Celiac Artery Stenting Research Articles

Pancreaticoduodenal Artery Aneurysm Complicated by Median Arcuate Ligament Syndrome.

To highlight median arcuate ligament syndrome as a potential cause for celiac artery stenosis and pancreaticoduodenal artery aneurysm, and describe treatment options in this setting. A 63-year-old male presented with a pancreaticoduodenal artery aneurysm and concomitant celiac artery stenosis that was treated with celiac artery stenting and aneurysm coiling. He subsequently developed stent fracture and celiac artery occlusion secondary to previously unrecognized median arcuate ligament syndrome causing reperfusion of the aneurysm. This was treated with open median arcuate ligament release and aorta to common hepatic artery bypass with good clinical result and stable 20-month surveillance imaging. It is critical to recognize median arcuate ligament syndrome as a cause of celiac artery stenosis in the setting of pancreaticoduodenal artery aneurysm given the high risk of failure of endovascular stenting. Open aorto-hepatic artery bypass and endovascular aneurysm coiling should be the preferred approach in these patients.

Severe Klebsiella pneumoniae pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism: A case report

Klebsiella pneumoniae (K. pneumoniae) is a clinically common Gram-negative bacillus that can cause community- and hospital-acquired infections and lead to pneumonia, liver abscesses, bloodstream infections, and other infectious diseases; however, severe pneumonia caused by hypervirulent K. pneumoniae (hvKp) complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism is rarely seen in the clinical setting and has not been reported in the literature. A 51-year-old man was hospitalized with fever and dyspnea. Persistent mild pain in the middle and upper abdomen began at dawn on the 3rd day following admission and developed into persistent severe pain in the left upper abdomen 8 h later. Based on chest computed tomography (CT), bronchoscopy, bronchoalveolar lavage fluid metagenomic next-generation sequencing, abdominal aortic CT angiography (CTA), and culture of the superior mesenteric artery embolus, adult community-acquired severe hvKp pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism was diagnosed. Notably, he recovered and was discharged from the hospital after receiving effective meropenem anti-infection, endovascular contact thrombolytic, and systemic anticoagulant therapies and undergoing percutaneous thrombus aspiration. Ten days later, the patient returned to the hospital for abdominal CTA examination, which indicated blocked initial common pathway of the celiac trunk and superior mesenteric artery, and local stenosis. Therefore, celiac trunk artery stenting was performed in Chongqing Hospital, and postoperative recovery was good. We report a case of hvKp severe pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism and suggest that clinicians should consider the possibility of a Gram-negative bacillus infection and conduct effective pathogen detection in a timely fashion when managing patients with severe community-acquired pneumonia before obtaining bacteriologic and drug sensitivity results. At the same time, when patients have severe pulmonary infection complicated by severe abdominal pain, an acute mesenteric artery embolism should be considered to avoid delays in treatment.

TCTAP C-082 A Case of Mesenteric Ischemia Treated with Celiac Artery Stenting

TCTAP C-082 A Case of Mesenteric Ischemia Treated with Celiac Artery Stenting

Early outcomes associated with use of the Zenith TX2 Dissection Endovascular Graft for the treatment of Stanford type B aortic dissection

ObjectiveTo evaluate short term outcomes related to the use of the Zenith TX2 Dissection Endovascular Graft (ZDEG) and the Zenith Dissection Bare stent (ZDES) for the treatment of Stanford type B aortic dissections. MethodsThis retrospective multicenter case cohort study collated data from 10 European institutions for patients with both complicated and uncomplicated type B aortic dissection treated with ZDEG and ZDES between 2011 and 2018. The primary end point was mortality at 30 and 90 days. Secondary end points included complications related to TEVAR, such as, type Ia endoleak, stroke, paraparesis, paraplegia, and retrograde type A dissection (RTAD). Statistical analysis was carried out using the t test, or one-way analysis of variance and the χ2 or Fisher exact tests. ResultsWe treated 120 patients (87 male; mean age, 62.7 ± 12.2years) either in the acute 76 (63.3%), subacute 16 (13.3%), or chronic 28 (23.3%) phase. Seven patients (5.8%) died within 30 days after the index procedure and two (1.7%) between 30 and 90 days. There was one instance of postoperative RTAD in a patient treated for rupture. Stroke and paraplegia occurred in three (2.5%) and five (4.2%), patients, respectively. Eight patients (6.7%) had a type Ia endoleak in the perioperative period. There were no instances of paraplegia, no permanent dialysis, and no requirement for adjunctive superior mesenteric or celiac artery stenting in the 33 patients (27.5%) who were treated by concurrent placement of ZDES distal to the ZDEG. The length and distal oversizing of ZDEG components used was less in this group. ConclusionsThe present series demonstrates a low (<1%) RTAD rate and favorable morbidity and mortality. The lower rate of paraplegia, dialysis, and visceral artery stenting in the cohort that had adjunctive use of ZDES is compelling and merits further assessment.

