|Year : 2015 | Volume
| Issue : 2 | Page : 68-70
A Novel Approach for Synchronous Open and Endo-repair of Concomitant Mesenteric and TASC "D" Aorto-iliac Occlusive Disease with Symptomatic Thoraco-abdominal Aortic Aneurysm
Sidharth Viswanathan, Vivek Agrawal, Shashidhar Kallappa Parameshwarappa, Ajay Savlania, P Shivanesan, Balasubramoniam Kavumkal Rajagopalan, Madathipat Unnikrishnan
Department of CVTS, Division of Vascular and Endovascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
|Date of Web Publication||31-Jul-2015|
Department of CVTS, Division of Vascular and Endovascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala
Source of Support: None, Conflict of Interest: None
Aorto-iliac and mesenteric occlusive disease co-existing with thoraco-abdominal aortic aneurysm are a very rare clinical association, which poses a great therapeutic challenge and adds to the complexity of the open surgical repair. We describe a case of a 60-year-old male with symptomatic Crawford Type I thoraco-abdominal aneurysm with concomitant visceral and aorto-iliac occlusive disease successfully treated by aorto-bifemoral and mesenteric artery bypass followed by thoracic endovascular aneurysm repair. This novel technical approach turned out to be safe and effective strategy to tackle these co-existing tandem lesions, which minimized morbidity compared to stressful total open surgical repair, leading to excellent patient recovery.
Keywords: Aorto-iliac occlusive disease, hybrid repair, mesenteric revascularization, thoracic endovascular aneurysm repair, thoraco-abdominal aneurysm
|How to cite this article:|
Viswanathan S, Agrawal V, Parameshwarappa SK, Savlania A, Shivanesan P, Rajagopalan BK, Unnikrishnan M. A Novel Approach for Synchronous Open and Endo-repair of Concomitant Mesenteric and TASC "D" Aorto-iliac Occlusive Disease with Symptomatic Thoraco-abdominal Aortic Aneurysm. Indian J Vasc Endovasc Surg 2015;2:68-70
|How to cite this URL:|
Viswanathan S, Agrawal V, Parameshwarappa SK, Savlania A, Shivanesan P, Rajagopalan BK, Unnikrishnan M. A Novel Approach for Synchronous Open and Endo-repair of Concomitant Mesenteric and TASC "D" Aorto-iliac Occlusive Disease with Symptomatic Thoraco-abdominal Aortic Aneurysm. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2022 May 26];2:68-70. Available from: https://www.indjvascsurg.org/text.asp?2015/2/2/68/161945
| Introduction|| |
Thoraco-abdominal aortic aneurysm (TAAA) is uncommonly associated with visceral artery stenoses (18%) while the presence of concomitant aorto-iliac occlusive disease is rarer still.  Total open surgical repair in this setting is highly demanding and technically challenging considering the poor accessibility of right iliac or femoral arteries in left thoraco-phreno-laparotomy approach for repair of TAAAs along with inability to support distal aortic perfusion with bypass circuitry using routine femoral cannulation. This limitation can contribute to substantial morbidity and mortality of total surgical repair. Hybrid techniques are pushing the frontiers in various aortic diseases and are effectively employed even in such complex combination of multiple vascular pathologies.
| Case Report|| |
A 60-year-old gentleman, presented with progressively worsening bilateral lower limb claudication for the duration of 6 months, with claudication distance of 10 steps. He also complained of having constant dull aching back pain but denied having postprandial abdominal pain or chest discomfort. He was a reformed smoker and hypertensive on irregular treatment. On examination, all his lower extremity pulses were absent bilaterally with an ankle-brachial index of 0.5 and vague epigastric pulsatile mass was palpable in the abdomen with bruit.
Preoperative computed tomogram (CT) angiography of chest and abdomen showed TAAA with maximum diameter of 6.6 cm extending from upper descending thoracic aorta at T6 vertebral level up to level of superior mesenteric artery (SMA) origin (Type I extent) [Figure 1]a. Ostio-proximal segments of celiac artery and SMA were occluded for length of 4 cm with extensive collaterals to upper and midgut from 70% stenosed inferior mesenteric artery (IMA) as the sole visceral arterial supply giving off a prominent arc of Riolan. About 50% ostial stenosis of the left renal artery was also noted. Total occlusion of infrarenal aorta was present just below the origin of IMA extending to both common iliac arteries, with reformation of external iliac and femoral arteries from internal iliac, epigastric, and lateral circumflex iliac collaterals (TASC "D")  [Figure 1]b. Preoperative investigations were unremarkable including normal renal and liver functions. His cardiac function was satisfactory with mild coronary artery disease on catheter angiography.
