Midterm Outcomes of Endovascular Abdominal Aortic Aneurysm Repair with Prevention of type 2 Endoleak by Intraoperative Aortic Side Branch Coil Embolization.

OBJECTIVE: The midterm results of endovascular abdominal aortic aneurysm repair (EVAR) with aortic side branch coil embolization during EVAR was evaluated. METHODS: Our center began coil embolization for all patent inferior mesenteric artery (IMA) and lumbar artery (LA) with an inner diameter more than 2.0 mm during EVAR since June 2015. When four or more LA were patent, coil embolization for LA with inner diameter 2.0 mm or less was done. EVAR without aortic side branches coil embolization was performed for 59 patients prior to June 2015 (control group) and 79 patients underwent EVAR with coil embolization during EVAR (coil group). The success rate of coil embolization for IMA and LA was evaluated in coil group. The frequency of type 2 endoleak (T2EL), freedom from aneurysm sac expansion (5 mm or more) rate and the rate of the aneurysm sac shrinkage (10 mm or more) were compared between the coil and control groups. Additionally, multiple logistic regression analysis for all patients was conducted to analyze whether IMA patency and the number of patent lumbar artery at the end of EVAR were the risk factors of the aneurysm sac expansion of 5 mm or more. RESULTS: The success rate of IMA coil embolization was 96.4% and that of LA was 74.5%. Compared to the control group, the frequency of T2EL was significantly lower in coil group at 7 days (1.3% vs. 60.4%, P <0.0001) and at 6 months (2.1% vs 38.2%, P <0.0001) after EVAR. The freedom from aneurysm sac expansion rate was significantly better in the coil group at 5 years (100% in coil group and 65.2% in control group, P = 0.002). The rate of aneurysm sac shrinkage was significantly better in coil group (15.5% vs. 2.0% at 1 year, 42.8% vs. 6.3% at 2 years and 53.4% vs. 17.8% at 3 years, p = 0.0007). The risk of aneurysm sac expansion of 5 mm or more was estimated to be 11 times greater when the IMA was patent, and 4.9 times greater when 3 or more LAs were patent at the end of EVAR. CONCLUSION: When IMA was occluded and the number of patent LA became 2 or less by aortic side branch coil embolization during EVAR, favorable mid-term results were safely obtained and good long-term result could be expected with EVAR.

Risk Analysis of Aneurysm Sac Enlargement Caused by Type II Endoleak after Endovascular Aortic Repair.

BACKGROUND: Although the preoperative risk factors associated with the occurrence of type II endoleak (ETII) after endovascular aortic repair (EVAR) have gradually become more evident, the preoperative risk factors associated with aneurysm sac enlargement caused by ETII remain unclear. This study aimed to determine the preoperative risk factors associated with aneurysm sac enlargement caused by ETII after EVAR. METHODS: This retrospective cohort study reviewed 519 EVARs performed for true abdominal aortic aneurysm between January 2006 and December 2018 at our institution. EVARs using commercially available bifurcated devices with no type I or III endoleaks during follow-up and with ≥12 months follow-up were included. A total of 320 patients were enrolled in the study. To identify the preoperative risk factors of sac enlargement after EVAR, Cox regression analysis was used to assess preoperative data. RESULTS: The median follow-up period was 60.8 months. Overall, 135 of 320 patients (42%) had ETII during follow-up, and 47 of 135 patients (35%) developed aneurysm sac enlargement. Multivariate analysis revealed that chronic kidney disease (CKD) stage ≥4 (hazard ratio [HR], 4.65; 95% confidence interval [CI], 2.13-10.15; P = 0.001), patent inferior mesenteric artery (IMA) (HR, 17.85; 95% CI, 2.46-129.73; P< 0.001), and number of patent lumbar arteries (LAs) (HR, 1.37; 95% CI, 1.13-1.68; P= 0.002) were risk factors of aneurysm sac enlargement caused by ETII. CONCLUSIONS: CKD stage ≥4, patent IMA, and number of patent LAs were independent risk factors for aneurysm sac enlargement after EVAR. In particular, patent IMA had the highest HR and seemed to have the greatest impact on long-term aneurysm sac enlargement. Hence, taking preoperative measures to address a patent IMA appears to be important in reducing the incidence of sac enlargement.

