Celiac Artery Research Articles

Duodenal Obstruction Caused by an Isolated Spontaneous Celiac Artery Dissection.

Duodenal Obstruction Caused by an Isolated Spontaneous Celiac Artery Dissection.

Effectiveness of Steerable Microcatheters During Transarterial Chemoembolization for Hepatocellular Carcinoma.

Although transarterial chemo-embolization (TACE) is a key treatment for hepatocellular carcinoma (HCC), its effectiveness depends on the cannulation of the microcatheter tip into the feeding artery. Steerable microcatheters allow remote operation of the tip, enabling its insertion into feeding arteries otherwise difficult to reach. This study investigated the indications and effectiveness of steerable microcatheters in TACE for HCC. We retrospectively examined 22 patients with HCC who underwent TACE using steerable microcatheters at our Department between December 2014 and July 2024. Previous TACE administration, number of TACE sessions, and feeding artery disruption affecting TACE were examined. Among the first TACE cases requiring steerable catheters, three demonstrated steep bifurcation of the celiac artery or superior mesenteric artery from the parent artery, two had sharp bends in the posterior segment, and four had the left hepatic artery bifurcating from the left gastric artery. All three procedures performed in the inferior phrenic artery required second TACE sessions. Steerable microcatheters were used in two patients during their eighth TACE session; both procedures involved selective cannulation of neovessels feeding from a new anastomotic branch to segment 4, following damage to the main feeding artery from repeated treatments. Steerable microcatheters were effective in reaching steep or strongly bending branches of the parent or feeding artery in the first TACE cases or neovessels and anastomotic branches in previous TACE cases. Studies with larger sample sizes are warranted to validate the use of steerable microcatheters for effective TACE.

Side branch interventions late after MFM implantation

Abstract Background MFM prostheses were developed for the endovascular treatment of aortic and great vessel aneurysms. Implanted between two healthy segments of arterial vessel, they centralize blood flow and trough Bernoulli's principle. Thereby hemodynamic stress into the aneurismal sac is reduced. Meantime, the porosity along entire prosthesis length preserves all side branches (SB) patent. Results from real clinical practice confirm the high success rate (nearly 100%) of MFM prostheses regarding side branch preservation at one-year follow-up [1,2]. However, late after MFM implantation SB intervention may be required (due to atherosclerosis or others). The access to SB covered by MFM is challenging due to: impossible ostial engagement of the guiding catheter, distance between target vessel ostium and prosthesis, the necessary for all devices used to cross MFM mesh. Materials and methods For the period 2016-2020 we implanted a specific type of MFM prosthesis in order to treat aneurysm of the abdominal aorta in 34 patients. A total of 129 side branches was covered. Within a mean follow-up period of 5 years, 129 side branches were preserved and 7 affected by stenosis or occlusion (two of them asymptomatic). Intervention on the branch covered by the MFM prosthesis was necessary in 5 patients (two males, two females; mean age 68 years). One patient had endovascular celiac trunk stenosis, one patient had both celiac trunk and superior mesenteric artery stenoses, one patient had superior mesenteric artery stenosis, and one patient had left renal artery stenosis. All lesions were intervened through radial or brachial approach. Guiding 6F Judkins right catheter was navigated close to the target branch ostium and the MFM mesh was crossed with .014¨ coronary wire. When guidewire was placed into target vessel small low-profile, coronary balloon is advanced across the mesh of the multilayer stent. Anchor balloon technique was used in order for guiding catheter to cross the mesh gradually. Once the guiding catheter is engaged, the lesion was treated with balloon pre-dilation and implantation of a low-profile, high radial force stent. Results All 4 patients and 5 affected vessels were successfully endovascularly intervened. We did not observe any procedure complications. Immediate resolution of clinical symptoms was achieved. At 1 year follow-up with CT scan all treated branch arteries were patent. Conclusions In patients with previously implanted multilayer stents, the mesh can be crossed safely with readily available coronary devices together with the balloon anchor technique. As such, endovascular treatment of stent-covered visceral and renal arteries is possible without open surgery.Catheter stabilizationSMA successfully treated

Luminal shape and aortic remodelling after total arch replacement for type A aortic dissection: conventional and frozen elephant trunks.