Effect of celiac axis compression on target vessel-related outcomes during fenestrated-branched endovascular aortic repair

ObjectiveTo report the effect of median arcuate ligament (MAL) compression on outcomes and technical aspects of celiac artery (CA) stenting during fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms. MethodsWe retrospectively reviewed the clinical and anatomic data on 300 consecutive patients enrolled in a prospective nonrandomized physician-sponsored investigational device exemption study from 2013 to 2018. From this group, 230 patients with CA incorporation by fenestration or directional branch were included. MAL compression was defined by preoperative computed tomography angiogram as a J-hook narrowing of the proximal CA at the level of the ligament; the shift angle between the downward and upward segments within the CA was measured. End points were technical success, rates of intraoperative or early (30-days) CA branch revision, and freedom from target vessel instability, defined by any death or rupture owing to target vessel complication, occlusion, or reintervention for stenosis, endoleak, or disconnection. ResultsCA incorporation was performed using fenestrations in 118 patients (51%) and directional branches in 112 (49%). MAL compression was present in 97 patients (42%), resulting in a stenosis of more than 50% in 48 (49%). MAL compression was more often present in patients with extent I to III TAAAs compared with extent IV TAAA-pararenal aortic aneurysms (56% vs 31%; P < .001). Technical success rate was 99%. Patients with MAL compression more often received a directional branch (65% vs 37%; P < .001), self-expanding bridging stent grafts (32% vs 16%; P = .007), adjunctive bare metal stents (46% vs 24%; P = .001), and coverage of the gastric artery (44% vs 22%; P < .001). An intraoperative (n = 6, 2.6%) or early (n = 1, 0.4%) revision of the CA branch was required in seven patients (3%) owing to dissection/occlusion (n = 2 [0.9%]), kinking/stenosis (n = 3 [1.3%]), stent dislodgement (n = 1 [0.4%]), or type IC endoleak (n = 1 [0.4%]). A shift angle of less than 120° was the most significant factor associated with CA branch revision (odds ratio, 10.9; 95% confidence interval, 2.3-88.9; P = .013). Freedom from CA branch instability was 97 ± 2% at 4 years, and this outcome was not associated with MAL compression (hazard ratio, 0.83; 95% confidence interval, 0.14-5.02; P = .588) or any other predictor. ConclusionsMAL compression was more common in extent I to III TAAAs, and related to additional challenges for CA stenting in fenestrated-branched endovascular aneurysm repair. This process may include bare metal stenting, gastric artery coverage, or early revision, especially in presence of an angulation of less than 120°. However, durable results can be achieved for CA incorporation despite these difficulties.

Transbrachial approach for successful recanalization and stenting of celiac artery

Mesenteric ischemia is an infrequent condition that presents either acutely or chronically. Endovascular treatment of mesenteric artery stenosis or short-segment occlusion by balloon dilation or stenting represents a less invasive therapeutic alternative to open surgical intervention, particularly in patients with comorbidities. We describe a case of ostio proximal celiac artery occlusion that was treated using balloon-expandable stent through the left brachial approach.

