Management of Coexistent Splanchnic and Renal Artery Occlusive Disease Juan Fontcuberta and Enrique Criado Coexistent occlusive diseases involving the splanchnic and renal arteries in patients with infrarenal abdominal aortic aneurysms (AAAs) have important implications at the time that treatment is selected, but they do not preclude endovascular aneurysm repair (EVAR). However, these diseases add complexity to the planning and execution of the procedure. The addition of endovascular procedures for the treatment of aortic branch stenosis increases the risks of the EVAR intervention. It lengthens the duration of the procedure, and it requires larger volumes of iodinated contrast agents with added renal toxicity. Additionally, intraluminal instrumentation also increases the risks of renal, splanchnic, and distal embolization, and it raises the possibility of a mechanical conflict between the visceral stents and the endovascular aortic prosthesis. The indications for renal or splanchnic revascularization in conjunction with EVAR are the same in general as in patients without an AAA, but there are some peculiarities that deserve special attention at the time of EVAR. In some situations it is necessary to stent the renal or splanchnic arteries in the absence of occlusive disease just to avoid their coverage at the time an endovascular graft is deployed. This can occur during the treatment of juxtarenal aneurysms when the endograft encroaches on the renal artery orifices and a stent has to be placed to prevent or correct renal artery coverage by the endograft. Renal artery stents are placed almost routinely in patients undergoing fenestrated aortic endografts. However, these procedures are not aimed at correcting renal artery stenosis but are done to preserve renal flow when the aortic endograft is placed above the level of the renal arteries. These interventions are the subject of other chapters in this text. Splanchnic Occlusive Disease and Endovascular Aneurysm Repair Almost one third of patients with AAAs have a significant stenosis of the celiac artery, and a severe stenosis of occlusion of the superior mesenteric artery (SMA) affects 10% of these patients. It is interesting to note that 50% of patients with severe renal artery stenosis might also harbor a significant celiac artery or SMA stenosis. The treatment of splanchnic artery stenoses at the time of EVAR is justified only in the presence of symptomatic disease with chronic mesenteric ischemia or occasionally in patients with an acute mesenteric ischemic event. In those cases it is advisable to address the mesenteric revascularization first, because this is potentially a life-threatening situation. Once the mesenteric ischemia is resolved, the AAA can be treated endovascularly. It is of paramount importance to recognize the asymptomatic existence of a severe stenosis or an occlusion of the SMA prior to EVAR. Placement of an endograft across the infrarenal aorta in the presence of collateral flow from the inferior mesenteric artery (IMA) to the SMA territory can eliminate the collateral flow to this territory, and most likely it will cause acute bowel ischemia. Such is a catastrophic event. Therefore, it is essential to ascertain before every EVAR that the IMA is not serving as a collateral source to the SMA territory. Currently, the preoperative evaluation of AAAs is done almost exclusively with cross-sectional imaging studies, mostly with computed tomography angiography (CTA), which allows the assessment of the status of the aorta and its branches. The presence of large collaterals from the IMA to the SMA territory is a clear indication for SMA revascularization before EVAR. This is best done as a separate procedure before EVAR, preferably with SMA stenting from a brachial approach to avoid disturbing the mural thrombus in the aortic aneurysm. In some cases, CTA underestimates the contribution of the inferior mesenteric to the superior mesenteric territory. In such patients, coverage of the IMA by the endograft can precipitate the development of symptomatic intestinal angina following EVAR even in the absence of obvious IMA-to-SMA collateral flow on preoperative imaging studies. This development should be readily treated with SMA revascularization. A more unusual and unpredictable situation can occur in patients with previous abdominal surgery in whom the collateral network between the left colon vasculature and the SMA territory has been interrupted. Under these circumstances, coverage of the IMA will likely result in left colonic or sigmoid ischemia. This unusual circumstance can occur in patients with previous colonic or retroperitoneal surgery, and therefore such a surgical history makes it advisable to obtain complete aortovisceral arteriography before EVAR. If the arteriogram reveals isolated left colonic perfusion from a patent IMA, an EVAR may be contraindicated and open aneurysm repair with IMA reimplantation may be more advisable. In asymptomatic patients with significant occlusion involving the three splanchnic arteries (>60% stenosis by duplex criteria or by angiographic evaluation), EVAR can disturb the collateral balance between the different vascular beds and create unexpected intestinal ischemia. In these situations, elective SMA revascularization may be advisable to prevent potential ischemic complications. From a technical standpoint, performing the transluminal splanchnic revascularization before EVAR is preferred, either done as a separate procedure or done sequentially in one operation. Splanchnic revascularization when deemed necessary should be done before EVAR. Occasionally, a hybrid approach is indicated in cases needing celiac or SMA revascularization before EVAR, when a transluminal intervention is not feasible and a high risk for open aortic aneurysm repair exists. An antegrade or retrograde bypass to the SMA or celiac artery can be followed by EVAR, preferably in separate procedures. In summary, splanchnic artery occlusive disease should always be evaluated prior to EVAR. Revascularization should be considered in the presence of symptomatic intestinal ischemia or when the IMA provides collateral flow to the SMA territory or when it is the main contributor to the blood supply of the left colon. Only gold members can continue reading. 