This study was performed to assess postoperative aortic remodelling (AR) after total arch replacement (TAR) for acute type A aortic dissection (AAD) with a frozen elephant trunk (FET) or conventional elephant trunk (cET). Furthermore, the shape of the residual true lumen (TL) was analyzed based on elliptical Fourier analysis (EFA) and evaluated as a predictor of AR. This study involved patients who underwent TAR with a cET or FET for AAD from December 2006 to January 2023 at five institutions. AR was assessed at the levels of the 4th thoracic vertebra (Th4), Th7, Th10, and above the coeliac trunk. The shape of the residual TL at all four levels was analyzed based on EFA to calculate shape patterns as principal component (PC) values. Inverse probability of treatment weighting (IPTW) was performed for adjustment between the groups. In total, 180 patients (88 with cET and 92 with FET) were enrolled. The complete AR rate, defined as false lumen remodelling throughout the entire descending thoracic aorta, was significantly higher in the FET than cET group (63.4% vs 32.0%, P = 0.0013). The IPTW-adjusted Fine-Gray regression model revealed that the mean PC2 (hazard ratio, 0.22; P < 0.001) and PC3 (hazard ratio, 0.24; P = 0.009) of the four levels were independent predictors of complete AR. In AAD repair, the AR rate was significantly higher with use of the FET than cET. The shape patterns of the residual TL can be an important reference for predicting postoperative AR.

Isolated Celiac Trunk Dissection as a Cause of Abdominal Pain

Isolated Celiac Trunk Dissection as a Cause of Abdominal Pain

Short and longterm outcome of minimally invasive therapy of median arcuate ligament syndrome.

Median arcuate ligament syndrome (MALS) is a rare disorder caused by compression of the celiac artery (CA) by the median arcuate ligament (MAL). Common symptoms include postprandial abdominal pain, diarrhea, and weight loss. While laparoscopic MAL division has long been considered the procedure of choice, robotic-assisted procedures have been increasingly used since their introduction. Aim of this study was to evaluate peri- and postoperative outcomes after minimally invasive MAL release. A retrospective analysis of patients undergoing minimally invasive MAL release at the Department of Surgery, Charité - Universitätsmedizin Berlin, between 2014 and 2023 was performed. 20 patients met the inclusion criteria and underwent either laparoscopic (n = 3) or robotic (n = 17) MAL release. Most common preoperative symptoms were postprandial abdominal pain (90%), weight loss (45%), diarrhea (30%), and nausea (25%). Comparing laparoscopic and robotic surgery, neither the median duration of surgery (minutes: 98 (90-290) vs. 125 (80-254); p = 0.765), the median length of hospital stay (days: 4 (3-4) vs. 5 (3-6); p = 0.179) and intraoperative blood loss (< 50ml in both groups, p = 1.0) showed significant differences. Peak systolic velocity in the CA was significantly reduced postoperatively (cm/s: 320 (200-765) vs. 167 (100-500), p < 0.001). Postoperatively, 17 (85%) patients reported symptom improvement, while 4 (20%) patients had no symptom relief at last follow-up. In 3 cases, follow-up imaging showed evidence of respiratory-related CA stenosis. Despite being complex and challenging procedures, laparoscopic and robotic-assisted MAL release are safe procedures with low risk of postoperative complications and good longterm outcomes.

Long-Term Outcomes of PETTICOAT Technique-Assisted Thoracic Endovascular Aortic Repair for the Treatment of Acute and Subacute Complicated Type B Aortic Dissection.

