Abstract
Introduction:
A retrograde approach of the celiac trunk (CT) and superior mesenteric artery (SMA) to catheterize the visceral vessels during a fenestrated endovascular aortic reparation (FEVAR) is a feasible option when standard access techniques have failed.
Report:
In this report we describe a patient with a previous endoluminal repair of an infrarenal aortic aneurysm, complicated by a persistent type 1a endoleak despite treatment with endoanchor fixation. A decision was made to proceed with a proximal 4 vessel FEVAR to treat the type 1a endoleak. Due to angulation of the mesenteric vessels, and a rotation of the fenestrated stent graft during deployment, the CT and SMA were unable to be catheterized. A decision was made to perform a median laparotomy for retrograde access of the aforementioned vessels, allowing successful catheterization and stenting. The patient was discharged 30 days following the procedure, without any major post-operative complications. Follow up at 6 weeks with a contrasted enhanced computerized tomography scan showed a stable repair with no residual type 1a endoleak.
Discussion:
Catheterization of the target vessels during a FEVAR can be difficult, especially in patients with challenging anatomy. Prolonged surgical time in an attempt to catheterize the vessels can result in increased morbidity for the patient, and ultimately may result in the procedure being abandoned or conversion to an open repair of the aneurysm. Retrograde access of the target vessels as a bailout measure during fenestrated stent graft repair due to failure of an antegrade approach has rarely been reported in the literature. Only a few cases are described in the available literature, however, none of them describe retrograde approach of both the CT and SMA as described in this case. A median laparotomy for retrograde access is a feasible alternative in these situations, and should be considered if the patient is suitable.
Highlights
Type I endoleak in a patient with previous endovascular aneurysm repair can often be difficult to treat.
The deployment of a fenestrated endoluminal stent graft, can be especially challenging in patients with complex anatomy.
An open retrograde approach of the visceral vessels is a feasible option, when standard access techniques have failed.
Introduction
The use of endoanchors in patients with a type 1a endoleak following endovascular repair of aortic aneurysm is well described.1,2 In patients where this is unsuccessful, an open repair or fenestrated endovascular aneurysm repair (FEVAR) is considered. 3 A fenestrated repair in these patients can be technically challenging, with difficulties catheterizing the target vessels frequently encountered. We describe the case of successful retrograde catheterization of the target vessels, where routine antegrade cannulation methods have failed.
Case Report
A 77-year-old female underwent an endovascular aortic repair (EVAR) of an abdominal aortic aneurysm (AAA) (Figure 1) using an InCraft device (Cordis) (Figure 2). Her background includes hypertension, type 2 diabetes mellitus and hypercholesterolemia.
CTA. AAA before EVAR. CTA, computerized tomography angiogram. AAA, abdominal aortic aneurysm. EVAR, endovascular aortic repair.
Angiogram using CO2 post EVAR. EVAR, endovascular aortic repair.
The infrarenal AAA had a maximum diameter of 55 mm. The common iliac arteries were of normal caliber. External iliac arteries were small (7 mm) and diseased. The aneurysm neck was 15 mm in length and had an angulation of approximately 40 degrees (Figure 1). During the initial EVAR the stent graft landed lower than expected on deployment, likely due to the severely angulated neck. The patient developed a type 1a endoleak, which persisted despite proximal fixation with endoanchors (Figure 3). A proximal extension cuff was not feasible due to the short distance between the lowest renal artery (right), and the bifurcation of the graft (30 mm). Due to the close proximity of the SMA and right renal artery, chimney treatment was considered not appropriate. Therefore a FEVAR procedure was performed with a custom made 4 fenestration Anaconda endograft (Vascutek/Terumo, Inchinnan, UK) with coated balloon-expandable stents (BeGraft, Bentley Innomed, Hechingen, Germany) as bridging stents (Figures 4 and 5).
A, Angiogram post endoanchors. B, CTA post endoanchors that shows type Iaendoleak. CTA, computerized tomography angiogram.
FEVAR plan. FEVAR, fenestrated endovascular aortic repair.
Angiogram during FEVAR procedure. Type Ia endoleak. FEVAR, fenestrated endovascular aortic repair.
A trial deployment with a personalized mold of the patient’s aneurysm was successfully performed prior to the surgery (Figure 4).
Bilateral femoral cut-down and proximal left brachial artery cut down were performed to isolate access vessels. 7,000 IU of intravenous low molecular weight heparin was administered in total. Activated clotting time was maintained above 200 seconds during the procedure.
The fenestrated endograft was introduced through the right common femoral artery (CFA), while a 22F sheath was placed in the left CFA. The procedure was technically challenging due to the severely angulated aneurysm neck, and the angulation of the mesenteric vessels. On deployment the main body was slightly rotated. Unable to twist it, due to existence of previous EVAR and a narrow aortic bifurcation.
After multiple attempts only the left renal artery was successfully catheterized and a 6F 45 cm sheath was placed within the vessel.
A 7F (90 cm) sheath was placed in the abdominal aorta through the left axillary artery. The proximal stents of the fenestrated graft main body were deployed and the whole graft was fully deployed. The delivery system was exchanged with a 22F sheath. Attempts to catheterize the mesenteric vessels from above were also unsuccessful. A decision was made to perform a median laparotomy and dissect the celiac trunk and SMA to approach them in a retrograde fashion. The left renal artery was secured with a stent, with a sheath left in situ.
