Effect Of Celiac Axis Compression On Branch-related Outcomes During Fenestrated-branched Endovascular Aortic Repair
Francesco Squizzato, MD, Gustavo S. Oderich, MD, Emanuel R. Tenorio, MD, PhD, Bernardo C. Mendes, MD, Randall R. DeMartino, MD, MS.
Mayo Clinic, Rochester, MN, USA.
OBJECTIVES: To report the effect of median arcuate ligament (MAL) compression on outcomes and technical aspects of celiac artery (CA) stenting during fenestrated-branched endovascular aneurysm repair (F-BEVAR) for thoracoabdominal (TAAA) or pararenal (PRAA) aortic aneurysms.
METHODS: We retrospectively reviewed the clinical and anatomical data on 300 consecutive patients enrolled in a prospective non-randomized physician-sponsored investigational device exemption study from 2014 to 2018. From this group, 230 Patients with CA incorporation by fenestration or directional branch were included. MAL compression was defined by preoperative computed tomography angiogram as a J-hook narrowing of the proximal CA at the level of the ligament; the shift angle between the downward and upward segments within the CA was measured. Endpoints were technical success, rates of intraoperative or early (30-days) CA branch revision, and freedom from branch instability, defined by branch-related death, occlusion, rupture or reintervention for stenosis, endoleak or disconnection.
RESULTS: CA incorporation was performed using fenestrations in 118 patients (51%) and directional branch in 112 (49%). MAL compression was present in 97 patients (42%), and 48 (49%) had CA stenosis >50%. MAL compression was more often present in Extent I-III TAAAs compared to Extent IV-PRAs (61% vs 39%; P<.001). Technical success was 99%. Patients with MAL compression more often received a directional branch (65% vs 37%; P<.001), self-expanding bridging stent-grafts (29% vs 11%; P=.001), adjunctive bare-metal stents (46% vs 24%; P=.001), coverage of the gastric artery (44% vs 22%; P<.001), and branch extension distal to the shift angle (65% vs 15%; P<.001). An intraoperative (n=6, 2.6%) or early (n=1, 0.4%) revision of the CA branch was required due to dissection/occlusion (n=2, 0.9%), kinking/stenosis (n=3, 1.3%), stent dislodgement (n=1, 0.4%), or type I-C endoleak (n=1, 0.4%). A shift angle <120º was the most significant factor associated with CA branch revision (OR 10.9, 95%CI 2.3-88.9; P=.013). Freedom from CA branch instability was 97±2% at 4 years, and this was not associated to MAL compression (HR 1.17, 95%CI 0.14-5.12; P=.900) or any other predictor.
CONCLUSIONS: MAL compression is more common in Extent I-III TAAAs, and imposes additional chanllenges for CA stenting in F-BEVAR. This may require additional bare-metal stenting, gastric artery coverage, or early revision, especially in presence of an angulation <120º. However, excellent long-term results can be achieved for CA incporporation.
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