To evaluate the long-term outcomes of the provisional extension to induce complete attachment technique (PETTICOAT) for the treatment of acute and subacute complicated type B aortic dissection (TBAD). We retrospectively collected and analyzed the clinical data of patients with acute and subacute TBAD who were treated using the PETTICOAT technique at our center between March 2014 and March 2023. The primary endpoint was all-cause mortality; secondary endpoints were a composite of complications, such as entry flow, stent-graft-induced new entry (SINE), and re-intervention. The technical success was 92% (46/50). The perioperative mortality was 2% (1/50), and the procedure-related re-intervention was also 2% (1/50). The mean follow-up time was (74.9±33.9) months. The mortality was 4.1% (2/49). The incidence of aortic-related complications was 8.2% (4/49), including new entry flow, 2 retrograde type A aortic dissections, and 1 distal stent graft-induced new entry SINE. The procedure-related re-intervention rate was 4.1% (2/49). After 5 years of follow-up, the total aortic diameter at the renal artery level was reduced from that at the third year of follow-up but was still significantly larger than preoperatively (26.9±6.6 mm vs. 24.1±4.2 mm, p=0.013). While at the covered stent, bare stent, stentless, and celiac artery (CA) levels, the total aortic diameters did not change significantly compared with preoperative values, whereas true lumen (TL) diameters and TL ratios were maintained at obviously higher levels than preoperative. The rate of complete thrombosis of false lumen in the thoracic aortic segment was significantly higher than that in the abdominal aortic segment (79.6% vs 30.6%, p=0.0001). The results indicated that the PETTICOAT technique is safe and effective and could promote positive remodeling of the aorta from the level of the covered stent to the CA. Remodeling of the distal abdominal aorta may fluctuate and requires close follow-up review. The long-term results from our center suggest that the PETTICOAT technique promotes positive remodeling of the aorta from the level of the covered stent to the CA; whereas this advantage does not seem to be significant in the more distal segment of the abdominal aorta, mainly at the level of RA and distal. Therefore, further procedures may be required for aortic dissection of the abdominal segment. In addition, aortic remodeling may fluctuate to some extent during the follow-up period, especially in the abdominal visceral region, so close follow-up review is quite important, and prompt re-intervention is required if necessary.

Anatomical analysis of the abdominal aorta in a South African sample: influence of age and sex.

The anatomy of the abdominal aorta (AA) varies with age and sex; however, limited studies exist from South Africa. Given the increased incidence of endovascular treatment of the AA, reference values are relevant for interventionalists for improving the safety of endovascular procedures. Therefore, the study aimed to determine the lengths, diameters and tortuosity of the AA and their association with age and sex in a South African sample. After ethical approval, 97 computed tomography angiography (CTA) scans from an adult sample (54 male and 43 female), mean age 48.5 ± 17.2 years were analysed. The aortic length was measured from the origin of the coeliac trunk to the bifurcation point of the AA. The lumen diameters of the aorta were measured at three landmarks. Tortuosity of the AA was quantified with the tortuosity index and its prevalence was determined. The AA was longer in males and showed a significant weak positive correlation with age. The mean diameters of the AA were larger in males and had a significant strong positive correlation with age in both sexes (p < .001). There was a strong positive correlation between age and tortuosity in both sexes (p < .001). The prevalence of a tortuous c-shaped-curve phenotype was 8.2%, with a 7:1 male-to-female ratio. The dimensions and tortuosity differed between sexes and varied significantly with age. These findings may contribute towards reference values in the South African setting, inform patient selection and complement decision-making of endovascular treatment strategies.

Median Arcuate Ligament Syndrome: Where Are We Today?

Median arcuate ligament syndrome, or celiac artery compression syndrome (eponym: Dunbar syndrome), has historically been attributed to pathophysiologic vascular compression causing downstream ischemic symptoms of the organs supplied by the celiac trunk. However, the more we learn about the histology, clinical presentation, and treatment outcomes, health care providers are increasingly correlating the symptoms of MALS with the long-term, repetitive compression of the celiac ganglion rather than the celiac trunk. This article provides a comprehensive review of current MALS literature, emphasizing the multidisciplinary approach these patients require in all phases of their care. With most patients with MALS waiting an average of 10.5months to 2.6years, 9, 10 our need for better diagnostic protocols and clearer understanding of the pathophysiology of the disease is paramount. Further investigation into patient outcomes, associated conditions, and linked pathophysiology would help better characterize this disease with hopes of moving it from a diagnosis of exclusion to one of standard work-up with decreased time to treatment and symptom relief for patients.