|Figure 1: (a) Computerized tomography, volume rendered three dimensional angiogram image showing occlusion of ostio-proximal segments of celiac truck and superior mesenteric artery, with total occlusion of infra-renal aorta extending to both common iliac arteries. Extensive mesenteric collateral arcades noted with a large arc of Riolan fed by inferior mesenteric artery with 70% ostial stenosis; (b) Computed tomography, multi-planar reconstruction image showing Type I extent thoraco-abdominal aortic aneurysm of maximum diameter 6.6 cm|
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He underwent aorto-bifemoral bypass using 18 mm × 9 mm bifurcated bovine collagen-coated knitted polyester graft (Intergard, Maquet Getinge group, Intervascular, La Coitat Cedex, France) with side-biting clamp applied above IMA and selecting end-to-side configuration for proximal anastomosis to preserve flow to IMA and distal anastomoses onto both common femoral arteries. Considering the jeopardized and already precarious mesenteric supply, retrograde bypass from aortic graft to SMA within the root of the mesentery was also performed using reversed saphenous vein graft harvested from left thigh [Figure 2]. Laparostomy closure of abdomen was performed for a second look in view of noticing a dusky segment of the ileum (~10 cm) at the end of the procedure. He underwent thoracic endovascular aortic repair (TEVAR) the next day with Medtronic Valiant Thoracic Captivia 36 mm × 207 mm stent-graft system (Medtronic Inc., Minneapolis, MN, USA) using right femoral graft limb as access, deployed from 3 cm distal to left subclavian artery up to the level of occluded SMA ostium. The formal abdominal closure followed as bowels were found to be viable on re-look laparotomy. Subsequently he made a satisfactory recovery. On follow-up of 6 months, he remains symptom-free and in good health. The follow-up CT angiogram showed good stent-graft apposition with complete exclusion of the aneurysm and patent aorto-bifemoral and SMA bypass grafts [Figure 3]. Although proximal IMA was found occluded, distal IMA, and celiac branches were reformed from SMA collaterals.
|Figure 2: Peroperative photograph showing completed retrograde superior mesenteric artery bypass grafting using reversed saphenous vein from main body of polyester graft used for aorto-bifemoral bypass|
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|Figure 3: Computed tomography, volume rendered three dimensional angiogram images at follow-up showing well-opposed stent-graft in the thoraco-abdominal aorta with patent aorto-bifemoral and mesenteric bypass grafts|
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| Discussion|| |
Association of TAAA with aorto-iliac occlusive disease is a very rare clinical entity, which adds considerable challenge and complexity to the standard open procedure due to prolonged operative time required, the cumbersome operative approach to simultaneously tackle both the pathologies, the obscurity in providing adjuvant protective measures like distal aortic perfusion mandatory for TAAA repair with potentially significant viscera-renal and spinal cord dysfunction. Staged repair of the aorto-iliac occlusive disease using an extra-anatomic axillo-bifemoral bypass followed by open thoraco-abdominal repair is a reasonable approach to limit the complexity of open repair and obviating the need for distal aortic perfusion strategies, but is far from ideal considering the need for staged arterial procedures including visceral reconstruction, risk of graft compression while the patient is positioned for open thoraco-abdominal aneurysm repair and inferior long-term patency rates. Total open repair by simultaneous thoraco-abdominal aneurysm repair and aorto-bifemoral bypass grafting using a side-arm of the aorto-bifemoral bypass graft placed initially for distal perfusion and reducing cardiac afterload is yet another alternative,  but would add to considerable morbidity and mortality in such a setting further complicated by the superadded presence of mesenteric vascular disease requiring additional revascularization procedures in the form of orificial endarterectomy, mesenteric bypass grafting or open stent deployment. 
Few authors have designed novel techniques for distal aortic perfusion or for vascular access for thoracic aortic stent-graft deployment to treat the thoracic aortic aneurysm is patients who are not very symptomatic for peripheral arterial disease. , Stenotic segments in the iliofemoral conduit vessels (TASC A/B) can also be paved by prior balloon dilatation or covered stent placement to enable passage of stent-graft system into the aorta.  On the other hand, for patients with symptomatic TASC D aorto-iliac occlusion, like in the present report, the standard aorto-bifemoral bypass has proven track-record of being the most effective and durable procedure.
Asymptomatic triple-vessel disease of mesenteric arteries has been considered high-risk for the development of acute or chronic mesenteric ischemia warranting prophylactic revascularization.  All the more, patients with visceral artery occlusive disease who require aortic reconstruction have a much higher potential for the adverse postoperative outcome.  Prior or concomitant mesenteric bypass or angioplasty can be achieved with acceptable added morbidity.  The presence of preoperative 70% IMA stenosis with occluded ostio-proximal celiac artery and SMA resulting in critically compromised blood supply to the gut along with heavily diseased abdominal aorta justified our decision of SMA revascularization, which ultimately proved to be very crucial in view of the (asymptomatic) postoperative IMA occlusion.
An hybrid technique using stent-graft technology is now being widely employed to lessen morbidity of patients suffering from aortic diseases, as was implemented in the present case. The presence of nonaneurysmal viscero-renal artery bearing segment of abdominal aorta facilitated us to treat the occlusive and aneurysmal segments separately nonetheless in a single stage. Although conduit graft size of 10 mm is preferable,  in view of the smaller build of the patient 18 mm × 9 mm graft size was selected for aorto-bifemoral bypass where of the right limb provided access for smooth passage of stent-graft delivery system. The presence of celiac and SMA occlusion provided us with optimal distal landing zone, freedom from Type II endoleak and obviating the need for visceral debranching. Debranching and bypass of patent visceral arteries can also be utilized to perform hybrid endorepair of TAAAs in high-risk patients.  To our knowledge extensively diseased thoraco-abdominal aorta with aorto-iliac occlusion repaired by the concomitant aorto-bifemoral bypass and mesenteric revascularization followed by TEVAR has not been reported in the literature. Nevertheless this approach was found feasible, safe, and effective option to treat TAAAs of Type I extent associated with TASC "D" aorto-iliac occlusive disease.
| Conclusion|| |
The hybrid technique continues to find new horizon and application in vascular diseases particularly of complex and extensive nature. Simultaneous aorto-bifemoral bypass and mesenteric bypass with TEVAR for TAAAs affiliated with aorto-iliac and mesenteric vascular occlusive disease is a viable approach that can be undertaken with lesser morbidity and mortality risk as compared to complex and highly stressful total open surgical repair.
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[Figure 1], [Figure 2], [Figure 3]