Inferior Mesenteric Artery Snorkel for Endovascular Treatment of a Large Degenerating Saccular Aneurysm

Objective

Preservation of the inferior mesenteric artery (IMA) during endovascular aortic aneurysm repair (EVAR) is necessary for prevention of mesenteric ischaemia in the case of chronically occluded coeliac and superior mesenteric arteries (SMA). This case report presents an approach in a complex patient.

Methods

A 74 year old man with hepatitis C cirrhosis and recent non-ST elevation myocardial infarction presented with an infrarenal degenerating saccular aneurysm (58 mm), chronically occluded SMA and coeliac artery, and 9 mm IMA with high grade ostial stenosis. He also had concomitant atherosclerosis of the aorta with a narrow distal aortic lumen of 14 mm, which tapered to 11 mm at the aortic bifurcation. Endovascular attempts to cross long segment occlusions of the SMA and coeliac artery were unsuccessful. Thus, EVAR was performed using the unibody AFX2 endograft and chimney revascularisation of the IMA using a VBX stent graft. One year follow up demonstrated regression of the aneurysm sac to 53 mm with patent IMA graft and no endoleak.

Conclusion

Few reports have described techniques for endovascular preservation of the IMA, which is a necessary consideration in the context of coeliac and SMA occlusion. Because open surgery was not a good option for this patient, available endovascular options had to be weighed up. An added challenge was the exceptionally narrow aortic lumen in the context of aortic and iliac atherosclerotic disease. It was decided that the anatomy was prohibitive for a fenestrated design and extensive calcification was too limiting for gate cannulation of a modular graft. Thus a bifurcated unibody aortic endograft with chimney stent grafting of the IMA was successfully used as a definitive solution.

Outcomes of chimney/snorkel endovascular repair for symptomatic and ruptured abdominal aortic aneurysms

OBJECTIVE

Symptomatic and ruptured abdominal aortic aneurysms (AAAs) are increasingly being managed with endovascular aneurysm repair (EVAR). We aimed to identify the outcomes of symptomatic and ruptured AAAs that had undergone EVAR with a chimney or snorkel technique (ChEVAR).

METHODS

A retrospective cohort study was performed using the Vascular Quality Initiative registry from March 2013 to July 2019. All patients with symptomatic and ruptured AAAs with a proximal aortic zone of disease from 6 to 9 who had undergone ChEVAR were included. The outcomes were analyzed in accordance with the Society for Vascular Surgery reporting standards for EVAR.

RESULTS

ChEVAR was performed in 77 patients (ruptured, 35 [45.5%]; symptomatic, 42 [54.5%]). The median age was 73.0 years (interquartile range [IQR], 67.0-81.0 years), and 54 patients (70.1%) were men. The median maximum aneurysm diameter was 67.5 mm (IQR, 54.5-83.3 mm). All patients had American Society of Anesthesiologists class ≥III. For the patients with ruptured AAAs, the mean lowest preoperative systolic blood pressure was 95.3 ± 29.3 mm Hg. The fluoroscopy time was 57.4 minutes (IQR, 41.2-79.0 minutes). The proximal aortic zone of disease was zone 6 in 9 (11.7%), zone 7 in 21 (27.3%), zone 8 in 36 (46.8%), and zone 9 in 11 (14.3%) patients. ChEVAR involved more than one vessel in 55 patients (71.4%). No significant difference was found in 30-day mortality between the patients with ruptured vs symptomatic AAAs (11.4% vs 7.1%; P = .695). Reintervention was required for 10 patients (13.0%) at a median of 9 postoperative days, 2 (20.0%) of whom died. Postoperatively, 31 patients (40.3%) had experienced a major complication. A type I endoleak had occurred in nine patients (11.7%), two (22.2%) of whom died. Long-term follow-up data were available for 38 patients (49.4%) at a median of 406.5 days (IQR, 326.8-602.0 days) postoperatively. Of the 18 patients with long-term radiographic data, sac growth was detected in 4 (22.2%). A total of 14 patients had died at a median of 26.5 days (IQR, 3.0-468.5 days).

CONCLUSIONS

ChEVAR for symptomatic and ruptured AAAs can be performed with acceptable rates of morbidity and mortality. Long-term data are needed to determine the durability.