Interventional Management of Visceral Artery Aneurysms: Simple to Complex

AbstractVisceral artery aneurysms (VAAs) are uncommon but potentially life-threatening vascular disorders that can involve the celiac, superior, and inferior mesenteric arteries or their branches. They are often asymptomatic but can present with vague abdominal pain, secondary effects, or signs of hemorrhage. The most common site of involvement is the splenic artery, followed by the hepatic artery, the celiac axis, and mesenteric arterial branches. VAAs can be classified into two types: true aneurysms (TAs) and pseudoaneurysms (PSAs). Imaging, particularly multidetector computed tomography angiography, is the cornerstone in diagnosing VAAs. Treatment decisions are based on the risk of rupture and clinical deterioration in a patient with a VAA. The endovascular approach remains the mainstay in the treatment of VAAs. As a general guideline, PSAs, even when asymptomatic, should always be treated. TAs are treated based on their size and location. Deconstructive and reconstructive strategies are the standard treatment options for any VAA, and assessing the vascular anatomy and collateral circulation is paramount for treatment decisions.

Incidental Renal Infarction on imaging for Abdominal Aortic Aneurysm

A 59-year-old man who under surveillance for abdominal aortic aneurysm and peripheral artery disease, was investigatedwith a CT Angiogram aorta. The CT scan showed an abdominal aortic aneurysm reaching 6.2cm with significant thrombusburden, occluded coeliac artery, occluded left iliac artery, calcified stenosis of the right renal artery and features of chronicrenal infarct in the right upper pole. Technetium-99m dimercaptosuccinic acid (Tc-99m DMSA) renal scan was done todocument the extent of the infarction and for differential function of the kidneys.Keywords: Renal infarction, Abdominal Aortic Aneurysm, Contrast Enhanced CT, DMSA.

Spontaneous Isolated Celiac Artery Dissection in a Young Woman

Spontaneous Isolated Celiac Artery Dissection in a Young Woman

Extrarenal Visceral Arteries Injuries during Left Radical Nephrectomy: A 50-Year Continuing Problem

Due to their proximity to the left renal hilum, injuries to the superior mesenteric artery and celiac trunk are still reported during left radical nephrectomy, whether performed via open, laparoscopic, or robotic methods. The aim of this 50-year narrative review is to emphasize the anatomical and pathophysiological bases, risk factors, and strategies for the prevention, diagnosis, and treatment of such injuries.

Distal Pancreatectomy with and without Celiac Axis Resection for Adenocarcinoma: A Comparison in the Era of Neoadjuvant Therapy.

Distal pancreatectomy with celiac axis resection (DP-CAR) has been used for selected patients with pancreatic cancer infiltrating the celiac axis. We compared the short- and long-term outcomes between DP-CAR and distal pancreatectomy alone (DP) in patients receiving neoadjuvant therapy. Patients undergoing DP-CAR from 2013 to 2022 were retrospectively reviewed. Clinicopathologic features, post-operative morbidity, and survival outcomes were compared with patients undergoing DP after neoadjuvant chemotherapy. Twenty-two DP-CAR and thirty-four DP patients who underwent neoadjuvant chemotherapy were identified. There were no differences in comorbidities or CA19-9 levels. OR time was longer for DP-CAR (304 vs. 240 min, p = 0.007), but there was no difference in the transfusion rate (22.7% vs. 14.7%). Vascular reconstruction was more common in DP-CAR (18.2% vs. 0% arterial, p = 0.05; 40.9% vs. 12.5% venous, p = 0.04). There was no difference in morbidity or mortality between the two groups. Although there was a trend towards larger tumors in DP-CAR (5.1 cm vs. 3.8 cm, p = 0.057), the overall survival from the initiation of treatment (32 vs. 28 months, p = 0.43) and surgery (30 vs. 24 months, p = 0.43) were similar. DP-CAR is associated with similar survival and morbidity compared to DP patients requiring neoadjuvant chemotherapy and should be pursued in appropriately selected patients.

