Endovascular Thoracic Aortic Aneurysm Repair with Celiac Trunk
Embolization to Expand Short Distal Landing Zone
Authors: Hwan Jun Jae, Jae Hyung Park, Hyo-Cheol Kim, Jin Wook Chung
A 47-year-old man presented with an incidentally found descending thoracic aortic aneurysm. The patient had a previous history of myocardial infarction (6YA) and echocardiography revealed apical inferior dyskinesia with an ejection fraction of 34%. The aneurysm was a saccular aneurysm, arising from the anterolateral wall of the aorta and measuring 34 x 62 mm (Fig. 1, 2). The distance from the lower edge of the aneurysm to the CA (celiac axis) was 11 mm and that to the SMA (Superior mesenteric artery) was 25 mm. The cause of the aneurysm was considered to be related with a penetrating atherosclerotic ulcer of the aorta. Because of the high operative risk related with cardiac problems, endovascular repair with a stent graft was planned. To get an adequate distal landing zone and to prevent type II endoleak, we planned to occlude the CA trunk and deploy the stent graft just proximal to the SMA orifice. The patient had an aberrant right hepatic artery originating from the SMA and normal peripancreatic arteries on CTA, and we expected good collaterals and no visceral ischemic complications after occlusion of CA trunk. We occluded the CA trunk with 10 mm sized Amplatzer vascular plug (AGA Medical, Golden Valley, MN) (Fig. 3). The endovascular repair was performed with a stent graft (30 x 80 mm, Zenith TX2; Cook, Bloomington, IN) covering the orifice of the CA to secure distal landing zone. The completion angiography showed no endoleaks (Fig. 4). One-week follow up CTA also showed thrombosed aneurysm without endoleaks and good collateral flow to the celiac artery territory (Fig. 5). The patient was discharged on the 8th postoperative day without any visceral ischemic complications.
To achieve a complete exclusion of the aneurysm, adequate proximal and distal landing zones are necessary for fixation and sealing. The endovascular aneurysm repair with a stent graft covering the CA may be an acceptable endovascular approach in treating selected TAA patients with a limited distal landing zone. Because of the extensive collateral circulation between the CA and SMA, visceral ischemic symptoms seem to be uncommon after covering the CA with a stent graft.
The main trunk of the CA is usually short and it branches off to the common hepatic artery and the splenic artery. Compared with coils, the vascular plug can be very useful for embolizing the CA trunk without compromising the communication of these important branches