Patent Inferior Mesenteric Artery Research Articles

Inferior Mesenteric Artery Revascularization for Salvage of Mesenteric Ischemia

Often sacrificed in favor of the celiac and superior mesenteric arteries, the inferior mesenteric artery (IMA) can provide crucial inflow to the abdominopelvic viscera and spinal cord, especially in the presence of concomitant celiac or superior mesenteric artery (SMA) disease. We sought to elucidate the presentation and course of patients who had undergone IMA-specific revascularization. A retrospective analysis was performed of IMA revascularization procedures performed at an urban quaternary center from 2010 to 2020. Patients were included if concomitant renal artery, celiac artery, or SMA revascularization had been performed. Angioplasty, stenting, and open procedures were included. The patient characteristics, indications, and perioperative and long-term outcomes were analyzed. From 2010 to 2020, 10 patients had met the inclusion and exclusion criteria. Of the 10 patients, 9 were women (90%). Their median age was 71 years (range 47-88), and 80% had a history of smoking. Six patients had undergone elective IMA revascularization for chronic disease. Of the remaining four patients with acute symptoms, two had presented with an acute-on-chronic exacerbation of symptoms. All four patients with acute symptoms had presented as hospital transfers and had undergone intervention within 12 hours of transfer. However, two patients had had symptoms lasting >8 days before transfer. The 10 patients had undergone 16 procedures. Of the 10 patients, 8 had undergone IMA stenting, 1 had undergone percutaneous transluminal angioplasty alone, and 1 had undergone open IMA and aortic endarterectomy with patch angioplasty. Four patients had received concomitant celiac artery or SMA revascularization, with a large meandering mesenteric artery determining the choice to revascularize the IMA. In the six patients without celiac artery or SMA revascularization, three patients had had known SMA and celiac artery occlusions, and one had had a known occluded celiomesenteric trunk. In the four patients with acute symptoms, three small bowel resections and two laparotomies without bowel resection were performed. Six patients had required intensive care unit admission. Seven patients had had >1 year patency or had been lost to follow-up without known failure of IMA revascularization. Two patients died within 30 days with patent IMAs after withdrawal of care because of necrotic small bowel requiring resection. Two patients had undergone aortovisceral bypass after IMA occlusion—one patient on the day after IMA stenting and one patient at 17 months after IMA stenting. Revascularization of the IMA can serve as a reliable salvage option for patients with chronic or acute-on-chronic mesenteric ischemia, and should be considered for patients with high-grade stenosis or occlusion of the celiac artery and SMA.

Midterm Outcomes of Endovascular Abdominal Aortic Aneurysm Repair with Prevention of type 2 Endoleak by Intraoperative Aortic Side Branch Coil Embolization

The midterm results of endovascular abdominal aortic aneurysm repair (EVAR) with aortic side branch coil embolization during EVAR was evaluated. Our center began coil embolization for all patent inferior mesenteric artery (IMA) and lumbar artery (LA) with an inner diameter more than 2.0 mm during EVAR since June 2015. When four or more LA were patent, coil embolization for LA with inner diameter 2.0 mm or less was done. EVAR without aortic side branches coil embolization was performed for 59 patients prior to June 2015 (control group) and 79 patients underwent EVAR with coil embolization during EVAR (coil group). The success rate of coil embolization for IMA and LA was evaluated in coil group. The frequency of type 2 endoleak (T2EL), freedom from aneurysm sac expansion (5 mm or more) rate and the rate of the aneurysm sac shrinkage (10 mm or more) were compared between the coil and control groups. Additionally, multiple logistic regression analysis for all patients was conducted to analyze whether IMA patency and the number of patent lumbar artery at the end of EVAR were the risk factors of the aneurysm sac expansion of 5 mm or more. The success rate of IMA coil embolization was 96.4% and that of LA was 74.5%. Compared to the control group, the frequency of T2EL was significantly lower in coil group at 7 days (1.3% vs. 60.4%, P <0.0001) and at 6 months (2.1% vs 38.2%, P <0.0001) after EVAR. The freedom from aneurysm sac expansion rate was significantly better in the coil group at 5 years (100% in coil group and 65.2% in control group, P=0.002). The rate of aneurysm sac shrinkage was significantly better in coil group (15.5% vs. 2.0% at 1 year, 42.8% vs. 6.3% at 2 years and 53.4% vs. 17.8% at 3 years, p=0.0007). The risk of aneurysm sac expansion of 5 mm or more was estimated to be 11 times greater when the IMA was patent, and 4.9 times greater when 3 or more LAs were patent at the end of EVAR. When IMA was occluded and the number of patent LA became 2 or less by aortic side branch coil embolization during EVAR, favorable mid-term results were safely obtained and good long-term result could be expected with EVAR.