Exposure of the celiac trunk was achieved by dividing the left triangular ligament and gastrohepatic ligaments with caudal retraction of the lesser curve of the stomach. The celiac trunk was successfully dissected and isolated, and a 5F (11 cm) sheath was sited within the splenic artery. The transverse colon and omentum were retracted cranially, with retraction of the small bowel laterally, and the peritoneum was opened close to the duodenal-jejunal junction to achieve exposure of the SMA distal to the origin, and a 5F (11 cm) sheath was also sited. (Figures 6 and 7).
Angiogram during FEVAR. A, Retrograde access through celiac axis. B, Retrograde access through SMA. C, SMA and celiac axis retrograde access. FEVAR, fenestrated endovascular aortic repair. SMA, superior mesenteric artery.
F, Photo of median laparotomy. Two 4F sheaths in celiac trunk and SMA before upgrading them to 7F. SMA, superior mesenteric artery.
Through the celiac trunk access, using a 0.035 angled glide wire, a 5F 23 cm Berenstein catheter was sited within the aortic lumen, between the wall and the fenestrated graft. Through manipulation of the angled catheter, the glide wire was successfully navigated into the fenestration, and wire position was confirmed by inflating a 10 mm balloon through the fenestration. The glide wire was subsequently snared from the axillary artery, allowing for through and through access. The sheath in the celiac trunk was upsized to a 7F, and secured with a stent. The SMA was also successfully catheterized through the fenestration in a similar fashion. Since the flow to the right renal artery was preserved, as the fenestration of the customized graft matched with the origin of the vessel. Intraoperative decision was made not to pursue retrograde catheterization of the right renal artery, due to the prolonged duration of the procedure, and risk of increased morbidity to the patient (Figure 8).
Angiogram. Right renal artery without stent.
Bifurcated graft and extension limb were placed uneventfully. SMA and celiac trunk were closed with interrupted 6-0 Prolene stitches. Completion angiogram showed patency of all visceral vessels, and successful exclusion of the aneurysm with no residual endoleaks (Figure 9).
Final angiogram after FEVAR. FEVAR, fenestrated endovascular aortic repair.
Patient was taken to ICU as per routine protocol for post-operative monitoring. The patient made an uneventful recovery as an inpatient, and a contrast enhanced CT scan was performed day 6 post procedure which showed patency of all stents, and the left renal artery, with no evidence of an endoleak. A small infarct was identified in the left kidney with no impairment in renal function impairment, and was managed conservatively. The scan also highlighted a kink in the proximal part of the SMA stent (Figure 10). Although the patient was asymptomatic, a decision was made to perform an angioplasty (Figure 11). The patient was discharged from the hospital 20 days after the surgery with asymptomatic. CT angiogram 4 weeks post procedure showed correct exclusion of the AAA and patency of all the visceral branches (Figure 12).
CTA post FEVAR. Kink in the proximal SMA stent. CTA, computerized tomography angiogram. FEVAR, fenestrated endovascular aortic repair. SMA, superior mesenteric artery.
Final angiogram after SMA plasty. SMA, superior mesenteric artery.
CTA post FEVAR and SMA plasty. Type 1 endoleak excluded. CTA, computerized tomography angiogram. FEVAR, fenestrated endovascular aortic repair. SMA, superior mesenteric artery.
Informed consent has been obtained from the patient for publication of the case report and accompanying images.
Discussion
Retrograde access of the target vessels during a fenestrated repair, is a feasible bailout technique when antegrade cannulation fails. Very few cases are described in the literature using this technique. Although there is increased morbidity in comparison to a standard endovascular technique, it is considered less morbid than open surgical repair of the aneurysm as there is no cross-clamping of the aorta.
Verhoeven et al. described 11 cases of juxtarenal AAA or thoracoabdominal aneurysm that required retrograde target vessel access due to failure of an antegrade approach during a FEVAR. Six of these cases involved the left renal artery, 3 celiac trunk, one right renal and bilateral renal vessels in one patient. The target vessels were successfully catheterized in all of the cases, and secured with stent grafts. One short term (30 day) mortality was reported, and one reintervention due to progression of an iliac aneurysm. The authors concluded that retrograde target vessel access in FEVAR is a feasible bailout procedure when antegrade cannulation fails with a high rate of technical success; however, associated with a higher perioperative morbidity and longer hospital stay. 4
Haulon et al. also reported a case in which percutaneous retrograde target vessel access was required after a 4-vessel fenestrated graft. This was due to a severe kink at the proximal part of the left renal artery. A percutaneous trans-lumbar approach using computerized tomography angiography guidance was used. The stent was relined successfully with no major complications. 5
In patients with hostile anatomy, catheterization of the target vessels can be technically challenging. Prolonged unsuccessful attempts to catheterize the target vessels is associated with increased surgical time, and associated with increased intraoperative and post-operative morbidity and mortality.
This hybrid alternative is associated with less morbidity/mortality risk to the patient in comparison to open surgical repair as there is no clamping of the aorta. It is important that vascular surgeons recognize this is a feasible bailout option in situations where catheterization of the target vessels is difficult. Furthermore it is imperative that surgeons have a thorough understanding of the anatomy, and maintain good open surgical skills to successfully achieve surgical exposure to the target vessels.
Conclusion
We describe a case of retrograde access of both celiac trunk and SMA as a bailout technique during a FEVAR. This is a feasible technique and can be considered in patients who are suitable to successfully exclude the aneurysm and preserve patency of the target vessel, where standard antegrade approaches have failed. Further studies evaluating the long term outcomes in these patients are worthwhile.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