Stenting of superior mesenteric and celiac arteries does not increase complication rates after fenestrated-branched endovascular aneurysm repair

ObjectiveThis study compared complications in patients undergoing fenestrated-branched endovascular aneurysm repair (F-BEVAR) without and with stenting of the superior mesenteric artery (SMA) or celiac artery (CA), with particular attention to the length of coverage above the CA. MethodsA retrospective review was performed of a prospectively maintained database of patients treated with F-BEVAR for thoracoabdominal aortic aneurysms between July 2012 and May 2017. Data included demographics, risk factors, comorbidities, preoperative aneurysm characteristics, procedural data, and outcomes. Patients were grouped as follows: group 1, no SMA or CA stent; group 2, SMA or CA stent and <5 cm of coverage above the CA; and group 3, SMA or CA stent and ≥5 cm of coverage above the CA. Complications measured included death, myocardial infarction, respiratory failure, stroke or transient ischemic attack, paraplegia, acute kidney injury, mesenteric ischemia, and vascular complications. Individual and composite complications were compared between groups. ResultsThere were 223 patients who had data analyzed (group 1, 53 [24%]; group 2, 101 [45%]; and group 3, 69 [31%]). Mean age was 72 years (76% male). There was no difference in patients' characteristics between groups, except for hypertension (less common in group 2) and history of previous aortic surgery (more common in group 3). Group 2 (15%) and group 3 (90%) had higher spinal drain use than group 1 (2%; P < .0001). Mean operative time was longer in groups 2 and 3 compared with group 1 (group 1, 224 minutes; group 2, 253 minutes; and group 3, 313 minutes; P < .0001). Group 1 had more intraoperative complications, without difference in the technical success and mortality rates. Failure to deliver a bridging stent occurred in only 3 of 695 vessels (0.4%) intended, without difference between groups (P = .79). The incidence of major complications (individually and composite analysis) was similar between groups. On 30-day computed tomography angiography, there was no difference in type I or type III endoleaks (2%, 3%, and 6%) and branch patency (98%, 99%, and 99%) for groups 1, 2, and 3, respectively. At 3 years of follow-up, there was no difference in survival, stent patency, and branch instability. Group 3 had a higher reintervention rate compared with groups 1 and 2 (P < .0001); however, there was no difference between groups 1 and 2 (P = .31). ConclusionsPatients who needed SMA or CA incorporation with stents during F-BEVAR for aortic repair had more complex procedures, as assessed by operative time, brachial access, number of vessels incorporated, and spinal drain use. However, the extension of the repair did not affect the outcomes, demonstrated by similar mortality and morbidity rates between groups.

Superior Mesenteric and Celiac Artery Stenting Does Not Increase Complication Rate After Fenestrated or Branched Endovascular Aneurysm Repair

