Incorporation of Celiomesenteric Trunk With Double Kissing Directional Branches During Fenestrated-Branched Endovascular Aortic Repair

Introduction

The anatomy of the renal and mesenteric arteries is predictable in most patients, but several anatomical variations have been described. A common celiomesenteric trunk (CMT) is an infrequent variation that affects 0.5% to 3.4% of individuals.^1–3 Prior reports of patients with CMTs and aneurysmal or occlusive disease have focused on techniques of open or endovascular reconstructions, but none have described the use of fenestrated-branched endovascular aortic repair (FB-EVAR) for treatment of thoracoabdominal aortic aneurysms (TAAAs).^4–10 We report a patient who presented with a 7.9-cm TAAA affecting a CMT and was treated by FB-EVAR using double kissing directional branches for incorporation of the celiac axis (CA) and the superior mesenteric artery (SMA).

Clinical Presentation

A 70-year-old male patient presented with a 7.9-cm asymptomatic extent III TAAA 10 years after having undergone endovascular aortic repair (EVAR) using infrarenal bifurcated stent-graft and being lost to follow-up during the period (Figure 1). The patient’s medical history was notable for aortic root and hemiarch replacement for aneurysmal disease, hypertension, hyperlipidemia, cigarette smoking, obstructive sleep apnea, hernia repair, and prior alcohol dependence. A genetic evaluation did not reveal any genetically triggered aortic diseases. Preoperative computed tomography angiography (CTA) showed a TAAA involving a CMT and single bilateral renal arteries with distal extension into a bifurcated stent-graft and a 4-cm right common iliac artery aneurysm. The left renal artery was tortuous and had an upgoing orientation.

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Figure 1.

Illustration and 3-dimensional computed tomography angiography reconstruction showing a 7.9-cm extent III thoracoabdominal aortic aneurysm. The patient had a previous endovascular repair of the infrarenal aorta with caudal migration of a Cook Zenith endograft (Cook Medical, Bloomington, IN) and significant tortuosity of both iliac arteries, and an open composite aortic root and ascending hemiarch replacement with a Dacron graft. Note that the visceral vessels originate from the aneurysm sac as a common celiomesenteric trunk and that the left renal artery has an upgoing configuration. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.

Device Design

The patient was enrolled in a prospective physician-sponsored investigational device exemption protocol (G130266). A patient-specific thoracoabdominal fenestrated and branched stent-graft (Cook Medical Inc, Brisbane, Queensland, Australia) was planned with kissing double directional branches for the CMT to incorporate the CA and SMA as separate target vessels (Figure 2A). Two additional directional branches were designed for the main renal arteries. A small single fenestration was added for the left renal artery as a potential “bail out” strategy in the event of difficult catheterization via the directional branch. The stent-graft design is shown in Supplementary Figure 1. A transabdominal preloaded delivery system (TPDS) was used to facilitate branch catheterization via the brachial approach, as previously described. ¹¹

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Figure 2.

Device design and implantation. A patient-specific thoracoabdominal fenestrated-branched stent graft was designed with 4 directional branches and 1 small fenestration to assist left renal artery catheterization; a transabdominal preloaded delivery system was used (A). A 20-Fr right femoral sheath and a 12-Fr brachial sheath were advanced to the thoracic aorta and through-and-through femoral-brachial access was established (B). An 8-Fr left femoral sheath was placed and the left renal artery was catheterized to allow for calibration of the onlay fusion computed tomography angiography (CTA). The nose cone of the delivery system was accessed via the brachial sheath and the preloaded wires were retrieved (C). By permission of Mayo Foundation for Medical Education and Research. All rights reserved.

Technique

The procedure was performed using general anesthesia in a hybrid operating room with GE IGS 740 Discovery imaging (GE Healthcare, Chicago, IL), onlay fusion and high-definition imaging (video). Intraoperative neuromonitoring and near-infrared spectroscopy was used with no placement of prophylactic spinal drain. Open exposure of the right brachial artery and bilateral percutaneous femoral access was established using a preclosure technique. After systemic heparinization and calibration of the onlay fusion, a brachial-femoral wire was snared and a 12-Fr sheath was advanced via the right brachial access (Figure 2B). The left renal artery was catheterized from the femoral approach in anticipation of possible “snare-ride” technique. ¹² The thoracoabdominal device was oriented extra-corporeally and advanced via the right brachial-femoral wire (Figure 2C). The device was deployed with the directional branches approximately 2 to 3 cm proximal to the intended target vessels. Using the preloaded guidewires, the CA, SMA and right renal arteries were sequentially catheterized. The right renal artery was stented first using a Viabahn self-expandable stent-graft (Gore, Flagstaff, AZ) (Figure 3A). The SMA and CA were stented using VBX stent-grafts (Gore, Flagstaff, AZ), which were sequentially dilated and then post-dilated using “kissing” balloon technique (Figure 3B and C). The selection of stent-grafts was made based on 1-mm diameter oversize in relation to the native vessel and on minimal seal length of 2 cm in the target vessel. We opt for self-expandable stent grafts for renal arteries and balloon-expandable stent-grafts for mesenteric arteries. ¹³ The left renal artery was stented via the directional branch using a with a Viabahn self-expandable stent-graft. Due to difficulty in maintaining guidewire support because of upgoing orientation of the left renal artery, stent advancement was possible via the brachial access using a balloon-assisted technique via the left femoral access (Figure 4A and B). ¹⁴ The repair was extended distally into the bifurcated endograft with Cook Alpha thoracic stent grafts (Cook Medical Inc, Bjaeverskov, Denmark), which also covered the left renal fenestration to prevent endoleak (Figure 4B, arrow). Finally, a right straight iliac branch device (Cook Medical Inc, Bloomington, IN) was added to incorporate the right internal iliac artery and treat the right common iliac aneurysm (Figure 5).

