Outcomes of planned celiac artery coverage during TEVAR.
OBJECTIVE
Successful thoracic endovascular aneurysm repair (TEVAR) requires adequate proximal and distal fixation and seal. We report our experience of planned celiac artery coverage during endovascular repair of complex thoracic aortic aneurysms (TAA).


METHODS
Since 2004, 228 patients underwent TEVAR under elective (n=162, 71%) and emergent circumstances (66, 29%). Patients with inadequate distal stent grafts landing zones during TEVAR underwent detailed evaluation of the gastroduodenal arcade with communicating collaterals between the celiac and superior mesenteric artery (SMA) by computed tomography angiography and intraoperative arteriogram. If needed, in presence of a patent SMA and demonstration of collaterals to the celiac artery, the stent grafts were extended to the SMA with celiac artery coverage. Furthermore, instances when further lengthening of distal thoracic stent graft landing zone was needed to obtain an adequate seal, the SMA was partially covered with the endograft, and a balloon expandable stent was routinely deployed in proximal SMA to maintain patency. Outcome data were prospectively collected and analyzed retrospectively.


RESULTS
Thirty-one of 228 (14%) patients with TEVAR required celiac artery interruption; 24 (77%) had demonstrable collaterals to the SMA. Twelve (39%) of 31 patients underwent additional partial SMA coverage by stent graft, and proximal SMA stent. The majority of patients were females (n=20, 65%), the mean age was 74 years (range 55-87 years), and the mean TAA size was 6.5 cm. Postoperative complications included visceral ischemia in 2 (6%) patients, paraplegia in 2 (6%) patients, and death in 2 (6%) patients. All type 1b endoleaks (n=2, 6%) and type 2 endoleaks vial retrograde flow from the celiac artery (n=3, 10%) were successfully treated by transfemoral coil embolization. Over a mean follow-up of 15 months, there have been no other complications of mesenteric ischemia, spinal cord ischemia, SMA in-stent stenosis, or conversion to open surgical repair.


CONCLUSIONS
Our findings suggest that celiac artery coverage to facilitate adequate distal sealing during TEVAR with complex TAA is relatively safe in the presence of SMA-celiac collaterals. Pre-existing SMA stenosis can be successfully treated by balloon expandable stents during TEVAR, and endoleaks arising from distal stent grafts attachment site or via retrograde flow from the celiac artery can be successfully managed by transfemoral coil embolization. Although early results are encouraging, long-term efficacy of these procedures remains to be determined and vigilant follow-up is needed.
Mehta
Manish
M
The Institute for Vascular Health and Disease, Albany Medical College, The Vascular Group, and The Center for Vascular Awareness Inc., Albany, NY 12208, USA. mehtam@albanyvascular.com
Darling
R Clement
RC
Taggert
John B
JB
Roddy
Sean P
SP
Sternbach
Yaron
Y
Ozsvath
Kathleen J
KJ
Kreienberg
Paul B
PB
Paty
Philip S K
PS
D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000295:instrumentation; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D002445:Celiac Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D003097:Collateral Circulation; D003251:Constriction, Pathologic; D057867:Endoleak / Q000209:etiology; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006801:Humans; D007511:Ischemia / Q000209:etiology; D008297:Male; D017538:Mesenteric Artery, Superior / Q000000981:diagnostic imaging / Q000503:physiopathology; D008641:Mesenteric Vascular Occlusion / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D008875:Middle Aged; D009518:New York; D010264:Paraplegia / Q000209:etiology; D011474:Prosthesis Design; D012042:Registries; D012189:Retrospective Studies; D015607:Stents; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome