RS01. Planned Exclusion of the Celiac Artery During Complex Thoracic Endovascular Aortic Repair Procedures: Is It Safe?

Abstract

Achieving adequate proximal and distal fixation and maintaining visceral branch flow make thoracic endovascular aortic repair (TEVAR) procedures for thoracoabdominal aneurysm (TAAA) complex. Whereas superior mesenteric artery (SMA) and renal vessels must be preserved, there may be selected cases in which patent celiac arteries may be intentionally excluded. We sought to define the incidence of ischemic complications of celiac exclusion during complex TEVAR procedures and to define specific conditions in which the celiac can be safely covered. We performed a retrospective 12-year audit in two tertiary care institutions of patients with a suprarenal aneurysm or TAAA treated by standard TEVAR involving the distal thoracic aorta with intentional celiac fabric coverage or bare distal stent across the celiac (preserved), custom or modified aortic endografts (complex TEVAR/fenestrated EVAR [FEVAR]) involving multiple visceral branch endoprostheses with and without planned celiac exclusion, or a transabdominal hybrid approach with visceral debranching bypasses (with or without celiac revascularization) from distal inflow sites and staged or simultaneous long length thoracoabdominal endografting. The decision to exclude celiac arteries was made from preoperative computed tomography findings of a small diameter, stenotic origin, presence of replaced right hepatic artery, or existing large SMA celiac collaterals. Cases with a chronically occluded celiac were excluded. Primary end points were 30-day mortality, spinal cord ischemia, and any foregut ischemia occurring early or during late follow-up (ischemic acalculous cholecystitis or splenic infarction). There were 223 patients who met inclusion criteria (Table I). In the standard/complex TEVAR/FEVAR group, 26 patients (15%) had celiac coverage with 144 cases of celiac preservation. In the hybrid group, 11 cases (21%) had celiac exclusion, whereas 42 patients had a separate celiac bypass. In the standard/complex TEVAR/FEVAR group, celiac coverage did not result in significant increase in foregut ischemic events (3.8% vs 2.1%; P = .6; Table II). However, exclusion of the celiac artery during hybrid cases resulted in an increase in foregut ischemia (two early and one case presenting 1 year later) compared with patients having celiac bypass revascularization (27% vs 7%; P = .06). The incidence of spinal cord ischemia and 30-day all-cause mortality was not different with regard to celiac exclusion or between treatment groups. Selected celiac exclusion appears safe during standard/complex TEVAR/FEVAR procedures as long as SMA patency is ensured. A hybrid approach to complex TAAA requires separate bypass to all patent visceral branches including the celiac to minimize foregut ischemia.Table IDemographicsVariableTEVAR with celiac coverageTEVAR with celiac revascularizationHybrid without celiac revascularizationHybrid with celiac revascularizationNo.261441142M/F69/3174/2655/4568/32Urgent/emergent35131810History of aortic surgery27515536Dissection present12102710TEVAR, Thoracic endovascular aortic repair.Values are reported as percentage. Open table in a new tab Table IIPostoperative outcomesVariableTEVAR with celiac coverageTEVAR with celiac revascularizationTEVAR covered celiac vs TEVAR revascularized celiac, χ2 comparison P valueHybrid without celiac revascularizationHybrid with celiac revascularizationHybrid with and without revascularization, χ2 comparison P valueNo.26144114230-Day mortality7.7 (2)3.5 (5).319.1 (1)11.9 (5).79SCI3.8 (1)15.3 (22).120 (0)11.9 (5).57Foregut ischemia3.8 (1)2.1 (3).5927.2 (3)7.1 (3).06SCI, Spinal cord ischemia; TEVAR, thoracic endovascular aortic repair.Values are reported as % (No.). Open table in a new tab