Primary Conservative Therapy for Symptomatic Isolated Mesenteric Artery Dissection with Severely Compressed True Lumen or Large Dissecting Aneurysm.

PURPOSE: To investigate the safety and effectiveness of primary conservative therapy for patients with symptomatic isolated mesenteric artery dissection (IMAD) with a severely compressed true lumen and/or a large dissecting aneurysm. MATERIALS AND METHODS: A total of 35 consecutive patients (all men; median age, 53 y) with symptomatic IMAD with a severely compressed true lumen and/or a large dissecting aneurysm but without intestinal necrosis or arterial rupture who were treated with primary conservative therapy between November 2018 and February 2020 were assessed. A severely compressed true lumen was defined as luminal stenosis > 70%. A large dissecting aneurysm was defined as dissecting aneurysm diameter ≥ 1.5 times larger than the normal mesenteric artery diameter. RESULTS: There was a strong positive relationship among abdominal pain, degree of luminal stenosis, and length of dissection (R = 0.811; P < .001). Conservative treatment was successful in all patients. Abdominal pain was eliminated within 4.7 d ± 4.8 (range, 2-31 d) in all patients, within 3.6 d ± 1.2 (range, 2-6) in the 31 patients with minor or moderate abdominal pain, and within 13.3 d ± 11.9 (range, 6-31 d) in the 4 patients with severe abdominal pain. Complete or partial remodeling of the mesenteric artery was achieved in 6 (17.1%) and 29 (82.9%) patients, respectively, during 8.6 mo ± 4.3 of follow-up. CONCLUSIONS: Primary conservative therapy can be used safely and effectively in patients with symptomatic IMAD with a severely compressed true lumen and/or a large dissecting aneurysm but without intestinal necrosis or arterial rupture.

Multicentre randomised controlled trial to evaluate the efficacy of pre-emptive inferior mesenteric artery embolisation during endovascular aortic aneurysm repair on aneurysm sac change: protocol of Clarify IMA study.

INTRODUCTION: Type II endoleak (EL) is frequently seen after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) and is often considered responsible for aneurysm sac enlargement if it persists. In order to reduce type II EL and consequent sac enlargement, pre-emptive embolisation of the inferior mesenteric artery (IMA), which is a main source for persistent type II EL, has been introduced in many vascular centres. At present, there is a lack of robust evidence to support the efficacy of pre-emptive embolisation of IMA on reduction of persistent type II EL with subsequent sac shrinkage. METHOD AND ANALYSIS: This multicentre, randomised controlled trial will recruit 200 patients who have fusiform AAA ≥50 mm/rapidly enlarging fusiform AAA, with patent IMA, and randomly allocate them either to a pre-emptive IMA embolisation group or non-embolisation control group in a ratio of 1:1. The primary endpoint is the difference of aneurysm sac volume change assessed by CT scans between the pre-emptive IMA embolisation group and the control group at 12 months after EVAR. The secondary endpoints are defined as change of aneurysm sac volume in both groups at 6 and 24 months, freedom from sac enlargement at 12 and 24 months after EVAR, prevalence of type II EL at 1, 6, 12 and 24 months evaluated by contrast-enhanced CT, reintervention rate, aneurysm related mortality, overall survival, perioperative morbidity, volume of contrast media used during EVAR and dosage of radiation. ETHICS AND DISSEMINATION: The protocol has been reviewed and approved by the ethics committee of Nara Medical University (No. 2113). The findings of this study will be communicated to healthcare professionals, participants and the public through peer-reviewed publications, scientific conferences and the University Hospital Medical Information Network Clinical Trials Registry home page. TRIAL REGISTRATION NUMBER: UMIN000035502.

Outcomes Following Inferior Mesenteric Artery Reimplantation During Elective Aortic Aneurysm Surgery.

