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When Cannulation Fails - Visceral Portal Plugging As A Bailout Due To Unfavorable Aortic Remodeling After Dissection Septostomy
Dylan Brooks, MD, Dora Zatyko, MD, Kyle Prochno, MD, Marvin Atkins, MD, Alan Lumsden, MD.
Houston Methodist Hospital, Houston, TX, USA.
This case describes successful endovascular management of a complex thoracoabdominal aortic aneurysm using a combination of hotwire endovascular septostomy and branched endovascular aneurysm repair (BEVAR). This is a 67-year-old male with a past medical history significant for type A aortic dissection with remote hemiarch ascending aortic repair, open proximal descending thoracic aortic replacement, and aorto-biiliac bypass for infrarenal abdominal aortic aneurysm. He presented to our clinic with post-dissection aneurysmal degeneration of the thoracoabdominal aorta and severe true lumen compression which we decided to treat using a staged endovascular approach.
The first stage involved aortic septostomy using a modified hotwire technique to create a single aortic lumen, facilitating thoracic endograft placement and true luminal gain for interval branched fenestrated endograft repair. Following adequate remodeling, definitive repair was performed using commercially available four-branched endograft.During the total transfemoral BEVAR procedure, catheterization of the celiac artery proved technically unfeasible due to aortic remodeling and target vessel displacement by our endograft. After several unsuccessful attempts, the celiac portal was temporarily abandoned and the remainder of the BEVAR was completed. The patient returned to the operating room 48 hours later via left upper extremity access, but again the celiac artery could not be catheterized. To confirm adequate collateralization to the celiac axis prior to embolization of his remaining graft fenestration, temporary balloon occlusion of the celiac portal and selective arteriography of the superior mesenteric artery was performed which demonstrated robust retrograde perfusion of the hepatic and splenic territories via the pancreaticoduodenal arcade. The celiac fenestration was then successfully embolized with an appropriately oversized vascular plug.
This strategy aligns with previously described techniques for managing unused fenestrations or branches in F/B-EVAR. As previously reported, failure to cannulate a target vessel during F/B-EVAR may necessitate prompt intraoperative occlusion to prevent persistent type III endoleaks. This case highlights the importance the role of dynamic testing to assess visceral collateralization when target vessel incorporation is not feasible. Familiarity with occlusion devices and embolization techniques is essential when using complex endografts, particularly in anatomically altered aortas following septostomy.
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