Extension of complex endovascular aortic repair into the mesenteric arteries (superior mesenteric artery [SMA] and celiac artery [CA]) may be associated with increased complications. The purpose of this study was to evaluate complications in patients undergoing complex endovascular aortic repair with ZFEN devices (Cook Medical, Bloomington, Ind) and those in a physician-sponsored investigational device exemption clinical trial to compare groups defined by stenting location and the length of coverage above the CA. A retrospective review of a prospectively maintained database was performed on patients undergoing fenestrated or branched endovascular aneurysm repair procedures for thoracoabdominal aortic aneurysms between September 2012 and May 2017. Patients were grouped according to presence of stents in the SMA or CA and the length of aortic coverage above the CA: group I, no SMA or CA stent; group II, SMA or CA stent and <5 cm coverage above CA; and group III, SMA or CA stent and ≥5 cm coverage above CA. Variables included demographics, risk factors, comorbidities, preoperative aneurysm characteristics, procedural data, and early outcomes. Individual and composite complications were compared between groups (death, myocardial infarction, respiratory failure, stroke/transient ischemic attack, paraplegia, acute kidney injury, mesenteric ischemia, and vascular complications). We treated 223 patients during the study period (mean age, 72 years; 76% male). There was no difference in demographics, risk factors, and comorbidities between groups, except hypertension was less common in group II and history of previous aortic surgery was more common in group III (Table). Group II (15%) and group III (90%) had higher spinal drain use than group I (2%; P < .0001). Operative time and brachial access use were greater in groups II and III compared with group I (P < .0001). There was no difference in technical success and mortality rates. Major complications (individually and composite analysis) were similar among groups. The 30-day computed tomography angiography showed no difference regarding type I or type III endoleak and branch patency for groups I, II, and III, respectively (Table I). Patients who needed SMA or CA incorporation with stents during fenestrated or branched endovascular aneurysm repair had more complex procedures, as assessed by operative time, brachial access, number of vessels incorporated, and spinal drain use. However, the extension of the repair did not have an impact on the outcomes, demonstrated by similar mortality and complication rates between groups.TableDemographics, risk factors, perioperative data, and early outcomesGroup I (n = 53)Group II (n = 101)Group III (n = 69)P valuesDemographics and risk factors Age, years74 ± 772 ± 770 ± 9NS Female sex12 (23)24 (24)26 (38).09 Coronary artery disease31 (58)55 (54)32 (46).38 Congestive heart failure11 (21)13 (13)14 (20).32 Hypertension52 (98)87 (86)67 (97).006 Hypercholesterolemia46 (87)76 (75)56 (81).22 Tobacco use52 (98)95 (94)64 (93).41 Chronic obstructive pulmonary disease32 (60)61 (60)39 (57).86 Diabetes mellitus12 (23)21 (21)10 (14).46 Chronic kidney diseasea19 (36)45 (45)31 (45).52 History of stroke/TIA7 (13)15 (15)11 (16).91 Prior open aortic repair2 (3.8)5 (5)22 (32)<.0001 Prior endovascular aortic repair2 (3.8)16 (16)32 (46)<.0001Perioperative data Spinal drainage1 (1.9)15 (15)62 (90)<.0001 Percutaneous femoral access13 (26)38 (38)51 (74)<.0001 Brachial access4 (7.6)49 (49)64 (93)<.0001 Technical success, %1009999.70 Operative time, minutes224 ± 72253 ± 72313 (95)<.0001 No. of stented vessels, mean1.8 ± 0.43.4 ± 0.63.7 ± 0.7<.0001 Estimated blood loss, mL378 ± 344385 ± 364477 ± 56.18Early outcomes Death2 (3.8)1 (1)3 (4.3).35 Estimated blood loss >1000 mL1 (1.9)6 (6)6 (8.8).28 Myocardial infarction2 (3.8)1 (1)0 (0).18 Congestive heart failure0 (0)0 (0)0 (0)— Respiratory failureb2 (3.8)6 (6)4 (5.8).83 Stroke/TIA0 (0)0 (0)1 (1.4).33 Paraplegia0 (0)0 (0)3 (4.3).14 Acute kidney injuryc2 (3.8)5 (5)3 (4.3).94 Mesenteric ischemia2 (3.8)2 (2)3 (4.3).65 Vascular or access complications5 (9.4)15 (15)10 (14).62 Composite complications12 (23)24 (24)13 (19).74 Endoleak type I or III1 (1.9)3 (3)4 (5.6).55 Target vessel patency, %989999.88NS, Not significant; TIA, transient ischemic attack.Categorical variables are presented as number (%). Continuous variables are presented as mean ± standard deviation.aNational Kidney Foundation classification stages 3-5 (estimated glomerular filtration rate <60).bReintubation or mechanical ventilation >48 hours.cRisk, Injury, Failure, Loss, and End-stage (RIFLE) criteria. Open table in a new tab

Staged retroperitoneal mesenteric revascularisation and aortobifemoral bypass after endovascular rescue for acute mesenteric ischaemia

Visceral artery revascularisation through a retroperitoneal approach provides an infrequent yet viable, alternative means of managing mesenteric ischaemia in patients with previous abdominal operations. We present a unique case implementing...

Results from multiple prospective single-center clinical trials of the off-the-shelf p-Branch fenestrated stent graft