Risk Analysis of Aneurysm Sac Enlargement Caused by Type II Endoleak after Endovascular Aortic Repair

Although the preoperative risk factors associated with the occurrence of type II endoleak (ETII) after endovascular aortic repair (EVAR) have gradually become more evident, the preoperative risk factors associated with aneurysm sac enlargement caused by ETII remain unclear. This study aimed to determine the preoperative risk factors associated with aneurysm sac enlargement caused by ETII after EVAR. This retrospective cohort study reviewed 519 EVARs performed for true abdominal aortic aneurysm between January 2006 and December 2018 at our institution. EVARs using commercially available bifurcated devices with no type I or III endoleaks during follow-up and with ≥12 months follow-up were included. A total of 320 patients were enrolled in the study. To identify the preoperative risk factors of sac enlargement after EVAR, Cox regression analysis was used to assess preoperative data. The median follow-up period was 60.8 months. Overall, 135 of 320 patients (42%) had ETII during follow-up, and 47 of 135 patients (35%) developed aneurysm sac enlargement. Multivariate analysis revealed that chronic kidney disease (CKD) stage ≥4 (hazard ratio [HR], 4.65; 95% confidence interval [CI], 2.13-10.15; P=0.001), patent inferior mesenteric artery (IMA) (HR, 17.85; 95% CI, 2.46-129.73; P< 0.001), and number of patent lumbar arteries (LAs) (HR, 1.37; 95% CI, 1.13-1.68; P= 0.002) were risk factors of aneurysm sac enlargement caused by ETII. CKD stage ≥4, patent IMA, and number of patent LAs were independent risk factors for aneurysm sac enlargement after EVAR. In particular, patent IMA had the highest HR and seemed to have the greatest impact on long-term aneurysm sac enlargement. Hence, taking preoperative measures to address a patent IMA appears to be important in reducing the incidence of sac enlargement.

Outcomes of Preventive Embolization of the Inferior Mesenteric Artery during Endovascular Abdominal Aortic Aneurysm Repair

PurposeTo evaluate the impact of preemptive inferior mesenteric artery (IMA) embolization on outcomes of endovascular abdominal aortic aneurysm (AAA) repair (EVAR). Materials and MethodsFrom January 2015 to July 2017, all patients undergoing elective EVAR or fenestrated EVAR (F-EVAR) for asymptomatic AAA in a single tertiary hospital were retrospectively included. Three groups of patients were defined: patients with a patent IMA who underwent embolization during EVAR/F-EVAR (group 1), those with a patent IMA who did not undergo embolization during EVAR/F-EVAR (group 2), and those with a chronically occluded IMA (group 3). Preoperative aortic morphology, demographics, and procedural details were recorded. Aneurysmal growth (≥5 mm), reintervention, and overall mortality rates were analyzed using multivariate proportional hazard multivariate modeling. Propensity scores were constructed, and inverse probability weighting was applied to a new set of multivariate analyses to perform a sensitivity analysis. ResultsA total of 266 patients (male, 95% [n = 249]) with a median age of 70 (65–77) years were included, with F-EVAR procedures comprising 87 (32.7%) of the interventions. There were 52, 142, and 72 patients in groups 1, 2, and 3, respectively. Changes in aneurysmal sac size did not differ between groups, nor did overall survival or reintervention rates at 24 months. IMA embolization was not identified as an independently protective factor for aneurysmal growth during follow-up (relative risk [RR] = 2.82/mm [0.96–8.28], P = .060), whereas accessory renal arteries (RR = 5.07/mm [1.72–14.96], P = .003) and a larger preoperative aneurysmal diameter (RR = 1.09/mm [1.03–1.15], P = .004) were independent risk factors for sac enlargement. ConclusionsPreventive embolization of the IMA during EVAR or F-EVAR did not promote aneurysmal sac shrinking or decrease the reintervention rate at 2-year follow-up.

Prophylactic Aneurysm Embolization During EVAR Is Safe, Improves Sac Regression And Decreases The Incidence Of Type II Endoleak

Retrospective, single center review between 2015 and 2019. Perigraft aortic sac embolization using thrombin and gelfoam liquid was performed at the conclusion of endovascular aortic sac embolization (EVAR) in 44 patients with patent inferior mesenteric artery or lumbar arteries on sac angiogram. After an average follow-up of approximately 1 year, none of the aneurysm sacs increased in diameter and about two-thirds demonstrated sac regression. Freedom from type II endoleak was 87%. Patients only required reintervention for type Ib endoleak and limb occlusion. Perigraft aortic sac embolization was an effective prophylactic tool to prevent endoleak.

Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Endoleak management

Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Endoleak management

Short-term and Mid-term Outcomes after Use of the Native Infrarenal Aorta as Distal Landing Zone for Fenestrated-Branched Endovascular Aortic Repair

This study aimed to examine outcomes after use of the native infrarenal aorta as distal landing zone for fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal-thoracoabdominal aortic aneurysms (PRAA-TAAA). All F-BEVAR procedures for treatment of PRAA-TAAA (2011-2019) at 2 aortic centers were examined. The outcomes of interest were as follows: i) technical success, ii) perioperative morbidity, iii) preservation of lumbar arteries and the inferior mesenteric artery, iv) type IB endoleaks, v) reinterventions, vi) survival, vii) aneurysm sac behavior, and viii) infrarenal aortic changes. Twenty consecutive patients with distal landing in the native infrarenal aorta were included (median age 71years; 25% men). The median number of visible lumbar arteries at baseline was 7, and a patent inferior mesenteric artery (IMA) before the operation was present in 19 (95%) of the cases. There were no deaths within 30days. One patient (5%), operated on with a 4-BEVAR for a type 2 TAAA, experienced spinal cord ischemia (permanent paraplegia). The median decrease in the number of visible lumbar arteries at the first postoperative scan was 3 from the baseline value, whereas a patent IMA was preserved in 12 out of 19 patients. Only in one case (5%), a type IB endoleak was noted for an overall technical success rate of 95%, which required a standard EVAR 20months after the initial operation. The median follow-up duration for the study cohort was 491days; all patients were alive at the longest available individual follow-up, and no instances of new-onset type IB endoleaks were observed. Another 3 late reinterventions (in addition to the one mentioned previously) were performed during midterm follow-up, all because of target vessel instability. In patients with ≥12months of follow-up after the index procedure (n=12, 60% of the entire cohort), no instances of aneurysm sac increase >5mm were noted; the median largest aortic diameter was 51mm with a median difference from baseline of -6mm. The median distal landing zone diameter increase was 4mm from baseline but never beyond the nominal stent-graft diameter, whereas the median aortic bifurcation diameter differed 1mm from baseline. This preliminary experience shows that the use of the native infrarenal aorta as a distal landing zone for F-BEVAR is safe in the short term and midterm in patients with suitable anatomy, allowing the sparing of collateral vessels. Longer follow-up is warranted to assess durability.

Predictive Factor of the Possibility for Aortic Side Branches Coil Embolization during Endovascular Abdominal Aortic Aneurysm Repair.

Objective: Coil embolization of aortic side branches has been additionally performed to prevent type II endoleak during EVAR in our institute. In this study, we evaluated the predictive factors of the possibility for coil embolization of the inferior mesenteric artery (IMA) and lumbar artery (LA) during EVAR.Methods: Seventy-four EVAR patients during June 2015 and April 2019 were included in the study. The coil embolization procedural time for one vessel is limited to 10 min. Aortic side branches were selected with 4 Fr Shepherd hook type catheter (Medikit, Tokyo, Japan) and were embolized with Interlock (Boston Scientific, MA, USA) via microcatheter. As predictive factors, internal diameter of aortic side branches and the aortic diameter perpendicular to the origin of LA (aortic diameter) were evaluated.Results: Coil embolization was tried for 52 patent IMAs and all IMAs except two IMAs with ostial stenosis were successfully coil embolized (96.2%). Totally 190 LAs were patent and coil embolization was tried for 144 LAs. Among 144 LAs, 106 LAs (73.6%) were successfully coil embolized and the diameter was significantly longer (2.30±0.51 mm vs. 2.04±0.41 mm, p=0.007) and aortic dimeter was significantly shorter (30.0±8.1 mm vs. 40.5±11.6 mm, p<0.001) in successfully embolized LAs. Cut off value of successful LA coil embolization was 2.06 mm for internal diameter and 36.1 mm for aortic diameter by receiver operating characteristic curve analysis. Successful coil embolization rate for LAs with internal diameter longer than 2.0 mm and aortic diameter less than 36.2 mm was 90% (72 among 80 LAs).Conclusion: Coil embolization during EVAR for IMA was highly successful, if there was no calcified ostial stenosis. LA embolization was feasible especially for LAs with internal diameter ≥2.0 mm and aortic diameter ≤36.1 mm. This information would be useful to select the target vessel for aortic side branches coil embolization during EVAR. (This is a translation of Jpn J Vasc Surg 2019; 28: 389–396.)

Value of Preliminary Selective Lumbar and Inferior Mesenteric Artery Embolization to Prevent Type II Endoleaks After Endovascular Aneurysm Repair