BACKGROUND: The role of inferior mesenteric artery (IMA) reimplantation during open aortic reconstruction is debated. We assessed outcomes after inferior mesenteric artery reimplantation (IMAR) for aortic aneurysmal disease to help shed light on this question. METHODS: A single-center retrospective review of all IMARs performed during open aortic surgery over a 10-year period between 2000 and 2009 was carried out. The primary outcome was patency, while secondary outcomes included colonic ischemia and overall survival. Analysis was performed using Cox models and Kaplan-Meier estimates. RESULTS: Of 840 patients who underwent elective abdominal aortic aneurysm (AAA) reconstructions during this period, 70 underwent IMAR. Indications for IMAR included intraoperative colonic ischemia (n = 24), poor back bleeding (n = 52), large IMA (n = 5), internal iliac disease (n = 5), and prior colon surgery (n = 1). Follow-up imaging studies were available in 35 of 70 patients (computed tomography in 30 [86%] and duplex in 5 [14%]). Patency was confirmed in 32 of 35 patients (91%) over a median follow-up of 98 months. Both losses in patency were at 4 months and did not require an operation. One patient underwent left colon resection on postoperative day 9 because of ischemia. (Patency could not be confirmed.) No statistically significant predictor of patency was noted. Incidence of colonic ischemia was 1.4% in patients undergoing IMAR. The overall mortality was 51% in patients undergoing IMAR over the median follow-up period. The overall 10-year survival was 30% in patients undergoing IMAR for aortic aneurysmal disease. The nature of aneurysm (juxtarenal or higher juxta renal abdominal aortic aneurysm [JRAAA]) was associated with mortality, with a hazard ratio of 1.8 (P = 0.08) approaching significance. Ten-year survival was worse if IMAR was performed for intraoperative colonic ischemia (26% vs 34%) or in JRAAA (19.0% vs 38%; P = 0.03). Age per year at the time of repair was the only statistically significant predictor of survival (P < 0.001). CONCLUSION: IMAR for AAA remains necessary for select patients. Reimplantation is associated with excellent long-term patency and low risk of colonic ischemia.

Total Laparoscopic Inferior Mesenteric Artery Ligation and Direct Sac Puncture Embolization Technique for Treatment of Type II Endoleak.

Type II endoleak relates to aneurysm perfusion through a patent branch vessel. Reintervention for type II endoleak should be considered in the presence of significant aneurysm growth. Recurrences and subsequent reinterventions are frequent by occult type II endoleaks through feeder arterial branches. We report a case of a patient with a type II endoleak due to inferior mesenteric artery (IMA) patency associated with aneurysm sac growth after an unsuccessfully attempt of transarterial embolization. Laparoscopic ligation of the IMA with direct sac puncture embolization was performed. The postoperative and 1-year follow-up computed tomography angiography scan demonstrated no endoleak signs and aneurysm sac shrinkage. The proposed modification of this technique constitutes a novel approach to this entity. Total laparoscopic IMA ligation and direct sac puncture embolization technique may increase the success rate for the treatment of endoleaks type II by excluding the recurrences. This technique may offer a safe, feasible, and minimally invasive approach for type II endoleaks when other endovascular techniques are unsuccessful.

The role of the inferior mesenteric artery in predicting secondary intervention for type II endoleak following endovascular aneurysm repair.

OBJECTIVE: Endovascular aneurysm repair (EVAR) is associated with a greater risk of graft-related complications and need for secondary interventions compared with open repair. Type II endoleak (EL-2) is the most common complication. We examined the hypothesis that a functionally occluded inferior mesenteric artery (IMA) before EVAR was associated with fewer secondary interventions for EL-2. METHODS: All nonruptured abdominal aortic aneurysms (AAA) treated by EVAR using U.S. Food and Drug Administration-approved endografts from January 2005 to December 2017 were retrospectively reviewed, including computed tomography angiograms. Preoperative patency of the IMA and any secondary interventions performed after the index EVAR procedure were recorded. A functionally occluded IMA was defined as one that was (1) chronically occluded or severely stenosed on preoperative imaging or (2) coil embolized before EVAR. Secondary interventions for persistent EL-2 were indicated when AAA sac diameter increased by more than 5 mm. RESULTS: The study cohort comprised 490 patients (84 women) with a mean age of 74.8 ± 8.2 years. The mean preoperative AAA diameter was 5.6 ± 0.9 cm. One hundred twenty-nine patients (26.3%) died during follow-up. The mean follow-up of survivors was 38 months. Types (prevalence) of endoleak were I (2.4%), II (18.9%), III (0.7%), IV (0.5%), and V (0.2%). Patients with a functionally occluded IMA underwent significantly fewer secondary interventions for EL-2 compared with patients with a patent IMA (2.6% vs 7.1%; P = .020). All secondary interventions in the functionally occluded IMA group involved the lumbar arteries (LA). When the IMA was patent, secondary interventions were equally distributed between the LA and IMA. Logistic regression confirmed that a functionally patent IMA was associated with a greater number of secondary interventions for EL-2 (odds ratio, 3.0; 95% confidence interval, 1.2-7.5; P = .025). CONCLUSIONS: Patients with a functionally occluded IMA required significantly fewer secondary interventions for EL-2 after EVAR. In addition, the type of vessels intervened on were primarily LA. Among patients with a patent IMA, preoperative coil embolization may decrease secondary interventions and improve the long-term durability of EVAR.

Preoperative Inferior Mesenteric Artery Embolization is a Cost-effective Technique that May Reduce the Rate of Aneurysm Sac Diameter Enlargement and Reintervention After EVAR.

BACKGROUND: Type II endoleaks are the most common complications after endovascular repair of abdominal aortic aneurysms (EVARs). Some studies have shown the benefit of preventive inferior mesenteric artery (IMA) embolization, but its efficacy and cost-effectiveness continue to be controversial. The aim of this study was to evaluate the efficacy of this procedure on the increase in aneurysmal sac diameter during follow-up. MATERIALS AND METHODS: All consecutive patients who underwent the embolization of the IMA before EVAR in our center, between January 2014 and July 2016, were included. We retrospectively compared the diameter of the aortic aneurysm sac, the rate of endoleak and reinterventions, and the theoretical cost of management between these patients (group 2) and a historical cohort of patients treated for EVAR before January 2014 who did not undergo prior IMA embolization (group 1). RESULTS: Two hundred twenty-four patients were retrospectively analyzed. After exclusion, we compared a group of 37 embolized patients with a control group of 46 patients. The rate of enlargement in the aneurysmal sac diameter was significantly higher in the control group at 2 years (27.9% vs. 4.3%, P = 0.025). The type II endoleak rate at 2 years was significantly higher in the control group (53.1% vs. 18.2%, P = 0.012), as was the aneurysm-related reintervention rate (31.1% vs. 8.1%, P = 0.013). Multivariate analysis confirmed these results. At 2 years of follow-up, there was no difference in the overall cost of patient management between the 2 groups. CONCLUSIONS: Preventive IMA embolization is an effective, reliable, and cost-effective technique that seems to reduce the rate of the aneurysmal sac diameter enlargement, type II endoleak, and reinterventions after EVAR.

Inferior mesenteric artery embolization for persistent postpartum hemorrhage after sufficient bilateral iliac arteries embolization: safety and efficacy in eight patients.

OBJECTIVE: To assess the safety and efficacy of transcatheter arterial embolization (TAE) of the inferior mesenteric artery (IMA) for the management of post-partum hemorrhage (PPH). METHODS: A retrospective analysis was performed regarding eight patients (mean age, 34.4 y; age range, 31 - 40 y) who underwent TAE of the IMA for PPH between March 2001 and September 2018. Obstetric records, including maternal characteristics, clinical manifestations, complications, and clinical outcomes, as well as TAE details were obtained. RESULTS: All eight patients had primary PPH and the vaginal delivery mode. CT scans of two patients showed active bleeding from the lower uterus or hematoma and with the origin of contrast extravasation abutting the adjacent rectum. In seven patients, an aortogram or IMA arteriogram following persistent vaginal bleeding after sufficient embolization of the bleeding focus from the bilateral iliac arteries, found the bleeding focus of the IMA, while in one patient, the IMA bleeding focus was found at the second session 4 h after the first session. TAE of the IMA was technically successful in all eight patients and cessation of bleeding without repeated TAE or additional hemostatic surgery was achieved in all patients after TAE of the IMA. There were neither procedure-related complications nor bowel ischemia during follow-up. CONCLUSION: TAE of the IMA for PPH was safe and effective with successful hemostasis. Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries. ADVANCES IN KNOWLEDGE: Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries.