A New Bailout Maneuver to Manage Type IIIa Endoleak Due to Displaced Renal Bridging Stent Graft in Narrow Aorta.

To present endovascular management of an intraoperative type IIIc endoleak (EL) in a patient with migration of the right renal artery (RRA) bridging stent graft (BSG) during branched aortic aneurysm repair. The technique is demonstrated in an 80-year-old woman who underwent branched endograft repair of a symptomatic 6-cm type II TAAA. The t-Branch thoracoabdominal stent graft was positioned without difficulty. A "partial graft deployment" was performed, with the distal portion of the device remaining inside the delivery system and the right renal and superior mesenteric arteries were stented. When the constraining wires were removed, the RRA BSG migration from the branch was displayed, due to endograft twisting resulting in a horizontal rotation of the t-Branch. The RRA BSG remained oriented upward with the proximal edge positioned above the distal edge of the directional branch, making cannulation very difficult. This bailout technique uses a balloon placed at the level of the RRA BSG through the celiac artery (CA) directional branch; keeping the balloon inflated and in thrust, the edge of the BSG has moved downward making it possible to engage it and relining through the RRA directional branch. This paper describes an endovascular bailout technique for relining a displaced bridging stent graft, oriented upwards with the proximal edge positioned above the distal edge of the directional branch. This sophisticated technique adds to the spectrum of bailout techniques that can be applied in cases of type IIIa EL with migration and complete separation of BSG.

Hybrid Stent Graft Technique in Bridging Hostile Renal Arteries in Thoracoabdominal Branched Endografting

Patency of target arteries is crucial for fenestrated and branched endovascular aortic repair (F/B-EVAR) in thoracoabdominal aortic aneurysms (TAAAs). Occlusions more frequently occur in renal arteries (RAs) than in coeliac and superior mesenteric arteries, especially in patients with hostile anatomy treated by BEVAR. This study aimed to report RA outcomes using a hybrid bridging stent graft technique with distal self expandable (SE) combined with proximal balloon expandable (BE) stent graft during BEVAR with hostile RA anatomies. Clinical data from consecutive patients treated for TAAA by F/B-EVAR in three aortic centres (two in the USA, one in Europe) from 2016 to 2022 were prospectively collected. Renal artery orientation was defined as hostile in case of upward (type B) or downward + upward (type D) orientation. Hostile RAs accommodated by BEVAR and combination of SE + BE stent grafts were retrospectively evaluated. Intra-operative RA related complications, technical success, and branch occlusions were assessed as early outcomes. Primary and secondary RA patency, freedom from RA related re-interventions, and freedom from RA instability were assessed during follow up. Of 584 TAAAs managed by F/B-EVAR, 83 patients (14.2%) had 125 hostile RAs (type B, 45.6%; type D, 54.4%) managed by BEVAR with hybrid SE + BE stent grafts. Intra-operative complications occurred in three RAs (2.4%), including two dissections and one disconnection, all successfully managed with additional stent. Technical success was achieved in all cases, with no RA occlusions at 30 days. The median follow up was 21 (interquartile range 4, 38) months. Estimated three year RA primary patency was 97 ± 2%. Re-interventions were performed in five RAs (4.0%), including two RA branch embolisations for bleeding, two catheter thrombectomies with stent relining (bilateral occlusion in one patient), and one revision of type Ic endoleak. Freedom from RA related re-interventions and RA instability was 95 ± 2% and 91 ± 3% at three years, respectively. Renal artery secondary patency was 99 ± 1% at three years. In hostile RA anatomies, a combination of distal SE and proximal BE stent grafts as bridging stenting in BEVAR is safe and effective, with low rates of occlusion, re-interventions, and branch instability at midterm follow up.