Preliminary selective lumbar artery (LA) and inferior mesenteric artery (IMA) embolization to prevent type II endoleaks (T2ELs) has not been widely evaluated. Our aim was to determine the rate of endoleak and size decrease of infrarenal abdominal aortic aneurysm after endovascular aneurysm repair (EVAR) after pre-emptive coil embolization of IMA and LA in patients at high risk for T2EL. Between September 2014 and September 2019, 139 of 244 patients (56.9%) who underwent EVAR for abdominal aortic aneurysm also underwent selective percutaneous embolization of the IMA and LA before or during EVAR because of risk factors for T2EL. The embolization was performed using either coils or vascular plugs to achieve occlusion of the target vessel confirmed on angiography. Computed tomography and contrast-enhanced ultrasound imaging were performed at 1 month and 6 months and yearly after the procedure to detect endoleaks and to assess the aneurysm sac diameter. Mean follow-up was 23 ± 16 months (range, 1-61 months). Patients had a median of five (range, one to eight) patent LAs and IMAs on preoperative imaging. After completion of embolization, 80% (range, 20%-100%) of direct arterial flow to the aneurysm sack was occluded, with no procedurally related complications. Follow-up imaging showed T2EL in seven patients (5 %). Increase of the aneurysm sac was seen in eight patients during follow-up, of whom two had type I endoleak and six had T2EL. Six T2EL-related interventions were performed during follow-up, of which only one was successful. Shrinkage of the aneurysm sac diameter was in mean 9.2 ± 7.7 mm, which was statistically significant (P < .001). Surgery was required in one patient for proximal type I endoleak. No aneurysm-related death occurred. Preliminary selective LA and IMA embolization for patients at risk for T2EL is safe and effective in preventing development of T2EL. This procedure is associated with rapid decrease in aneurysm sack size.

Intra-abdominal Aortic Aneurysm Sac Angiography After Endovascular Aortic Repair Predicts Type II Endoleak

Incidence of type II endoleak (T2E) is a major concern as a negative late outcome after endovascular aneurysm repair (EVAR). Since 2015, we have performed n-butyl-2-cyanoacrylate (NBCA) injection into the abdominal aortic aneurysm (AAA) sac during EVAR for prevention of T2E. As an assistant of NBCA injection, intra-aneurysm sac angiography (IASA) has been performed for confirming the patent lumbar artery (LA). Although we reported a satisfactorily reduced incident rate of T2E by NBCA injection, there was a question of whether NBCA injection was routinely necessary for all EVARs. The aim of this study was to evaluate the relationship between T2E after EVAR and the finding of no contrasted LA on IASA. During EVAR, a 5F catheter was placed into the aneurysm sac from the contralateral side of the femoral artery before deployment of aortic stent grafts. For cases without type I and type III endoleak by completion digital subtraction angiography, IASA was performed to look for the patent LA. Between November 2017 and December 2019, there were 76 patients who underwent IASA during EVAR. Among them, we evaluated non-NBCA-injected patients because LA was not identified by IASA. The incidence of T2E at 7 days and the AAA sac diameter at 6 months after EVAR were evaluated by contrast-enhanced and plain computed tomography (CT), respectively. Among patients undergoing IASA, there were 14 patients (18.4%) in whom patent LA was not identified by IASA during EVAR. Preoperative AAA mean diameter was 54.1 ± 8.8 mm. Patent LAs were identified in 11 patients by preoperative contrast-enhanced CT. The mean number of patent LA pairs was 1.8 ± 1.3. Preoperative contrast-enhanced CT also identified patent inferior mesenteric artery in six cases, and five were coil embolized during EVAR. EVAR was performed using one of five stent grafts: Endurant (Medtronic, Santa Rosa, Calif), four; AFX2 (Endologix, Irvine, Calif), four; Aorfix (Lombard Medical, Irvine, Calif), three; Zenith Alpha Abdominal (Cook Medical, Bloomington, Ind), two; and Excluder (W. L. Gore & Associates, Flagstaff, Ariz), one. Postoperative contrast-enhanced CT at 7 days showed no T2E in all patients. Postoperative CT at 6 months was performed in seven patients. It showed AAA sac shrinkage in five patients (71.4%) and no AAA sac enlargement. IASA after EVAR might be able to predict no T2E when LAs are not identified on IASA.

The association between perioperative embolization of hypogastric arteries and type II endoleaks after endovascular aortic aneurysm repair