ObjectiveThe purpose of this study was to report prospective data of an off-the-shelf fenestrated endograft (Zenith p-Branch; Cook Medical, Bloomington, Ind) from four centers for the treatment of patients with pararenal abdominal aortic aneurysms. MethodsData were combined from four single-center investigational studies conducted in the United States and Europe. The p-Branch endograft consists of a proximal off-the-shelf component incorporating a scallop for the celiac artery, a superior mesenteric artery fenestration, and two conical pivot fenestrations to preserve flow to the renal vessels. The device is available in two configurations, a left renal fenestration at the same (configuration A) or lower (configuration B) longitudinal position than the right to accommodate varied anatomy of the patients. ResultsBetween August 2011 and September 2015, 76 patients (82% male; mean age, 72 years; 65 elective and 11 emergent) were enrolled, with 55% implanted with option A and 45% with B. The device was deployed successfully in all patients, and stents were placed in all target vessels except in three cases (one elective, two emergent): a left kidney was sacrificed in one patient, and a right renal artery was left unstented in two patients during the index procedure. There was no 30-day mortality. During follow-up (mean, 25 ± 13 months), 10 late deaths occurred (6 elective, 4 emergent; none related to device or procedure), and there were no ruptures or conversions to open repair. Two patients experienced bowel ischemia; one case resolved with nonoperative treatment and one required superior mesenteric artery and celiac artery angioplasty and stent placement. Renal artery occlusion occurred in eight patients (11%) and was deemed procedure related in 63% (5/8) of these patients. Four of these were successfully intervened on with preservation of renal function. The overall renal insufficiency incidence was 7% (5/76). One patient developed renal failure requiring dialysis. ConclusionsEarly results incorporating learning curves for physicians with a new device and delivery system indicate that the use of the Zenith p-Branch device is feasible and safe. Long-term follow-up is needed to assess the effectiveness and durability of this treatment strategy and to refine the indications for use.

Trading scalpels for sheaths

The skill set of the acute care surgeon can be expanded by formal training. We report the first series of traumatic vascular injury (TVI) treated by acute care surgeons trained in endovascular techniques (ACSTEV). We retrospectively reviewed patients admitted to our trauma center with TVI over 5 months who survived for more than 24 hours and had catheter diagnosis and/or therapy by ACSTEV. Demographics, admission data, and outcomes were reviewed. Follow-up ranged from 0 day to 150 days. Most patients were male (63%) and sustained blunt mechanism (91%). Mean (SD) age was 48.2 (21.9) years, and mean (SD) Injury Severity Score was 32.1 (11.8). Mean (SD) admission systolic blood pressure, heart rate, Glasgow Coma Scale (GCS) score were 126.12 (30.4) mm Hg, 101.21 (28.2) beats per minute, and 10.8 (4.73), respectively. Forty-six patients underwent 48 endovascular procedures for TVI: 32 angiograms and 16 venograms were obtained. Two pelvic angiograms and one aortic arch angiogram were negative and required no treatment. One superficial femoral artery arteriogram showed minor luminal defects requiring anticoagulation only. Pseudoaneurysms were found in 17 vessels, vessel truncation in 4, active extravasation in 5, stenosis in 1, and dissection with thrombus in 1. Four patients had resuscitative endovascular balloon occlusion of the aorta performed before catheter intervention for pelvic hemorrhage. Procedures included aortic repair (4), pelvic embolization (13), splenic embolization (5), lumbar artery embolization (1), bronchial artery embolization (1), profunda artery embolization (1), common carotid artery stent (1), celiac artery stent (1), inferior vena cava filter placement (14) and retrieval (2), and pharmacomechanical thrombolysis (1). Treatment material included coils (12), Gelfoam (4), and nitinol plugs (3). No procedural or device-related complications occurred. Mortality was 14.7% unrelated to any endovascular procedure. One patient had repeat coil embolization of a pelvic pseudoaneurysm on postoperative Day 7. ACSTEV can safely treat TVI with good success. We performed nearly 10 procedures per month underscoring the role of the ACSTEV for training and care of TVI in a high-volume trauma center. Therapeutic study, level V.

Symptomatic Delayed Aortic Dissection After Superior Mesenteric Artery Stenting for Chronic Mesenteric Ischemia

Chronic mesenteric ischemia most commonly occurs secondary to atherosclerotic disease of the mesenteric arteries. Patients are often older than 60 years and can present with postprandial abdominal pain, nausea, diarrhea, and significant weight loss. Symptomatic disease has traditionally been managed with open surgical repair, but endovascular strategies, such as percutaneous angioplasty and stenting, have emerged as the mainstays of therapy. Complications from stenting include plaque embolization, thrombosis, perforation, or dissection of the mesenteric arteries. We present a patient with symptomatic acute aortic dissection 18 months after celiac and superior mesenteric artery stent placement for chronic mesenteric ischemia.