8275 Recurrent Retroperitoneal Paraganglioma

Abstract Disclosure: J. Kang: None. V. Gupta: None. J.S. Subauste: None. Paragangliomas are rare, highly vascular neuroendocrine neoplasms that may originate from sympathetic or parasympathetic paraganglia and may secrete catecholamines. They are closely related to pheochromocytomas which are considered to be their intra-adrenal counterparts. A 65-year-old African American male with type 2 diabetes and tobacco use presented to his primary care physician with night sweats and unintentional weight loss of about 30 pounds in 3 months. Review of systems and laboratory workup was unremarkable. CT Chest/Abdomen/Pelvis with contrast showed a homogenous, well-circumscribed 4.6cm retroperitoneal mass causing mass effect on portal vein, Inferior vena cava, and right renal artery. Interventional radiology performed fine needle aspiration with intra-procedural blood pressure rising to 201/70 mmHg. Pathology showed paraganglioma, staining positive for synaptophysin, chromogranin A, CD 56 and S-100 protein. Plasma metanephrines were elevated at 2818 pg/mL, plasma normetanephrines at 1247 pg/mL with consistent 24-hour urine results. Workup for other adrenal hormones was negative. No family history of pheochromocytoma/paraganglioma or any clinical manifestations of Von-Hippel-Lindau syndrome or Neurofibromatosis were present. He was started on alpha blockade followed by beta blocker and surgical resection was planned. In the interim, escalating requirements of insulin were noted. Intra-operative course was complicated by systolic blood pressure rising to 290s which resolved after mass was removed. Immunohistochemical studies sent to Mayo, Rochester showed retained cytoplasmic SDHB expression in tumor cells. Hence, no further genetic testing was performed. Post excision, plasma-free metanephrines normalized with significant improvement in blood pressure and diabetes. He was followed with yearly plasma-free metanephrines for surveillance. Although asymptomatic, a three-fold rise of plasma metanephrines was noted five years later. CT Abdomen was concerning for recurrence. Dotate/PET scan showed dotate-avid para-aortic soft tissue lesion measuring 2.3 cm between the celiac artery and the superior mesenteric artery which was surgically excised with pathology consistent with paraganglioma (Ki67&amp;lt;1%). Diagnosis of paragangliomas is often in 3rd - 5th decade. About 30% are hereditary and associated with Von-Hippel-Lindau, Neurofibromatosis-1, MEN2A/B among other syndromes. They are mostly benign but SDHB pathogenic variants are likely to be malignant. Genetic testing should be considered in all paraganglioma patients to screen for germline pathogenic variants in SDH and other genes. Diagnosis of secretory paraganglioma is by urinary and/or plasma fractionated metanephrines and catecholamines. Treatment of choice is surgery when amenable to resection with preoperative medical blockade to prevent perioperative complications. Presentation: 6/1/2024

Symptomology of celiac artery compression: Classifying patients by the degree of celiac artery stenosis and secondary changes in collateral branches on computed tomography angiogram

PurposeThis study aimed to analyze the correlation between the degree of celiac artery (CA) stenosis and the secondary changes in collateral branches in patients with CA compression (CAC) by CT and to classify patients by the combination of the two imaging features. MethodsPatients with CAC identified by contrast-enhanced CT from January 2012 to December 2013 were retrospectively enrolled and divided into the symptomatic group and asymptomatic group. CA stenosis was categorized as mild, moderate, or severe, and collateral circulation as invisible, visible, or prominent. The correlation between the imaging features was analyzed with Kendall’s Tau-b. Multivariate regression identified risk factors for symptomatic CAC. And patients were further classified into three subtypes (Type A to C) based on CA stenosis and collateral circulation. ResultsThis study included 150 patients (79 men, 71 women), with 49 (32.7 %) symptomatic. The collateral circulation classification correlated with the CA stenosis (Tau-b = 0.295, p < 0.001). And both imaging features were proven to be independent risk factors for the symptomatic CAC (all p < 0.05). Of the three subtypes of patients, only one patient with Type A (1/26 [3.8 %]) was symptomatic; a small proportion of patients with Type B (23/99 [23.2 %]) were symptomatic; and all patients with Type C (25/25 [100 %]) were symptomatic. ConclusionsThe development of collateral circulation is positively correlated with the degree of CA stenosis. Our proposed classification system based on the combination of the degree of CA stenosis and collateral circulation helps to identify patients with symptomatic CAC.

