Occlusion of the Celiac Artery during Endovascular Thoracoabdominal Aortic Aneurysm Repair Is associated with Increased Perioperative Morbidity and Mortality

Abstract

Background: Some studies suggest that celiac artery coverage during elective endovascular thoracoabdominal aortic aneurysm (TAAA) repair is safe given sufficient collateralization of visceral organ perfusion from the superior mesenteric artery. However, there is concern that celiac artery coverage may lead to increased risk of foregut or spinal cord ischemia with an attendant increased risk of mortality. We sought to investigate rates of bowel ischemia, spinal cord ischemia, and 30-day mortality associated with celiac artery coverage during TEVAR and complex EVAR. Methods: The Society for Vascular Surgery Vascular Quality Initiative database was queried for TEVAR and complex EVAR cases from 2012 to 2018. Inclusion criteria included TAAA pathology and endograft extension to aortic zone 6. Patients with aortic rupture, trauma, prior thoracic aortic surgery, known preoperative occlusion of the left subclavian superior mesenteric, or celiac arteries were excluded. Cases with intraoperative celiac artery occlusion (CAO) were compared retrospectively to cases with celiac artery preservation (CAP). Primary outcomes included 30-day mortality and a composite end point of 30-day mortality, spinal cord ischemia (transient or permanent lower extremity neurologic deficit), and bowel ischemia (colonoscopic evidence of ischemia, bloody stools in a patient who dies prior to colonoscopy or laparotomy, or other documented clinical diagnosis). Univariable comparisons were performed using chisquared tests and Student's t-tests, as appropriate. Multivariable logistic regression analyses were employed to identify independent predictors of outcome. Results: There were 628 cases identified for inclusion in the study. Patients undergoing CAO (n = 44) were more likely to be female or to have higher rates of preoperative spinal drain use, American Society of Anesthesiologists score ≥3, low preop hemoglobin, and/or symptomatic presentation, but fewer mean number of aortic zones covered. CAO was associated with higher 30day mortality (5 of 44, 11%) compared to CAP (23 of 584, 4%), P = 0.039. The composite end point occurred at a significantly greater proportion for those who had CAO (10 of 44, 23%

Safety and Efficacy of Intentional Celiac Artery Coverage in Endovascular Management of Thoracoabdominal Aortic Diseases: A Systematic Review and Meta-analysis

“…4,13,26 Diverging data exist in the study of King et al who examined the effect of CAO versus CA preservation on mortality, spinal cord ischemia, and bowel ischemia in patients obtaining endovascular repair for TAAA, using data obtained through the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI). 10 The authors identified a total of 628 cases treated with EG, 44 patients among them (7% of the population) having inadvertent or intentional CAO and the remaining receiving CA revascularization. Their results showed that CAO was associated with higher 30-day mortality compared with patients with CA revascularization (11% vs 4%, respectively) and higher incidence of bowel ischemia (9% vs 2%, respectively).…”

“…The difference in their results which is in the higher range of the rates of similarly reported studies 9,13,18 could be attributed to the fact that there was lack of data regarding the preoperative imaging on establishing mesenteric circulation and the assessment of sufficient celiac collateralization in patients treated with CAO, thus not enabling the proper selection of "fit" patients for CAO. 10 The technique of CAO seems safe; however, its prognostic success was largely associated with 2 principal interconnected conditions. The first is the anatomical pattern of the splanchnic circulation, and the second is the preoperative demonstration of adequate collateral circulation between the celiac and SMA, which is crucial prior to considering intentional coverage of the CA.…”

“…If there is underlying SMA occlusive disease, the patient is at risk of developing mesenteric/visceral ischemia after the procedure even in the presence of an adequate collateral network. 10 As such, the presence of underlying SMA occlusive disease must be properly evaluated prior to EG deployment. Furthermore, SMA patency must be ensured at the end of the procedure.…”

“…Furthermore, SMA patency must be ensured at the end of the procedure. 12 2 0 3 Mehta et al 13 3 0 3 Delle et al 14 2 0 3 Li et al 15 2 0 2 Rose et al 9 3 0 3 Piffaretti et al 16 3 0 3 Fukushima et al 17 2 0 3 King et al 10 3 0 2 Banno et al 18 2 0 3…”

“…All data were derived from single-center studies except for those of 2 studies that were part of national registries. 9,10 The included studies reported a total of 2297 patients who were treated with thoracic EGs, whereas among them, 175 patients (7.6%) had insufficient distal landing zone and required intentional CA coverage. Twelve patients (7%) were treated on an emergent or urgent basis.…”