Use of Coronary Techniques in Celiac and Hepatic Artery Stenting in Post-Hepatic Transplant Patients

Use of Coronary Techniques in Celiac and Hepatic Artery Stenting in Post-Hepatic Transplant Patients

Isolated celiac artery dissection

Spontaneous celiac artery dissection is rare, and its natural history is not well studied. The objective of this study was to review our experience with the evaluation and management of this condition. During the last 8 years, 19 patients (14 men, five women) presented with the diagnosis of spontaneous celiac artery dissection. Each patient's clinical course was retrospectively reviewed, and patients were contacted for assessment of current symptoms. All patients had computed tomography scans documenting a celiac artery dissection without concomitant aortic dissection. Ages ranged from 39 to 76 years. Seven patients presented with abdominal pain, and 12 were diagnosed incidentally. All patients were initially treated with observation because none had threatened end organs. Patients presenting with aspirin or clopidogrel therapy were continued on these medications, but no patients were prescribed any medications due to their dissection. Three patients continued to have abdominal pain and eventually underwent celiac artery stenting. Pain improved after the intervention in all three. One patient with aneurysmal degeneration of the celiac artery underwent surgical repair. No other patients required intervention. Eighteen patients had follow-up within a year of data collection in the clinic or over the phone. The average time from the initial diagnosis to follow-up for the entire cohort was 46 months. None had abdominal or back pain related to the celiac dissection, had lost weight, or had to change their eating habits. Celiac artery dissection can be safely managed initially with observation. If abdominal pain is persistent, endovascular stenting may stabilize or improve the pain, and surgical reconstruction can be done for aneurysmal degeneration or occlusion, both unusual events. Long-term anticoagulation does not appear necessary in these patients.

Simultaneous coil embolization and angioplasty using a self-expanding nitinol stent to treat pancreaticoduodenal artery aneurysms associated with celiac artery stenosis

The degeneration of pancreaticoduodenal arcade vessels due to pancreaticoduodenal artery aneurysms is associated with celiac artery stenosis or occlusion. While technical advances have made it possible to treat pancreaticoduodenal arcade aneurysms (PDAA) and celiac artery stenosis by endovascular techniques, there is no consensus regarding their optimal treatment. To treat pancreaticoduodenal arcade aneurysms (PDAA) by simultaneous coil embolization and celiac artery stenting, and propose indications for treating PDAA with celiac artery stenosis by this method. We reviewed 11 patients who underwent transcatheter coil embolization (TCE) to treat PDAA. When the aneurysmal neck size was less than half of the short axis of the aneurysm we used packing only, when it was more than half of the short axis we undertook isolation. In the latter situation, when there was evidence of celiac artery stenosis, we performed celiac artery stenting using self-expandable stents. Ten of the 11 patients (91%) presented with celiac axis stenosis due to median arcuate ligament compression. Coil-packing of the aneurysmal sac only, thus preserving the native arterial circulation, was done in five patients, another five underwent isolation by embolization of vessels distal and proximal to the PDAA with simultaneous stenting of the stenotic celiac axis, and one patient was treated by isolation only. One patient developed acute pancreatitis. There were no other complications and all aneurysms were successfully excluded. In one patient the celiac stent thrombosed after stopping the antiplatelet regimen. TCE can be effective in patients with PDAA. In the presence of celiac artery stenosis, we recommend isolation of the aneurysms with simultaneous stenting of the stenotic celiac trunk using self-expandable stents.

Eight Years Experience in the Management of Median Arcuate Ligament Syndrome by Decompression, Celiac Ganglion Sympathectomy, and Selective Revascularization

We aim to review an 8-year experience of median arcuate ligament syndrome (MALS) with chronic gastrointestinal ischemia (CGI) and evaluate clinical outcomes of arcuate ligament decompression, celiac sympathectomy, and selective revascularization. Between December 2002 and March 2012, of 25 patients referred with symptoms of CGI, 11 patients (10 women and 1 man) had clinical signs of abdominal angina and radiological evidence of MALS. Mean age was 50 ± 20.4 years. Median symptom duration was 34 months. All patients had median arcuate decompression and celiac sympathectomy. In all, 8 did not require revascularization, 2 had retrograde celiac and/or superior mesenteric artery (SMA) stenting, and 1 had SMA bypass. There was no mortality. The 30-day morbidity was 9%. Mean follow-up was 60 months. Eight patients noted complete relief of abdominal pain, and 1 reported some improvement. The MALS is not solely a vascular compression syndrome. The neurological component requires careful celiac plexus sympathectomy in addition to arcuate ligament decompression.

