Causes and consequences of mesenteric embolization after endovascular aorto-iliac intervention — a nested case control study

Abstract

Background: Causes and consequences of mesenteric embolization after endovascular aorto-iliac procedures have not been studied adequately. Methods: Consecutive patients with mesenteric embolization after endovascular aorto-iliac intervention between 2011 and 2015 (case-group, n = 9) were investigated and compared with age, gender and procedure-matched random controls (n = 36). Results: Compared to the control group, a higher proportion of patients with mesenteric embolization were current smokers (89% vs. 53%; P = 0.048) and had renal insufficiency at admission (44% vs. 11%; P = 0.019). In patients treated for aorto-iliac occlusive disease, aortic irregularity (shagginess) was more severe (P = 0.015), visceral thrombus volume was larger (P = 0.004) and operation-time was longer (P = 0.009) among the case-group. However, no differences were found between cases with mesenteric embolization caused by endovascular aortic aneurysm repair versus controls. Myoglobin, arterial blood lactate, aspartate aminotransferase, alanine aminotransferase and pancreatic amylase levels were elevated in 100%, 67%, 89%, 89%, 89% and 56% of patients with mesenteric embolization, respectively. Overall in-hospital mortality among cases was 33% (3/9). The in-hospital mortality was 17% (1/6) in patients treated with open abdomen therapy, of whom five were managed with stomas. Conclusion: Smoking cessation, careful patient selection and procedure planning with identification of severe shaggy aortas might prevent mesenteric embolization during aorto-iliac procedures. In suspected cases of mesenteric embolization, elevated myoglobin and arterial blood lactate may be indicative of this complication. Aspartate and alanine aminotranferases, as well as pancreatic amylase, are also relevant tests to assess the extent of organ ischaemia. Damage control with open abdomen therapy and the creation of stomas seem justifiable in order to improve survival in this complex situation.

The Shaggy Aorta Syndrome: An Updated Review

“…SA has been identified as an independent risk factor for spinal cord injury 49 or mesenteric embolization 46 after thoracic endovascular aortic repair (TEVAR). SA represents an independent risk factors for cerebral infarction after EVAR, 37,39 also after left subclavian artery coverage.…”

“…Sometimes, the aortic axis also represents the way to get to cardiac structures (i.e., aortic valve for TAVI, atrial, or ventricular septum for ventricular septal defect or atrial septal defect closure), and therefore accurate preoperative evaluation of the aorta is critical. 46 To minimize the complications related to SA syndrome, awareness and prompt diagnosis with new imaging measurements will help to better assess the patient risk. CT plays a central role in the diagnosis, risk stratification, and management of aortic diseases, 2 and, in Figures 2 and 3, impressive images of CT scans, belonging to our department's collection, are showed.…”

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“…(517,3) Está demostrado que el hallazgo de la SA genera mortalidad, embolización y complicaciones mayores en el 30% de los casos en cirugía abierta (518); el procedimiento híbrido (debranching total y endoprótesis) en el cayado aórtico parece una opción aceptable en el tratamiento de la aorta cuando encontramos este hallazgo asociado en las imágenes (519) y en pacientes con aneurismas de aorta ascendente. (520) En el TEVAR, la SA fue identificada como un factor de riesgo independiente de isquemia de médula espinal, (521) embolia mesentérica (522), embolización cerebral en EVAR (523,524) (aun a pesar de la oclusión de la arteria subclavia izquierda) (525), aumento de la embolización renal y mesentérica en EVAR y endoprótesis fenestradas (526,527); por otra parte, está demostrado el aumento en ACV y paraplejía en los pacientes que se realizan TAVI. (528) Dado todo lo expuesto previamente se debe prestar especial atención a este hallazgo en las imágenes, porque aumenta el riesgo de embolización en el tratamiento (endovascular o quirúrgico) de la patología aórtica (aneurismas, pseudoaneurisma o síndromes aórticos).…”