Stent Graft Treatment of AAA With Preservation of the Inferior Mesenteric Artery

Abstract

Coverage of the inferior mesenteric artery is standard in stent graft treatment of an infrarenal abdominal aortic aneurysm (AAA). Complications of colonic ischemia are rare, but risk factors include poor collateral flow from prior colonic surgery or from severe pelvic arterial occlusive disease. Preservation of inferior mesenteric artery (IMA) flow may prevent such complications in patients deemed to be at high risk for intestinal/pelvic ischemic complications. We have performed two unique cases of aortic stent grafting with preservation of IMA flow, comprising one IMA fenestration and one IMA snorkel. Record reviews of these two patients with details on the indications, technical details, and outcomes were recorded. A 53-year-old woman with a recent right hemicolectomy for cecal cancer also an enlarging AAA at 4.5 cm and a right iliac aneurysm of 3.8 cm. Given the recent colonic resection, the need to occlude the right internal iliac artery, and a stenotic left internal iliac artery, her risk for colonic ischemia was thought to be significantly higher than the average. To avoid this, a single fenestration was made with a back table modification of a Zenith graft (Cook Inc, Bloomington, Ind) and a Viabahn stent (W. L. Gore, Flagstaff, Ariz) and was used to fenestrate the IMA. On follow-up, the patient had no complications with no evidence of colonic ischemia and successful treatment of her AAA (Fig 1). The second patient was a 61-year-old man with a history a left iliac stent placed previously for calf claudication who developed severe, progressive hip claudication and impotence. Computed tomography angiography showed 3.5-cm iliac aneurysms and a 3.7-cm distal aortic aneurysm with preocclusive right and totally occluded left internal iliac arteries. There was a 7-mm-diameter inferior mesenteric artery coming off the AAA with severe stenosis at its origin. An Endologix AFX stent graft (Endologix, Irvine, Calif) was used to treat the aortoiliac aneurysmal disease with a long Viabahn snorkel stent placed into the IMA. Both iliac limbs were extended to the externals. Follow-up computed tomography showed complete exclusion of the aortoiliac aneurysms with no endoleak, and the patient had resolution of his hip claudication and impotence (Fig 2). Preservation of IMA flow with modified stent graft techniques is feasible and may reduce complications of colonic and pelvic ischemia in highly selected patients.Fig 1Fenestration technique. CTA, Computed tomography angiography; IMA, inferior mesenteric artery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)