PMC10310467_01
Coronal computed tomography angiogram (CTA) findings (A) saccular aneurysm measuring up to 5.8 cm with circumferential calcification; (B) coronal and (C) sagittal pre-operative three dimensional reconstruction computed tomography (CT); and (D) a schematic of the stenotic inferior mesenteric artery (IMA). The patient's entire gastrointestinal system was fed by a dilated IMA that was 90% stenosed at the origin with prominent collaterals (Illustration by Shin Mei Chan).
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Subsequent CT angiography (CTA) noted long segment occlusion of the coeliac trunk and SMA; circumferential calcification of the perivisceral, perirenal, and infrarenal aorta with a 14 mm lumen, which tapered to a narrow aortic bifurcation of 11 mm; near occlusive, calcified IMA ostial atherosclerosis with post-stenotic dilation to 9.3 mm and prominent 7-8 mm IMA for the remainder of its course; patent, mildly diseased bilateral internal iliac arteries; large mesenteric collaterals arising from the superior rectal artery; and a prominent Arc of Riolan (Fig. 1A-D).
Surgical technique (A) Balloon angioplasty of the severely stenotic inferior mesenteric artery (IMA) in anticipation of the transaxillary snorkel. A Gore VBX (8L x 79 mm) was placed into the IMA extending proximally into the proximal aspect of zone 9 of the aorta. This was performed concomitantly with placement of an Endologix AFX2 (22 x 90 x 16 x 30 mm) (B) Endurant II cuff was placed and aligned with the top portion of the Gore VBX stent graft (C) Simultaneous balloon angioplasty of the cuff and the VBX stent was performed (D) Subsequent angiography showing complete aneurysm exclusion, as well as brisk unimpeded aorto-iliac and IMA flow. The final arteriogram demonstrated inline flow (E) Schematic demonstrating stent configuration (Illustration by Shin Mei Chan).
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The stenotic IMA ostium was serially dilated using 5 mm and 6 mm balloons (Fig. 2A) to allow advancement of an 8L x 79 mm VBX balloon expandable stent graft (W.L. This covered stent was then insufflated and deployed immediately following deployment of the AFX2 aortic stent graft (Fig. 2B). Simultaneous balloon angioplasty of the cuff and the VBX stent was again performed (Fig. 2C). Completion angiography demonstrated no endoleak and brisk, unimpeded, and augmented flow into the IMA with retrograde filling of the SMA and its branches (Fig. 2D). A schematic of the stent configuration is demonstrated in Fig. 2E.
Three dimensional reconstruction computed tomogram at one year follow up (A) Coronal and (B) Sagittal views. There was no evidence of endoleak and the inferior mesenteric artery remained patent. At this time, the patient's aneurysm was completely thrombosed and regressed.
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At the one year follow up, CTA demonstrated a completely thrombosed aneurysm sac with maximum diameter of 5.3 cm, widely patent IMA chimney graft and Arc of Riolan, and no evidence of endoleak (Fig. 3A and B).