title: Editor's choice - A shaggy aorta is associated with mesenteric embolisation in patients undergoing fenestrated endografts to treat paravisceral aortic aneurysms.
abstract: OBJECTIVE
  Bowel ischaemia is a life-threatening complication of endovascular aneurysm repair. This study aims to evaluate the factors associated with mesenteric ischaemia in patients undergoing fenestrated aortic endografts to treat paravisceral aneurysms.
  
  
  METHODS
  Consecutive patients undergoing double or triple fenestrated stent graft insertion were retrospectively analysed. No patients were declined surgery based on anatomic complexity. Preoperative demographics, procedure-related variables, and anatomical factors were examined. Using 3D software, the aortic thrombus volume from the coeliac axis to the lowest renal, aortoiliac tortuosity, and aortic irregularity index (as graded by 3 independent assessors, graded 0-3 based on severity) were compared. Univariate analysis was performed to identify risk factors for the development of bowel ischaemia.
  
  
  RESULTS
  Ninety-nine patients underwent elective aneurysm repair (64 triple fenestrations and 35 double fenestrations), 5% of which developed bowel ischaemia, and of these 80% (4/5) died. Mesenteric ischaemia was significantly associated with increased aortic irregularity (median [range], 2 [1-3] vs. 1 [0-2], p = .005, ischaemia vs. no ischaemia) and increased thrombus volume (37 ± 8 vs. 21 ± 12, p = .007) but not aortoiliac tortuosity (1.4 [1.2-1.5] vs. 1.30 [1.2-1.7], p = .3), inferior mesenteric or internal iliac artery patency. Mesenteric ischaemia was also associated with a significantly higher preoperative creatinine (mean ± SD: 183 ± 74 vs. 111 ± 43, p = .007).
  
  
  CONCLUSIONS
  The presence of aortic irregularity and increased thrombus volume in the paravisceral segment predicts the occurrence of mesenteric and renal ischaemia in patients treated with fenestrated endografts. This is likely to be related to graft manipulation and catheterisation of visceral vessels.
authors: Department of Vascular Surgery, Royal Free Hospital NHS Foundation Trust, London NW3 2QG, UK.
authors: S D
authors: SD
authors: Patel
authors: Department of Vascular Surgery, Royal Free Hospital NHS Foundation Trust, London NW3 2QG, UK.
authors: J
authors: J
authors: Constantinou
authors: Department of Vascular Surgery, Royal Free Hospital NHS Foundation Trust, London NW3 2QG, UK.
authors: H
authors: H
authors: Hamilton
authors: Department of Vascular Surgery, Royal Free Hospital NHS Foundation Trust, London NW3 2QG, UK.
authors: M
authors: M
authors: Davis
authors: Department of Vascular Surgery, Royal Free Hospital NHS Foundation Trust, London NW3 2QG, UK. Electronic address: krassi.ivancev@gmail.com.
authors: K
authors: K
authors: Ivancev
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D017558:Elective Surgical Procedures / Q000379:methods; D057510:Endovascular Procedures / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome
keywords: EVAR; Embolisation; Fenestrated; Mesenteric ischaemia