAAA were treated with branched EVAR between 09/2007 and 06/2016 using a single step or open branch staged procedure with temporary aneurysm sac perfusion. TASP side branches were completed after 1-12 months. Postoperative mesenteric ischemia was defined as laparotomy for suspected or proven intestinal malperfusion. Mesenteric ischema with intestinal resection, patency of visceral branches to the celiac trunk (CTR), the superior (SMA) and inferior mesenteric artery (IMA), rate of reintervention and perioperative mortality was analyzed. Results - 118 patients were treated with BEVAR, 46 without an aneurysm sac perfusion (single-step) and 72 with open branch and TASP. Laparotomy for suspected mesenteric ischemia was performed in 9 patients and 8 (6.7 %) patients had small bowel or colon resections 1-120 days (mean: 3.1 days) after the endovascular intervention. Cause of acute mesenteric ischemia was multiple embolic disease (n=1), multiorgan failure with secondary intestinal malperfusion (n=3), SMA malperfusion (n=1) and left colonic ischemia related to IMA occlusion (n=3). Mesenteric ischemia with intestinal resection was more frequently observed in the single step group (15.2 %) in comparison to the open branch TASP group (1.4 %, p=0.005). Other risk factors for mesenteric ischemia were age >80 years (0.021), perioperative hypotension (p=0.041), reoperation for bleeding (p=0.001), embolic events (p=0.036) and > 2 visceral arteries with occlusive disease (p = 0.001). Overall perioperative mortality caused by primary mesenteric ischemia related to visceral artery occlusion was 2.5 %, although mortality in patients with laparotomy, intestinal resections and other comorbidities was 7/8 (87.9 %). Conclusion - Mesenteric ischemia following branched EVAR is a relevant complication with high perioperative mortality requiring early diagnosis, regular follow-up and immediate reinterventions. Staged procedures with open branch/temporary aneurysm sac perfusion seem to reduce the risk of mesenteric ischemia.