ObjectiveType II endoleaks (T2ELs) are the most common type of endoleak after endovascular aneurysm repair (EVAR). The iliolumbar artery arising from the hypogastric artery is often a major source of T2ELs, and transarterial embolization of the iliolumbar artery through the hypogastric artery is sometimes performed to interrupt sac expansion during follow-up. Considering the equivocal results of an association between hypogastric embolization and T2ELs in previous studies, this topic has re-emerged after the advent of iliac branch devices. This study reviewed our series to clarify whether hypogastric embolization is associated with T2ELs at 12 months after EVAR. MethodsPatients who underwent elective EVAR between June 2007 and May 2017 at our institution were retrospectively reviewed. Patients with postoperative computed tomography angiography (CTA) at 12 months were included. Patients in whom CTA revealed type I or type III endoleaks during follow-up, who required reinterventions before 12 months, and who had solitary iliac aneurysms were excluded. The primary outcome was the incidence of T2ELs at 12 months after EVAR. The associations of patients' characteristics, anatomic factors, hypogastric embolization, and type of endograft with the primary outcome were analyzed. ResultsIn total, 375 patients were enrolled. During the median follow-up of 59.5 months (interquartile range, 19-126 months), 40 patients died, and 50 reinterventions were performed. In 108 patients (28.8%), either hypogastric artery was embolized to extend distal landings to the external iliac artery. Bilateral and unilateral embolization was performed in nine and 99 patients, respectively. In total, 153 patients (40.8%) had T2ELs found by CTA at 12 months. In the univariate analysis, the status of hypogastric artery occlusion or embolization was not significantly different between patients with and without T2ELs. However, there were not enough patients to detect a 10% difference in T2ELs with >80% statistical power. In the multivariate analysis, significant associations with T2EL were observed for female sex (P = .049), patent inferior mesenteric artery (P = .006), and presence of five or more patent lumbar arteries (P < .001) but not for hypogastric embolization. In addition, compared with the Zenith (Cook Medical, Bloomington, Ind) endograft, the Excluder (W. L. Gore & Associates, Flagstaff, Ariz) endograft was significantly related to T2EL (P = .001). ConclusionsNo significant association between hypogastric embolization and T2EL was demonstrated in this retrospective study, which lacked adequate statistical power.

Multicentre randomised controlled trial to evaluate the efficacy of pre-emptive inferior mesenteric artery embolisation during endovascular aortic aneurysm repair on aneurysm sac change: protocol of Clarify IMA study

IntroductionType II endoleak (EL) is frequently seen after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) and is often considered responsible for aneurysm sac enlargement if it persists. In...

Laparoscopic Clipping of the Inferior Mesenteric Artery and Intraoperative Indocyanine Green Angiography for Type II Endoleak Following Endovascular Aneurysm Repair.

Background: Type II endoleaks from a patent inferior mesenteric artery (IMA) occur in up to one-third of patients undergoing endovascular repair of abdominal aortic aneurysms. In the majority of patients, retrograde flow in the aneurysmal sac outside the endograft will seal over time and is rarely associated with sac enlargement or aortic rupture. Intervention is generally recommended in patients with progressively enlarging endoleaks, especially when the sac diameter increases >10 mm during the follow-up, and endovascular IMA embolization has a high rate of treatment failure. Methods: We report a procedure of laparoscopic IMA clipping combined with intraoperative indocyanine green (ICG) angiography to confirm vascular anatomy, colonic perfusion, and the technical success of the procedure. Results: Three selected octogenarian patients with persistent type II endoleak after endovascular repair of abdominal aortic aneurysm underwent IMA clipping with ICG angiography. Mean operative time was 58 ± 9 minutes. There were no procedure-related complications, and no hypersensitivity reactions nor other side effects associated with ICG dye administration occurred. All patients were discharged home on postoperative day 1 and are asymptomatic and free of recurrence at a mean follow-up of 15 months. Conclusions: Laparoscopic IMA clipping is a safe remedial procedure in patients with type II endoleak after endovascular repair of abdominal aortic aneurysms.

Natural history of isolated type II endoleaks in patients treated by fenestrated-branched endovascular repair for pararenal and thoracoabdominal aortic aneurysms

ObjectiveType II endoleaks (T2ELs) are common after endovascular aneurysm repair (EVAR), but little is known about their natural history in patients treated by fenestrated-branched EVAR (F/BEVAR). We sought to evaluate the natural history of isolated T2EL after F/BEVAR for pararenal aortic aneurysms (PRAs) and thoracoabdominal aortic aneurysms (TAAAs). MethodsConsecutive patients enrolled in a prospective nonrandomized study to investigate F/BEVAR for PRAs and TAAAs at a single institution (2014-2017) were identified. Computed tomography angiography images at discharge and during follow-up were reviewed. Patients with ≥12 months of follow-up were included and divided in two groups for comparison based on the presence or absence of T2ELs. Patients with any non-T2ELs were excluded. Multivariable logistic regression was used to assess factors associated with T2EL occurrence. Primary outcomes were absolute and relative sac diameter change and sac diameter increase >5 mm. Secondary outcomes included overall survival, aorta-related death, reinterventions, and conversion or rupture. ResultsThere were 184 patients (136 male [74%]) with PRAs (n = 70 [38%]) and TAAAs (n = 114 [62%]) with an average age of 74 ± 7 years included. Isolated T2ELs were seen in 76 patients (41%); of these, 71 T2ELs (93%) were primary. Patients with T2ELs were more likely to have larger aneurysms (mean baseline diameter, 66 ± 8 mm vs 63 ± 8 mm; P = .01), patent inferior mesenteric artery (66% vs 32%; P < .001), and more lumbar arteries (mean, 6 ± 1 vs 4 ± 1; P < .001). In the multivariable analysis, these were all independently associated with T2EL occurrence. Of all T2ELs, only 18 (24%) resolved spontaneously during a mean follow-up of 31 ± 15 months. Mean absolute sac diameter reduction for patients without T2ELs and with T2ELs, at 12 and 36 months, was 10.2 ± 5.9 mm vs 2.6 ± 6.4 mm and 16.3 ± 7.3 mm vs 5.7 ± 11.3 mm, respectively (P < .001). For the same groups, the mean percentage sac diameter reduction at 12 and 36 months was 16.4% ± 9.4% vs 3.8% ± 9.8% and 26.4% ± 11.6% vs 8.8% ± 17.7%, respectively (P < .001). Overall, 13 patients showed sac increase >5 mm, and all these instances were recorded in the T2EL group; 8 required reintervention. T2ELs were not associated with decreased overall survival, freedom from aorta-related death, or freedom from any reintervention. ConclusionsIsolated T2ELs are common after F/BEVAR for PRAs and TAAAs, usually seen early; they are most often associated with inferior mesenteric or lumbar artery flow and tend to persist in follow-up. Their presence is associated with impaired sac shrinkage and risk of sac growth with subsequent need for secondary interventions. Although not associated with decreased overall survival or loss of freedom from aorta-related death, T2ELs require serial imaging surveillance.