"Aortoiliac-Mesenteric Steal Syndrome" Treated with Inferior Mesenteric to Common Iliac Artery Transposition.

We report the case of a 54-year-old female who presented with chronic mesenteric ischemia symptoms which could also be provoked on walking 50-100 m. Computed tomography angiography demonstrated ostial occlusion of all 3 mesenteric vessels, with extensive collateralization reconstituting the inferior mesenteric artery from the iliac arteries. As such, her abdominal pain was secondary to preferential flow to the lower limbs stealing from mesenteric vasculature. Endovascular management was trialed, but failed after short-term improvement, so the patient underwent successful transposition of inferior mesenteric to left common iliac artery. Mesenteric ischemia presenting with pain on walking secondary to preferential flow to the lower limbs has not been previously reported, and vascular and general surgeons should be aware of this unusual differential for abdominal pain.

Pre-emptive nonselective perigraft aortic sac embolization with coils to prevent type II endoleak after endovascular aneurysm repair.

OBJECTIVE: Pre-emptive selective embolization of inferior mesenteric artery (IMA), lumbar arteries (LAs), and perigraft sac for prevention of type II endoleak (T2EL) has not been widely adopted. We perform pre-emptive nonselective perigraft aortic sac embolization with coils (PNPASEC) in patients at high risk for development of T2EL (four or more patent LAs, patent IMA ≥3 mm, and ≥30-mm aortic flow lumen). The goal of this study was to see whether PNPASEC decreases T2ELs requiring reinterventions. METHODS: All 266 patients undergoing elective endovascular aneurysm repair between September 1, 2007, and October 31, 2015, were retrospectively evaluated from a prospectively maintained database. Patients (N = 212; 211 men) with preoperative and postoperative contrast-enhanced computed tomography scans were included. Our PNPASEC technique involves leaving a wire in the sac after cannulation of the contralateral gate and inserting large (0.035-inch) coils into the sac after bifurcated graft deployment. T2EL and reintervention rates were compared between patients who underwent PNPASEC (group I) and those who met the criteria but did not have PNPASEC (group II) and those who did not meet the criteria (Group III). RESULTS: Forty-seven (22.2%) patients were PNPASEC candidates and 165 (77.8%) patients (group III) were not. Among PNPASEC candidates, 16 (7.5%) underwent PNPASEC (group I) and 31 (14.6%) did not (group II). There were no significant differences between groups in terms of comorbidities, aneurysm size, and anatomic and neck characteristics. Mean number of patent LAs was similar between group I (4.5 ± 0.8) and group II (4.5 ± 0.9), which was significantly greater than in group III (1.9 ± 1.3; P < .001); 43.6% of group III patients had patent IMA. Mean follow-up was 44 ± 25 months. T2EL at 6 months was observed in 48.4% in group II, 3.0% in group III, and 6.3% in group I (P < .001). Sac diameter increase was seen in 38.7% in group II vs 6.1% in group III and 6.3% in group I (P < .001), with complete sac shrinkage in 23.3% in group II vs 23.8% in group III and 50.0% in group I (P = .09). T2EL-related interventions were performed in 29.0% in group II vs 1.2% in group III and 6.3% in group I (P < .001). Any endoleak at last follow-up was seen in 25.8% in group II vs 2.4% in group III and none in group I (P < .001). CONCLUSIONS: Nonselective perigraft sac coil embolization in patients at high risk for T2EL (20% of patients undergoing endovascular aneurysm repair) is effective in preventing development of T2EL and is associated with decrease in sac size and reintervention rates.