8:32 AM Abstract No. 16 - ■ FEATURED ABSTRACT Stenting of superior mesenteric artery chronic total occlusions in patients with chronic mesenteric ischemia: technical and clinical outcomes

Purpose While endovascular treatment of chronic mesenteric arterial stenosis is well accepted, management of chronic total occlusions (CTO) remains controversial with historical mainstays of treatment consisting of bypass or endarterectomy. Our goal is to evaluate the clinical and technical outcomes of endovascular recanalization and stenting of CTOs of the superior mesenteric artery (SMA). Materials and Methods We performed a retrospective review of 46 patients (18 M, 28 F) who underwent endovascular stenting of CTOs of the SMA between February 2008 and July 2012. All patients had symptoms of chronic mesenteric ischemia. Procedural and follow-up data were collected for assessment of technical success, safety and outcomes. Technical success was defined as the ability to traverse and stent the SMA occlusion without significant residual stenosis. Patency and freedom from symptom recurrence were calculated by Kaplan Meier analysis. Results Technical success was achieved in 40 of 46 patients (87%). Twelve patients underwent concurrent stenting of the celiac artery. Of the 6 technical failures, 2 were referred for bypass, 3 underwent celiac artery stenting, and 1 was lost to followup. Within 24 hours of the procedure, complete symptomatic relief was reported by 39 of 40 (97%) patients, while 1 patient (3%) reported partial improvement. No patients reported stable or worsening of symptoms. Imaging followup (22 US, 8 CTA) was obtained in 30 of 40 (75%) patients with a mean followup of 11.2 months. Kaplan Meier analysis revealed a primary patency of 100% at 3mo, 96% at 6mo, 80% at 1yr, and 72% at 2yrs. Symptomatic recurrences, which was observed in 5 patients, correlated to restenosis/reocclusion on imaging. All 5 patients underwent successful assisted or secondary PTA and/or stenting procedures. Kaplan Meier analysis of freedom from symptom recurrence showed primary and assisted rates of 80% and 100% at 1 year, and 77% and 97% at 2 years. There were 3 (7%) minor access-related complications and no major complications. Conclusion Endovascular stenting of CTOs of the SMA is a safe and effective procedure with an acceptable technical success rate and excellent mid-term clinical outcomes.

Endovascular Rescue of a Thoracoabdominal Fenestrated Endograft Presenting With Combined Type 1 and Type 3 Endoleaks From Aortic Graft Migration and Visceral Stent Separation

To describe successful endovascular rescue of a prior fenestrated endograft repair of a thoracoabdominal aneurysm that presented with combined type I and type III endoleaks due to aortic stent migration and subsequent visceral stent dislodgement. A 67 year old male with significant cardiac dysfunction and chronic renal insufficiency underwent fenestrated endograft repair of a 7 cm type IV thoracoabdominal aneurysm with 4 fenestrations in 2008. He presented with acute onset abdominal pain. CT scan revealed type I and III endoleaks with aneurysm enlargement to 10 cm. Angiography revealed the superior mesenteric and renal artery stents within their target vessels, but separation from their respective fenestrations in the aortic graft with significant gaps (>15 mm) and resultant type 3 endoleaks. The celiac artery stent was fractured; part of it remained within the celiac artery and part within the celiac fenestration and a 30 mm craniocaudal gap between the two pieces. All 4 visceral stents were patent with intact distal flow. A large proximal type 1 endoleak was also seen. All fenestrations were successfully catheterized via percutaneous approach and gaps were successfully bridged with covered stents eliminating the type III endoleaks. A thoracic endograft was placed proximally to repair the type I endoleak. Completion angiography demonstrated successful resolution of the type I and type III endoleaks with flow through all 4 branches and tertiary vessels. Endovascular rescue of prior branched endografts is a feasible solution in patients at prohibitive risk for open surgery.