The role of the inferior mesenteric artery in predicting secondary intervention for type II endoleak following endovascular aneurysm repair

ObjectiveEndovascular aneurysm repair (EVAR) is associated with a greater risk of graft-related complications and need for secondary interventions compared with open repair. Type II endoleak (EL-2) is the most common complication. We examined the hypothesis that a functionally occluded inferior mesenteric artery (IMA) before EVAR was associated with fewer secondary interventions for EL-2. MethodsAll nonruptured abdominal aortic aneurysms (AAA) treated by EVAR using U.S. Food and Drug Administration-approved endografts from January 2005 to December 2017 were retrospectively reviewed, including computed tomography angiograms. Preoperative patency of the IMA and any secondary interventions performed after the index EVAR procedure were recorded. A functionally occluded IMA was defined as one that was (1) chronically occluded or severely stenosed on preoperative imaging or (2) coil embolized before EVAR. Secondary interventions for persistent EL-2 were indicated when AAA sac diameter increased by more than 5 mm. ResultsThe study cohort comprised 490 patients (84 women) with a mean age of 74.8 ± 8.2 years. The mean preoperative AAA diameter was 5.6 ± 0.9 cm. One hundred twenty-nine patients (26.3%) died during follow-up. The mean follow-up of survivors was 38 months. Types (prevalence) of endoleak were I (2.4%), II (18.9%), III (0.7%), IV (0.5%), and V (0.2%). Patients with a functionally occluded IMA underwent significantly fewer secondary interventions for EL-2 compared with patients with a patent IMA (2.6% vs 7.1%; P = .020). All secondary interventions in the functionally occluded IMA group involved the lumbar arteries (LA). When the IMA was patent, secondary interventions were equally distributed between the LA and IMA. Logistic regression confirmed that a functionally patent IMA was associated with a greater number of secondary interventions for EL-2 (odds ratio, 3.0; 95% confidence interval, 1.2-7.5; P = .025). ConclusionsPatients with a functionally occluded IMA required significantly fewer secondary interventions for EL-2 after EVAR. In addition, the type of vessels intervened on were primarily LA. Among patients with a patent IMA, preoperative coil embolization may decrease secondary interventions and improve the long-term durability of EVAR.

Pre-emptive nonselective perigraft aortic sac embolization with coils to prevent type II endoleak after endovascular aneurysm repair

ObjectivePre-emptive selective embolization of inferior mesenteric artery (IMA), lumbar arteries (LAs), and perigraft sac for prevention of type II endoleak (T2EL) has not been widely adopted. We perform pre-emptive nonselective perigraft aortic sac embolization with coils (PNPASEC) in patients at high risk for development of T2EL (four or more patent LAs, patent IMA ≥3 mm, and ≥30-mm aortic flow lumen). The goal of this study was to see whether PNPASEC decreases T2ELs requiring reinterventions. MethodsAll 266 patients undergoing elective endovascular aneurysm repair between September 1, 2007, and October 31, 2015, were retrospectively evaluated from a prospectively maintained database. Patients (N = 212; 211 men) with preoperative and postoperative contrast-enhanced computed tomography scans were included. Our PNPASEC technique involves leaving a wire in the sac after cannulation of the contralateral gate and inserting large (0.035-inch) coils into the sac after bifurcated graft deployment. T2EL and reintervention rates were compared between patients who underwent PNPASEC (group I) and those who met the criteria but did not have PNPASEC (group II) and those who did not meet the criteria (Group III). ResultsForty-seven (22.2%) patients were PNPASEC candidates and 165 (77.8%) patients (group III) were not. Among PNPASEC candidates, 16 (7.5%) underwent PNPASEC (group I) and 31 (14.6%) did not (group II). There were no significant differences between groups in terms of comorbidities, aneurysm size, and anatomic and neck characteristics. Mean number of patent LAs was similar between group I (4.5 ± 0.8) and group II (4.5 ± 0.9), which was significantly greater than in group III (1.9 ± 1.3; P < .001); 43.6% of group III patients had patent IMA. Mean follow-up was 44 ± 25 months. T2EL at 6 months was observed in 48.4% in group II, 3.0% in group III, and 6.3% in group I (P < .001). Sac diameter increase was seen in 38.7% in group II vs 6.1% in group III and 6.3% in group I (P < .001), with complete sac shrinkage in 23.3% in group II vs 23.8% in group III and 50.0% in group I (P = .09). T2EL-related interventions were performed in 29.0% in group II vs 1.2% in group III and 6.3% in group I (P < .001). Any endoleak at last follow-up was seen in 25.8% in group II vs 2.4% in group III and none in group I (P < .001). ConclusionsNonselective perigraft sac coil embolization in patients at high risk for T2EL (20% of patients undergoing endovascular aneurysm repair) is effective in preventing development of T2EL and is associated with decrease in sac size and reintervention rates.