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Management of Coexistent Splanchnic and Renal Artery Occlusive Disease Juan Fontcuberta and Enrique Criado Coexistent occlusive diseases involving the splanchnic and renal arteries in patients with infrarenal abdominal aortic aneurysms (AAAs) have important implications at the time that treatment is selected, but they do not preclude endovascular aneurysm repair (EVAR). However, these diseases add complexity to the planning and execution of the procedure. The addition of endovascular procedures for the treatment of aortic branch stenosis increases the risks of the EVAR intervention. It lengthens the duration of the procedure, and it requires larger volumes of iodinated contrast agents with added renal toxicity. Additionally, intraluminal instrumentation also increases the risks of renal, splanchnic, and distal embolization, and it raises the possibility of a mechanical conflict between the visceral stents and the endovascular aortic prosthesis. The indications for renal or splanchnic revascularization in conjunction with EVAR are the same in general as in patients without an AAA, but there are some peculiarities that deserve special attention at the time of EVAR. In some situations it is necessary to stent the renal or splanchnic arteries in the absence of occlusive disease just to avoid their coverage at the time an endovascular graft is deployed. This can occur during the treatment of juxtarenal aneurysms when the endograft encroaches on the renal artery orifices and a stent has to be placed to prevent or correct renal artery coverage by the endograft. Renal artery stents are placed almost routinely in patients undergoing fenestrated aortic endografts. However, these procedures are not aimed at correcting renal artery stenosis but are done to preserve renal flow when the aortic endograft is placed above the level of the renal arteries. These interventions are the subject of other chapters in this text. Splanchnic Occlusive Disease and Endovascular Aneurysm Repair Almost one third of patients with AAAs have a significant stenosis of the celiac artery, and a severe stenosis of occlusion of the superior mesenteric artery (SMA) affects 10% of these patients. It is interesting to note that 50% of patients with severe renal artery stenosis might also harbor a significant celiac artery or SMA stenosis. The treatment of splanchnic artery stenoses at the time of EVAR is justified only in the presence of symptomatic disease with chronic mesenteric ischemia or occasionally in patients with an acute mesenteric ischemic event. In those cases it is advisable to address the mesenteric revascularization first, because this is potentially a life-threatening situation. Once the mesenteric ischemia is resolved, the AAA can be treated endovascularly. It is of paramount importance to recognize the asymptomatic existence of a severe stenosis or an occlusion of the SMA prior to EVAR. Placement of an endograft across the infrarenal aorta in the presence of collateral flow from the inferior mesenteric artery (IMA) to the SMA territory can eliminate the collateral flow to this territory, and most likely it will cause acute bowel ischemia. Such is a catastrophic event. Therefore, it is essential to ascertain before every EVAR that the IMA is not serving as a collateral source to the SMA territory. Currently, the preoperative evaluation of AAAs is done almost exclusively with cross-sectional imaging studies, mostly with computed tomography angiography (CTA), which allows the assessment of the status of the aorta and its branches. The presence of large collaterals from the IMA to the SMA territory is a clear indication for SMA revascularization before EVAR. This is best done as a separate procedure before EVAR, preferably with SMA stenting from a brachial approach to avoid disturbing the mural thrombus in the aortic aneurysm. In some cases, CTA underestimates the contribution of the inferior mesenteric to the superior mesenteric territory. In such patients, coverage of the IMA by the endograft can precipitate the development of symptomatic intestinal angina following EVAR even in the absence of obvious IMA-to-SMA collateral flow on preoperative imaging studies. This development should be readily treated with SMA revascularization. A more unusual and unpredictable situation can occur in patients with previous abdominal surgery in whom the collateral network between the left colon vasculature and the SMA territory has been interrupted. Under these circumstances, coverage of the IMA will likely result in left colonic or sigmoid ischemia. This unusual circumstance can occur in patients with previous colonic or retroperitoneal surgery, and therefore such a surgical history makes it advisable to obtain complete aortovisceral arteriography before EVAR. If the arteriogram reveals isolated left colonic perfusion from a patent IMA, an EVAR may be contraindicated and open aneurysm repair with IMA reimplantation may be more advisable. In asymptomatic patients with significant occlusion involving the three splanchnic arteries (>60% stenosis by duplex criteria or by angiographic evaluation), EVAR can disturb the collateral balance between the different vascular beds and create unexpected intestinal ischemia. In these situations, elective SMA revascularization may be advisable to prevent potential ischemic complications. From a technical standpoint, performing the transluminal splanchnic revascularization before EVAR is preferred, either done as a separate procedure or done sequentially in one operation. Splanchnic revascularization when deemed necessary should be done before EVAR. Occasionally, a hybrid approach is indicated in cases needing celiac or SMA revascularization before EVAR, when a transluminal intervention is not feasible and a high risk for open aortic aneurysm repair exists. An antegrade or retrograde bypass to the SMA or celiac artery can be followed by EVAR, preferably in separate procedures. In summary, splanchnic artery occlusive disease should always be evaluated prior to EVAR. Revascularization should be considered in the presence of symptomatic intestinal ischemia or when the IMA provides collateral flow to the SMA territory or when it is the main contributor to the blood supply of the left colon. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease Management of Acute Limb Ischemia Complicating Aortic Reconstruction Treatment of Dyslipidemia and Hypertriglyceridemia Endovascular Renal Denervation Stay updated, free articles. Join our Telegram channel Join
