Objective: To evaluate the impact of celiac artery (CA) compression by median arcuate ligament (MAL) on technical metrics and long-term CA patency in patients with complex aortic aneurysms (cAAs) undergoing fenestrated/branched endograft repairs (f/b-EVARs).
Methods: Single center, retrospective review of patients undergoing f/b-EVARs and requiring incorporation of the CA between 2013 and 2023. Patients were divided into two groups - those with (MAL+) and without (MAL-) CA compression - based on preoperative computed tomography angiography (CTA) findings. MAL was classified in three grades (A, B and C) based on the degree and length of stenosis. Patients with MAL grade A had ≤ 50% CA stenosis measuring ≤ 3 mm in length. Those with grade B had 50%-80% CA stenosis measuring 3-8 mm long while those with grade C had >80% stenosis measuring > 8 mm in length. Endpoints included device integrity, CA patency and technical success - defined as successful implantation of the f/b-device with perfusion of CA and no endoleak.
Results: 180 patients with cAAs (pararenal: 128; thoracoabdominal:52) required incorporation of the CA during f/b-EVAR. Majority (73%) were male, with a median age of 76 (69, 81) years and aneurysm size of 62 (57, 69) mm. Seventy-eight patients (43%) had MAL+ anatomy, including 33 patients with MAL grade A, 32 with grade B and 13 with grade C compression. The median length of CA stenosis was 7.0 (5.0 - 10.0) mm. CA was incorporated using fenestrations in 177 (98%) patients. Increased complexity led to failure in CA bridging stent placement in four MAL+ patients but completion angiography showed CA perfusion and no endoleak, accounting for a technical success of 100%. MAL+ patients were more likely to require bare metal stenting in addition to covered stents (p=.004). Estimated blood loss, median operating room time, contrast volume, fluoroscopy dose and time were higher (p<.001) in MAL+ group. Thirty-day mortality was 3.3%, higher (5.1%) in MAL+ patients compared to MAL- patients (2.0 %). At a median follow-up of 770 (198, 1525) days, endograft integrity was observed in all patients and CA events - kinking (7), thrombosis (1) and endoleak (2) - occurred in 10 (5.6%) patients. However, only two patients required reinterventions. MAL+ patients had overall lower long-term survival.
Conclusions: CA compression by MAL is a predictor of increased procedural complexity during f/b-device implantation. However, technical success, long-term device integrity and CA patency are similar to that of patients with MAL- anatomy.
Keywords: Celiac artery stenting; Complex aortic aneurysms; Endovascular repair; Fenestrated/Branched endografts; Median arcuate ligament.
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