Type 2 Endoleak Incidence and Fate After Endovascular Aneurysms Repair in a Multicentric Series: Different Results with Different Devices?

The aim of this work is describing incidence and fate of type 2 endoleaks (T2ELs) in a multicentric cohort of patients treated by endovascular aneurysms repair using the Ovation device (Endologix) and comparing them with a group treated using the Excluder (W. L. Gore & Associates). This is a retrospective study conducted on 261 patients treated using the Ovation device and 203 using the Excluder. Outcomes were intraprocedural, 30-day, 12-month, and mean time follow-up T2EL incidence and related reinterventions. Patent inferior mesenteric artery (IMA), ≥3 lumbar arteries (LAs), intrasac thrombus volume, the mean diameter of common and external iliac arteries, external iliac artery stenosis (>70%), diameter ≤5mm, iliac tortuosity ratio ≤0.5, thrombosis, and calcification were noted and considered as potentially influencing outcomes. Patients of the Ovation group presented significantly more thrombosed, calcified, and tortuous iliac vessels than those in the Excluder group. No significant differences were noted in sac thrombosis, IMA, and LA patency. At completion angiography, T2EL was evident in 57 Ovation and 46 Excluder patients (P=0.832). At 1 month, it was evident in 33 Ovation group and 28 Excluder group patients (P=0.726). At 12-month and mean time (30.14months) follow-up, no differences were evident between the 2 groups (P=0.940 and 0.951, respectively). The log-rank test showed that the rate of T2EL-related reintervention was not different between the 2 groups (P=0.46). Regarding anatomical characteristics, a statistically significant difference was not observed between patients presenting or not with T2EL (P>0.05). Data showed no significant differences in terms of T2EL incidence between the 2 study groups. None of preoperative anatomical features were found to be significantly associated with the appearance of T2EL.

An Anatomical Explanation for a Chronic Gastrointestinal Complaint

Introduction: Median Arcuate Ligament Syndrome (MALS) is an anatomic abnormality causing vascular compression. Variation in the location of either the fibrous band of the median arcuate ligament or the origin of the celiac trunk results in stenosis. This causes ischemia and delayed gastric emptying. Our case demonstrates the extensive workup patients endure prior to being accurately diagnosed with MALS. Case: 75 yo female with a 20 year history of chronic dyspepsia, H. pylori, and C. difficile presented to the ED complaining of worsening nausea and two days of hematochezia. The patient stated new onset dysphagia to both solids and liquids. 2 months prior to presentation, she recalls frequent episodes of abdominal pain requiring multiple ED visits and weight loss of 15lbs. On initial examination, the patient was found afebrile, normotensive, with laboratory results showing a WBC count of 19.3x103 cells/μL, hemoglobin of 16.0 g/dL, and platelet count of 307 x 103 cells/ μL. Physical exam showed an abdomen mildly tender to palpation in the LUQ and LLQ without rebound or guarding. Patient was admitted and placed empirically on piperacillin / tazobactam. Abdominal CT demonstrated wall thickening, trace fluid, and adjacent fat stranding involving the distal transverse, descending, and proximal sigmoid colon likely representing an infectious or inflammatory colitis with a patent inferior mesenteric artery. EGD was only positive for mild antral erythema and few duodenal erosions with no ulcers and samples were obtained to test for H. pylori. During colonoscopy, biopsies obtained showed erythema and congestion consistent with ischemic colitis. A duplex ultrasound was performed, revealing a peak systolic velocity (PSV) within the celiac artery of 285 cm/s, correlating to >70% occlusion. The previous CT results were examined retrospectively and mild compression of the celiac trunk by the median arcuate ligament was noted. A diagnosis of median arcuate ligament syndrome (MALS) was made. Conclusions: We present a case of MALS which depicts a rare diagnosis, initially presenting with vague symptoms such as postprandial epigastric pain and weight loss. These non-specific complaints mimic more common conditions, delaying proper diagnosis and treatment.It is prudent to consider MALS as a cause of chronic mesenteric ischemia when evaluating patients with unresolved abdominal pain and weight loss to prevent delay in curative surgical treatment.

