Southern Association For Vascular Surgery

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Outcomes of TEVAR with Celiac Artery Parallel Grafting using Sandwich Technique for Thoracic Aneurysms with Inadequate Seal Zone
Muzzamil Aziz, H. Edward Garrett, Jr.
UT-Memphis, Memphis, TN

No definitive endovascular solution exists for patients with thoracic aortic pathologies who have inadequate seal length at the level of the celiac artery but adequate seal at the level of the superior mesenteric artery (SMA). We present single institution outcomes for this subset of patients using thoracic endovascular aortic repair (TEVAR) with celiac artery parallel grafting in a sandwich configuration.
Retrospective analysis of a prospectively maintained database of all patients undergoing TEVAR between October 2014 and August 2017 at our institution was performed. All patients during the study period who underwent TEVAR with celiac artery parallel grafting using the sandwich technique were identified. All patients were evaluated by computerized tomography angiogram (CTA) preoperatively. Post-operative surveillance included CTA at one month and yearly after the procedure. Patients with chronic kidney disease who were not on dialysis had non-contrast CT scans to monitor thoracic aortic aneurysm sac diameter; celiac stent patency was followed clinically for these patients. For sac enlargement or symptoms suggestive of mesenteric ischemia, CTA or a celiac doppler flow study was done.
Twelve patients were identified during the study period who underwent TEVAR with celiac artery parallel grafting using the sandwich technique. Mean age was 68 years. Seven (58%) patients had type 1 or type 5 thoracoabdominal aortic aneurysm (TAAA) with involvement of the origin of the celiac artery, 4 (33%) patients had thoracic aortic aneurysm with inadequate sealing length above the celiac artery, and 1(8%) patient had a penetrating ulcer at the level of origin of the celiac artery. All patients had adequate seal zone at the level of the SMA. Lumbar drains were placed in 10(83%) patients. Mean diameter of the aortic grafts used was 37 mm (range 31 to 45mm). All thoracic endografts were CTAG (W.L. Gore and Associates, Flagstaff, AZ), and all celiac stent grafts were Viabahn (W.L. Gore and Associates, Flagstaff, AZ). No intraoperative endoleak was identified. Technical success was achieved in 11(92%) patients. 30-day mortality was 8%. Among the surviving patients, one patient (8%) developed paraplegia followed by complete recovery. Mean follow-up was 22 months (range 1-46 months). Secondary intervention rate was 17%; two patients developed type 1B endoleak and underwent distal extension with an endograft at 24 and 26 months. Two patients (17%) were found to have type 2 endoleak with no sac enlargement. No patients developed any symptoms of mesenteric ischemia. No gutter leak was identified in any patient during the follow up period. 63% of patients had surveillance CTA data available confirming patency of the celiac stent. One celiac stent which had been patent at 24 months was occluded on CTA at 33 months. No patients died during the follow-up period.
Celiac artery parallel grafting using sandwich technique is a reliable method of endovascular repair of thoracic aortic pathologies with inadequate distal seal zone with acceptable mid-term
outcomes and an acceptable reintervention rate. Larger cohorts with longer follow up are needed to further evaluate the outcome of this technique for this subset of patients.

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