Percutaneous Transabdominal Access Of The Superior Mesenteric Artery (SMA) For False Lumen Embolization After Fenestrated-branched Endovascular Aortic Aneurysm Repair (F-BEVAR)
Khalil H. Chamseddin, MD, Jesus Porras Colon, MD, Carla K. Scott, MD, Mirza S. Baig, MD, Carlos H. Timaran, MD.
UT Southwestern, Dallas, TX, USA.
Demographics: Persistent flow of the false lumen after F-BEVAR for chronic dissecting aortic aneurysms is a frequent indication of secondary interventions. We describe herein an alternative technique for false lumen embolization of the visceral arteries. History: A 64-year-old male with a history of a type A aortic dissection repair subsequently developed an 11-cm chronic type B dissecting Extend II thoracoabdominal aneurysm. Staged repair was performed and initially included total arch replacement with elephant trunk extension. A 3-vessel branched endovascular repair was performed 4 weeks later. Postoperatively, CT angiogram (CTA) revealed persistent perfusion of the aneurysm false lumen from a re-entry tear in the chronically dissected superior mesenteric artery (SMA). Transgraft embolization of the SMA false lumen was first attempted but could not be completed because of retrograde migration of the coils and plugs into the aortic false lumen given high flow. Plan: A secondary intervention was planned with retrograde embolization of the SMA false lumen given the proximity of the SMA to the abdominal wall. Because of multiple prior laparotomies and a hostile abdomen, an ultrasound-guided transabdominal percutaneous access of the SMA in a retrograde fashion was performed avoiding bowel. Using a modified Seldinger technique a 6-Fr sheath was placed into the SMA (Fig). Intravascular ultrasound and retrograde angiogram confirmed true lumen access. The SMA false lumen was accessed through a tear and packed with coils. A distal covered stent was deployed antegrade against the coils to seal the distal aspect of the SMA dissection. The percutaneous SMA access was closed with a 6-French Angio-Seal. Completion angiogram confirmed false lumen exclusion, secure closure of the access site and excellent distal perfusion. The postoperative course was unremarkable. The 30-day follow-up CTA demonstrated patent celiac, renal and SMA branches without false lumen flow and stable aneurysm sac.Discussion: Percutaneous transabdominal retrograde SMA access can be considered an alternative approach for false lumen embolization after F-BEVAR when standard techniques are not feasible or unsuccessful. 
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