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Figure 3.

The device was deployed, and the celiac axis, superior mesenteric artery and right renal artery were catheterized from the brachial access. The right renal artery was stented with a Viabahn 7×75 stent-graft (Gore, Flagstaff, AZ) and secured proximally by an iCAST 7×38 mm stent-graft (Atrium Maquet, Hudson, NH) (A), the superior mesenteric artery (SMA) and the celiac axis (CA) were both stented with VBX 6×79 mm and 5×79 mm stent-grafts, respectively (Gore, Flagstaff, AZ) (B). Kissing-balloon dilation was performed in the SMA and CA stents (C). By permission of Mayo Foundation for Medical Education and Research. All rights reserved.

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Figure 4.

The left renal artery was catheterized via the brachial access and the wire was secured by an inflated balloon placed via the left femoral access. This allowed the sheath and stent to be safely advanced, and the artery was stented with a Viabahn 7×75 mm stent-graft (Gore, Flagstaff, AZ), secured proximally by a VBX 7×59 mm stent-graft (Gore, Flagstaff, AZ) and distally by a self-expanding bare metal Innova 7×20 mm stent (Boston Scientific, Marlborough, MA) to prevent kinking (A). The repair was extended caudally with thoracic stent-grafts, covering the designed fenestration (arrow). Selective digital rotational angiography revealed widely patent target vessels and exclusion of the aneurysm sac with no type I or III endoleak, dissection or embolization (B). By permission of Mayo Foundation for Medical Education and Research. All rights reserved.

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Figure 5.

Illustration and 3-dimensional computed tomography angiography reconstruction showing the endovascular repair of an extent III thoracoabdominal aortic aneurysm with 4 patent directional branches, no kink or compression of the bridging stents, and no endoleak. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.

Selective digital rotational angiography and cone beam computed tomography (CBCT) with and without contrast-enhancement revealed widely patent target vessels and exclusion of the aneurysm sac with no type I or III endoleak, dissection, or embolization. Total endovascular time was 192 minutes with fluoroscopy time of 98 minutes. Total contrast used was 155 mL. The patient was discharged home on postoperative day 4 with no complications. A follow-up CTA was done at 1 month and at 6 months postoperatively, and both exams showed successful repair with incorporation of the CMT, patency of all directional branches, no evidence of type I or III endoleak, no signs of aortic wall injury, dissection, or intramural hematoma. At 7 months, the patient presented with acute type B_3,5 aortic dissection, which was successfully treated by proximal thoracic endovascular aortic repair with left carotid-subclavian bypass. ¹⁵ Repeat CTA done after the dissection repair showed no additional complication, widely patent directional branches and excluded TAAA.

Discussion

This case illustrates several pitfalls of device design and implantation in a patient with variation of the 4-vessel anatomy, CMT, and difficult orientation of the left renal artery. Whereas during open surgical repair these variations can be easily overcome, FB-EVAR requires creative planning to secure successful sealing in normal aortic or target vessel segments. The presence of early vessel bifurcation frequently poses limitations not only for the renal arteries but also for mesenteric vessels. ¹⁶ Among patients with CMT, the relatively large diameter and short length of the common trunk prevent successful sealing of a bridging stent, warranting modifications in the standard approach. The options of intentional occlusion of the celiac axis or a hybrid extra-anatomical reconstruction should be considered as alternatives in these cases but are limited by the risks of gastric or hepatic ischemia and the potential morbidity of an open approach. We opted for a design with 2 directional branches using a “kissing stent technique,” which has been widely applied in bifurcation lesions. The relatively large diameter of the common trunk assured the ability to place the 2 stents side-by-side without compression, but the “kissing balloon” technique with intraoperative CBCT assessment assured absence of stent compression and widely patent branches. It is estimated that one-third of patients with CMTs have short trunk lengths between 7 and 14 mm, but patients with longer trunks may be treated by single branches. ³

Apart of the CMT variation, the patient’s anatomy was challenged by iliac tortuosity and an upgoing left renal artery, which is not ideally suited for directional branches. Therefore, a contingency plan for access into the left renal artery was devised using a single “bail out” fenestration with preemptive left renal catheterization via the femoral approach for “snare-ride” or “balloon-assisted” stent placement.^12,14 Using the balloon-assisted technique, we were able to successfully advance the bridging stent to incorporate the left renal artery using the directional branch. Finally, the patient’s history of multifocal disease and predisposition for aneurysmal progression emphasize the importance of genetic evaluation and staged approach. Even with a negative genetic evaluation and 2 postoperative CTAs showing no signs of aortic wall injury, the patient presented an acute type B dissection 7 months following the initial operation. Fortunately, the creation of longer sealing zones during the TAAA repair allowed a proximal thoracic stent graft to treat the type B dissection by endovascular technique.

Conclusion

Double kissing directional branches should be considered as an alternative to incorporate vessels with early bifurcation such as a CMT.

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