"Mesenteric Steal" Physiology as a Cause of Claudication and Chronic Mesenteric Ischemia.

Aortoiliac occlusive disease results in varying degrees of pelvic and lower extremity arterial insufficiency. Treatment approach has evolved, and endovascular therapies are being successfully reported for high-grade lesions. However, Trans Atlantic Inter-Society Consensus D often necessitates open revascularization. Disease limited to the infrarenal segment does not typically affect intestinal perfusion in the absence of visceral aortic or mesenteric vessel involvement. Chronic mesenteric ischemia most commonly occurs due to atherosclerotic disease of 2 or 3 of the mesenteric vessels. The marginal artery of Drummond is an important component of the collateral network that allows for continued intestinal perfusion. We report a case of short-segment subtotal infrarenal aortic occlusion, proximal to the inferior mesenteric artery (IMA) in the absence of significant mesenteric disease. The patient had resultant lifestyle limiting claudication and chronic mesenteric ischemia. Angiographic evaluation demonstrated "mesenteric steal" physiology with retrograde flow via the arc of Riolan and IMA to perfuse the aortoiliac circulation. Successful endovascular recanalization with a balloon-expandable covered stent was achieved, resolving the arterial insufficiency in both the mesenteric and lower extremity vascular beds. The patient denied any symptoms on postoperative day 1 and at 1-month follow-up.

Spontaneous Isolated Inferior Mesenteric Artery Dissection With Chronic Mesenteric Ischemia: Case Report and Endovascular Management.

We report the clinical details, imaging findings, and management for a 39-year-old female presenting with recurrent episodes of pain in abdomen due to systemic lupus erythematous vasculitis associated with spontaneous isolated inferior mesenteric dissection. Spontaneous mesenteric artery dissection is an uncommon cause of mesenteric ischemia. Symptomatic spontaneous isolated inferior mesenteric artery (IMA) dissection is a rare condition, and its association with systemic lupus erythematosus is not previously described in the English literature. The optimal treatment options are debatable and include medical management, surgical reconstruction, and endovascular therapy. We wish to highlight spontaneous isolated IMA dissection as a rare etiology for chronic mesenteric ischemia and its management by endovascular methods.

Snorkel Technique for Inferior Mesenteric Artery During Endovascular Repair of Abdominal Aortic Aneurysm.

PURPOSE: The snorkel technique is commonly used to preserve renal arteries in juxta renal aneurysm during endovascular repair. Herein, we present a patient who underwent bifurcated endograft implantation with snorkel technique for inferior mesenteric artery (IMA) in order to preserve the major source of bowel circulation. CASE REPORT: A 69-year-old male patient was diagnosed with abdominal aortic aneurysm. His history revealed that he had bowel resection due to a car accident 30 years ago. In addition, he was given relaparotomy 4 times due to intestinal complications. Computed tomography showed fusiform aneurysm with a maximal diameter of 60 mm and chronical occlusion of the superior mesenteric artery. Inferior mesenteric artery was found to be hypertrophic. During EVAR, 6 mm × 10 cm covered VIABAHN Endoprosthesis (Gore Medical) was implanted to the IMA over a 0.018 guidewire via puncture of the left axillary artery. Initially, the main body of the aortic stent-graft (Gore C3, size 23-14-16) was implanted to the infra renal segment of the aorta (below the renal arteries and the orifice using VIABAHN) via the right femoral artery. Next, the contralateral leg (Gore, 14-12-00) was implanted. Computed tomography was examined at 1- and 32-month postoperatively, and no endoleak or patency of IMA stent was detected. CONCLUSION: In this case of IMA-dependent circulation of the intestinal system, the protection of IMA via snorkel technique was successful.

Identification of Anatomical Risk Factors for Type II Endoleak to Guide Selective Inferior Mesenteric Artery Embolization.