Preservation of the Inferior Mesenteric Artery With a Surgeon-customised Fenestration

Abdominal aortic aneurysms (AAA) are most frequently treated by endovascular aneurysm repair (EVAR). A recognised drawback of EVAR is loss of the inferior mesenteric artery (IMA), which when associated with the additional occlusion of both hypogastric arteries, puts the patient at risk of ischaemic colitis or pelvic ischaemia. A surgeon-customised fenestration technique used in a 70 year old man with an AAA, occluded hypogastric arteries, and a large IMA is described. The diameter of the IMA, distance to the lower renal artery, and clock face positions were assessed with TeraRecon software (TeraRecon Foster City, CA, USA). The main body of an Endurant stent graft (Medtronic, Dublin, Ireland) was partially unsheathed. The location and shape of the fenestration was drawn on the graft between two rows of stent. A 6 mm fenestration was created by using a 1205 °C cautery loop tip (Accu-Temp; Beaver-Visitec International, Waltham, MA, USA). To prevent the burning of the polyester, the graft was continuously irrigated with cold isotonic saline. A segment of a 25 mm Amplatz goose neck snare (Medtronic) was sutured around the fenestration with a polytetrafluoroethylene monofilament suture (CV-5 Gore-Tex; WL Gore & Associates, Flagstaff, AZ, USA) to serve as a radio-opaque marker (Fig. 1A). The graft was then re-sheathed by using a silicone rubber band tightly wrapped around the graft and loosened gradually when the sheath came over (Fig. 1B). Once the stent graft was deployed, the fenestration and the IMA were catheterised with a SIM1 catheter and a 7 × 22 mm covered stent (Advanta V12; Maquet, Sunderland, UK) (Fig. 2A and B) was subsequently deployed and flared with a 9 × 20 mm angioplasty balloon.Figure 2(A) Catheterisation of the inferior mesenteric artery by surgeon-customised fenestration. (B) Post-operative three dimensional reconstruction showing patency of the fenestration and occlusion of both hypogastric arteries.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Surgeon-customised fenestration is a straightforward technique that provides an option for maintaining IMA patency in patients at risk of ischaemic colitis and pelvic ischaemia following infrarenal EVAR.

Safety and durability of infrarenal aorta as distal landing zone in fenestrated or branched endograft repair for thoracoabdominal aneurysm

ObjectiveManufacturers often recommend the iliac arteries as the distal landing zone in fenestrated or branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aneurysm. It is not uncommon to choose distal landing at the infrarenal aorta for preservation of lumbar arteries or the inferior mesenteric artery (IMA); however, the safety and durability of this procedure have not been verified in the literature. MethodsConsecutive patients who underwent FB-EVAR with distal landing at the infrarenal aorta were reviewed retrospectively. The primary outcome measured any type IB endoleak over time. Secondary outcomes measured perioperative complications of paraplegia and bowel ischemia, preservation of lumbar artery and IMA, and degeneration of infrarenal aorta (diameter of infrarenal aorta at landing zone) and common iliac arteries (maximum diameters) over time. ResultsBetween August 2011 and August 2017, 40 patients (40% male with a mean age of 72 ± 8 years) affected by types I (37.5%), II (25.0%), III (20.0%), and V (17.5%) thoracoabdominal aneurysms were included. The mean aneurysm diameter was 6.4 ± 1.5 cm. There was no immediate or delayed type IB endoleak with mean follow-up period of 15 ± 18 months (range, 0-72 months). Postoperative complications included six (15%) spinal cord ischemia (five temporary and one permanent) and no mesenteric ischemia. There were three deaths (7.5%) within 30 days. Follow-up with computed tomography arteriography showed that 37 patients (92.5%) had at least one lumbar artery preserved. Out of the 31 preoperatively patent IMA, 23 (74.2%) were preserved. There was one incidental finding of new focal dissection distal to the stent graft end. Mean infrarenal aorta diameters were 24.8, 27.7, 27.7, and 29.4 mm immediately preoperatively, and at 1 and 2 years postoperatively, respectively. The mean maximal right common iliac diameters were stable and measured 15.8, 15.9, and 14.8 mm preoperatively, immediately postoperatively, and 1 year postoperatively, respectively. Mean maximal left common iliac diameters were also stable and measured 15.7, 15.9, and 14.7 mm preoperatively, immediately postoperatively, and at 1 year postoperatively, respectively. ConclusionsOur early experience showed that distal landing at the infrarenal aorta was secure in FB-EVAR with no type IB endoleak, although the observation of gradual infrarenal aortic degeneration mandates regular surveillance.