A three-year experience with the balloon expandable GORE® VIABAHN® VBX in the treatment of thoraco-abdominal aortic aneurysms within the EXPAND Trial

The EXPAND registry is a post-market, multicenter registry that aims at evaluating the safety and performance of the GORE® VIABAHN® VBX Balloon Expandable Endoprosthesis (VBX stent) implanted in peripheral vessels. This subgroup analysis assesses the three-year outcomes of the VBX stent as a bridging stent-graft (BSG) for visceral vessels during branched endovascular aortic repair (BEVAR). This prospective, multicenter, observational registry includes 16 European sites. Patients were enrolled from November 2018 to March 2022. Endpoints included three-year primary patency (PP), secondary patency (SP), and stent graft-related death and serious adverse events (SAE). Seventy-three patients of whom 57 (78.1%) were male with a mean age of 73 years (± 8.1) were included. At three years, 42 (57.5%) patients returned for follow-up. Overall, 223 target vessels (TV) were treated. The estimated freedom from loss of TV primary patency was 93.6%. Per target vessel primary patency rates were 97.0% for the celiac trunk, 93.9% for the superior mesenteric artery (SMA), 91.2% for the left renal artery, and 92.5% for the right renal artery. The overall estimated freedom from loss of secondary patency was 96.8%, and freedom from target vessel instability was 94.5%. The VBX stent demonstrated excellent sustained results at three years with almost 94% primary patency, 97% secondary patency, and 94.5% freedom from target vessel instability. Patency in the renal arteries was lower than in the celiac trunk and SMA. The VBX stent appears to be a reliable bridging stent for target vessels in BEVAR.

Midterm single center results with the use of custom-made endografts with inner branches, a call for attention.

ObjectiveTo evaluate the patency of bridging covered stents (BCS) bridged to inner branches in custom-made thoracoabdominal endografts. MethodsSingle-center retrospective study identifying all patients undergoing fenestrated or branched endovascular aortic repair (f/b EVAR) in whom the reno-visceral target vessels (TV) were bridged with a BCS to an inner branch of a custom made (CMD) endograft.. Technical success and perioperative complications were noted. Follow-up BCS patency were evaluated and in patients with follow-up, two groups based on BCS were created, a group with BCS occlusion and a group with BCS patent. Uni und multivariable analysis were performed to analyze factors related to visceral and renal bridging stent occlusion. ResultsFrom 2019-2022, 69 patients undergoing complex aortic repair had at least one TV bridged to an inner branch built into a CMD endograft. 86% of the grafts had only inner branches, whereas 14% had a mix of fenestrations for the visceral TV and inner branches for the renal arteries. Twenty-five percent of patients presented as urgency and received an endograft originally designed for another patient and available on our shelf at the time. 245 TVs were connected to inner branches: celiac trunk (CT): 54, superior mesenteric artery (SMA): 59, renal artery (RA): 132. Technical success was 99%. There was a 23% complication and 9% perioperative mortality rate. At follow-up, we identified 6% of visceral and 14% of renal BCS occlusions. The primary patency for RA BCS was 83% at 12 months and 58% at 24 months. For the CT-SMA BCS, Kaplan-Maier (KM) showed a patency of 99% and 96% at 12 and 24 months. In the univariate analysis a misaligned TV ostium (p 0.001), the postoperative BCS diameter on postoperative CTA (p 0.02) and the preoperative infrarenal aortic angle >60º (0.007) were correlated with RA BCS occlusion. In the multivariate analysis only the misaligned TV ostium (p 0.002) and infrarenal angle > 60° (p 0.01) were significantly correlated. ConclusionsIn our series of complex aortic repair, the incorporation of inner branches to bridge TVs is associated with a high renal BCS occlusion rate. Improper alignment of the branches with the TV ostium and acute aortic angles might play a significant role. Further research on this technology is needed.