Incorporation Of The Inferior Mesenteric Artery In Complex Endovascular Aortic Aneurysm Repairs
Brook A. Mitchell, Joshua D. Adams, MD.
Carilion Clinic, Roanoke, VA, USA.
OBJECTIVES: This study reports the technical aspects and outcomes of fifteen patients who underwent fenestrated/branched endovascular aortic repair (F/B-EVAR) with incorporation of the inferior mesenteric artery (IMA). Preservation of a patent IMA during complex endovascular aortic repair may decrease the incidence of colonic ischemia and reduce the incidence of IMA related Type II endoleaks which have demonstrated systemic pressures within the aneurysm sac. A phenomenon which could lead to sac expansion and failure of endovascular repair. To date, there is one reported case of preservation of the IMA with a surgeon-modified FEVAR. This study represents the largest reported series of patients with incorporation of patent IMA during complex endovascular aortic repairs.
METHODS: Review of a prospectively maintained database including all patients who underwent a F/B-EVAR from November 1, 2015 to September 1, 2019 was performed. Patients undergoing F/B-EVAR for aortic aneurysmal disease with planned inclusion of the IMA based on preoperative plan were included in the study. Primary endpoints included technical success, perioperative mortality, incidence of ischemic colitis, presence or absence of IMA-associated endoleak at follow-up, secondary reinterventions, and IMA patency.
RESULTS: 189 patients were reviewed. Fifteen patients (87% male with a mean age of 67 ± 14 years) including 6 patients with complex AAA, 6 patients with aneurysmal degeneration of chronic Debakey III dissection, and 3 patients with AAA and aortoiliac occlusive disease (AOD) were further analyzed. Technical success was 100% with all IMA’s stented through either a surgeon-modified fenestration (n=12) or endobranch (n=3). Ten complex endovascular repairs (67%) involved all visceral arteries (5 or 6 vessel FEVAR), three (20%) involved a lower pole renal and the IMA (two vessel FEVAR), and two (13%) involved the IMA only. Incidence of bowel ischemia and perioperative mortality was 0% with a mean follow-up of 397 ± 375 days. Cumulative IMA patency was 100% (15/15). One patient (7%) underwent a secondary outpatient reintervention to repair an IMA-associated Type IC endoleak.
CONCLUSIONS: In properly selected patients incorporation of the IMA in complex endovascular repair is safe and may prevent colonic ischemia and reduce the incidence of clinically significant IMA-related Type II endoleaks. Further study is needed to determine the long-term outcomes of endovascular IMA preservation in this population.
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