BACKGROUND: It is unclear which patients are the best candidates for inferior mesenteric artery (IMA) embolization to reduce type II endoleak (ELII). Therefore, this study aimed to identify the anatomical risk factors for ELII after endovascular aneurysm repair (EVAR) and to determine the best candidates for preventative, preoperative IMA embolization. MATERIALS AND METHODS: Between April 2007 and September 2014, 196 patients underwent standard EVAR. Anatomical risk factors of postoperative, persistent ELII were detected using logistic regression analysis. Preoperative treatment of the IMA occlusion in patients with anatomical risk factors was performed to reduce ELII. RESULTS: ELII was detected in 48 patients (24.5%). Overall, patency of the IMA (odds ratio [OR], 4.13; P = 0.004) and lumbar artery (LA) diameter ≥2.0 mm (OR, 3.30; P = 0.008) were significant risk factors for ELII, whereas an Endurant stent graft protected against ELII (OR, 0.22; P = 0.023). However, in patients with patent IMA, IMA diameter ≥3.0 mm (OR, 4.09; P = 0.011), LA diameter ≥2.0 mm (OR, 3.16; P = 0.043), and aortoiliac aneurysm (OR, 6.36; P = 0.026) were significant risk factors for ELII. Incidence rates of ELII in patients with and without these factors were 37.8% and 11.2%, respectively. ELII did not occur in patients with risk factors who underwent treatment of preoperative IMA occlusion. CONCLUSIONS: Patients with these risk factors are the candidates for undergoing treatment of preoperative IMA occlusion to reduce ELII.

Systematic review of laparoscopic ligation of inferior mesenteric artery for the treatment of type II endoleak after endovascular aortic aneurysm repair.

OBJECTIVE: Type II endoleak after endovascular aneurysm repair (EVAR) is frequently caused by persistent flow from the inferior mesenteric artery (IMA). The aim of this study was to assess the perioperative and midterm efficacy of laparoscopic ligation of the IMA for treatment of endoleak. METHODS: MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane databases and key references were searched with Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology for studies reporting on laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR. RESULTS: Eight case studies and one study of a retrospective nature were identified. In total, 20 patients (18 men; mean age, 73.6 ± 2 years; with a mean abdominal aortic aneurysm diameter of 64.3 ± 10 mm) who underwent post-EVAR laparoscopic ligation of the IMA for type II endoleak were analyzed. The mean time from EVAR until intervention ranged from 6 to 18 months. All but one patient were asymptomatic; in 9, the aneurysm sac was enlarged, and in 11, the endoleak was considered persistent without sac enlargement. The mean procedural duration was 99 ± 24 minutes, with technical success rate of 90% (18/20); in two cases, the patients were successfully reoperated on laparoscopically in 24 hours. The mean hospitalization was 3.6 ± 1.2 days, with 0% (0/20) perioperative and 30-day mortality. No patient underwent open conversion or showed signs of intestinal ischemia. During follow-up of 32.6 ± 12 months, 13 of 20 patients had aneurysm sac regression, whereas the rest had a stable sac diameter without evidence of persistent type II endoleak. CONCLUSIONS: Laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR is a feasible and safe technique in specialized centers with high technical success rate and good midterm outcomes.

Chimney Stent-Graft Repair for Concurrent Inferior Mesenteric Artery Aneurysm and Infrarenal Abdominal Aortic Aneurysm: Case Report.

PURPOSE: To report a rare case of concurrent inferior mesenteric artery (IMA) aneurysm and infrarenal abdominal aortic aneurysm (AAA) with a novel indication for the use of chimney stent-graft technique in this patient. CASE REPORT: An 82-year-old man with an asymptomatic 4.4-cm fusiform AAA and 3.6-cm IMA aneurysm, coupled with chronic occlusion of celiac artery and superior mesenteric artery at the ostia, underwent endovascular repair of both aneurysms. Preservation of the IMA and treatment of both aneurysms were achieved with IMA aneurysm stenting, aortic aneurysm stenting and IMA chimney stenting. At 1, 6, and 12 months surveillance, the grafts remained patent without endoleak. CONCLUSIONS: The IMA chimney with aortic stenting technique may be safely used in patients who require preservation of the IMA during AAA and IMA aneurysm repairs.