Celiac Artery Stenting to Facilitate Hepatic Yttrium-90 Radioembolization Therapy

Radioembolization offers a novel way to treat the nonresectable, liver predominant hepatic malignancies with better tumor response and overall progression-free survival rates. Transarterial catheter-based radioembolization procedure involves the hepatic arterial administration of glass- or resin-based beta emitting Yttirum-90 microspheres. Safe delivery of the tumoricidal radiation dose requires careful angiogram planning and coil embolization to quantify lung shunting and prevent systemic toxicity, respectively. Diagnostic pretreatment angiogram also serves to identify the hepatic arterial variant anatomy and other coexisting pathologies that might require a different or alternative approach. We describe a complex case of celiac artery stenosis with tortuous pancreaticoduodenal arterial arcade precluding access to the right hepatic artery for performing radioembolization. Celiac artery stenting of the stenosis was performed to facilitate subsequent safe and successful Yttrium-90 microsphere radioembolization.

Results of Single- and Two-Vessel Mesenteric Artery Stents for Chronic Mesenteric Ischemia

Conclusions: Stenting of both the celiac artery and the superior mesenteric artery (SMA) for chronic mesenteric ischemia (CMI) does not reduce recurrent symptoms or reinterventions compared with stenting of the SMA alone. Isolated celiac stenting carries a high risk of symptom recurrence. Summary: Mesenteric artery stenting is gaining wider acceptance for the treatment of CMI. It relieves symptoms of CMI in 78% to 100% and has lower morbidity and mortality compared with open reconstruction. However, the durability of mesenteric stenting is questioned. Primary patencies have ranged from 30% to 82%, and 17% to 64% of patients have recurrent symptoms at 2 years of follow-up (Atkins MD et al [J Vasc Surg 2007;45:1162-71]; AbuRahma AF et al [J Endovasc Ther 2003;10:1046-53]). It is generally agreed that the SMA is the primary target vessel for revascularization for patients with CMI. In open surgical procedures, it is debated whether revascularization of the SMA alone is adequate treatment. In endovascular therapy for CMI, it is also unclear whether stenting of the celiac artery in addition to the SMA adds to the durability treatment. The purpose of this study was to describe the outcomes of single-vessel vs two-vessel mesenteric stent placement in patients with CMI secondary to atherosclerotic disease. The authors reviewed 101 patients (41 men, mean age 73 ± 13 years) who were treated with mesenteric artery stents from 1998 to 2008. Patients treated with single-vessel SMA stents (group A), two-vessel celiac artery and SMA stents (group B), and patients treated with isolated celiac artery stenting (group C), were reviewed with respect to clinical data and outcomes. The groups were analyzed for differences in morbidity and mortality and freedom from recurrent symptoms and reintervention. There were 61 patients in group A, 24 in group B, and 16 in group C. Demographics, cardiovascular risk factors, and clinical presentation were similar among the three groups. The three groups had similar early mortality (2%, 4%, and 0%, respectively), morbidity (18%, 26%, and 12%, respectively), and symptom relief (95%, 78%, and 100%, respectively). Freedom from reintervention at 1 and 3 years was similar in group A (86% ± 5% and 50% ± 9%), group B (67% ± 11% and 67% ± 11%), and group C (63% ± 13% and 63% ± 113%). Differences in freedom from restenosis were similar at 1 and 3 years in group A (54% ± 7% and 44% ± 9%), group B (47% ± 12% and 39% ± 12%), and group C (43% ± 13% and 34 ± 13%). Primary and secondary patencies at 3 years were 57% and 96% for SMA stents and 61% and 87%, respectively, for celiac stents (P > .05). Celiac artery stenting alone was associated with symptom recurrence in 38% compared with recurrence rates of 18% in patients who underwent SMA stent placement (P = .06). Two-vessel stenting was associated with more complications (33%) compared with stenting of the SMA (18%) or celiac artery (6%) alone. The higher complication rate was due to more interprocedural complications (residual stenosis or dissection). Comment: There was no added benefit to two-vessel stenting compared with single-vessel stenting for treatment of CMI. Long-term results were similar, with nearly identical rates of restenosis, reintervention, and symptom recurrence. Two-vessel stenting was associated with more complications. The study was limited by its retrospective design. It is possible there was a bias toward placement of two stents in patients with more symptoms or when the anatomy of the SMA was suboptimal for stenting. It is conceivable patients with poor collateralization between the celiac and SMA with significant gastric ischemic manifestations of CMI may benefit from stenting both arteries. Overall, however, the data do not support a policy of routine stenting of the celiac and SMA for treatment of CMI.