PMC5573203_01
PMC5573203_02
Patient 1 (fourfold branched stent-graft). (A) Preoperative computed tomography (CT) scan of a thoracoabdominal aortic aneurysm of 6.6 cm, occlusion of the celiac trunk, high-grade stenosis of the superior mesenteric artery (SMA), small distal aortic diameter, and poststenotic dilatation of a large inferior mesenteric artery (IMA). (B) Postoperative CT scan after treatment by a monoiliac, fourfold branched stent-graft (SMA, both renal arteries, IMA) with a right-sided iliac plug and a left-to-right iliofemoral crossover bypass. Arrows point towards the IMA.
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fig1
Distal aortic diameter was too small for a bifurcated graft (Fig. 1A). To preserve two visceral arteries for intestinal perfusion, procedure was planned as a left-sided, monoiliac, fourfold branched stent-graft with side branches to the SMA, both renal arteries, and the IMA (Fig. 1B). The patient also received a right-sided iliac plug and an iliofemoral left-to-right crossover bypass (Fig. 1B).
PMC5573203_03
Patient 2 (fivefold branched stent-graft). (A) Preoperative computed tomography (CT) scan of a pararenal aortic aneurysm of 8.5 cm, high-grade stenosis of the right hypogastric artery, left iliac and hypogastric artery occlusion, and a large inferior mesenteric artery (IMA). (B) Postoperative CT scan after treatment by a monoiliac, fivefold branched stent-graft (celiac trunk, superior mesenteric artery, both renal arteries, IMA) with over-stenting of the right hypogastric artery and a right-to-left femorofemoral crossover bypass. Arrows point towards the IMA.
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Patient 2 (aged 57 years) had a pararenal AA of 8.5 cm with a high-grade stenosis of the right hypogastric artery, an occlusion of the left iliac and hypogastric artery, and a large IMA of 4.5 mm (Fig. 2A). Because of the high-grade stenosis of the right hypogastric artery and difficult anatomy, catheterism of this hypogastric artery failed (as previously feared) and the ostium had to be covered by a stent-graft, resulting in occlusion of both hypogastric arteries (Fig. 2B). The patient additionally received a femorofemoral right-to-left crossover bypass (Fig. 2B).
PMC5573203_04
Patient 3 (twofold branched stent-graft). (A) Preoperative computed tomography (CT) scan of an infrarenal aortic aneurysm of 4.9 cm, occlusion of both hypogastric arteries, a dominant lumbar artery, and a large inferior mesenteric artery (IMA). (B) Postoperative CT scan after treatment with a bi-iliac, twofold branched stent-graft (dominant lumbar artery and IMA). Insertion shows radiograph of the two branches. (C) CT scan after 24 months with patent branch to the lumbar artery and an asymptomatic occlusion of the IMA branch but no signs of kinking of the IMA extension and sufficient intestinal collateralization. Arrows point towards the dominant lumbar artery and the IMA.
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The IMA (4.0 mm) showed collaterals to the left hypogastric and sacral arteries, and a large lumbar artery (4.0 mm) supplied blood flow to the pelvis and the spinal collateral network (Fig. 3A). An endovascular procedure was performed with a bi-iliac stent-graft and two additional branches to the IMA and the dominant lumbar artery (twofold branched stent-graft; Fig. 3B). Postoperatively and after 12 months, CT scan and ultrasound examination showed regular results with a patent IMA branch (Figure 3, Figure 4). However, routine control after 24 months demonstrated an occlusion of the IMA stent-graft without any signs of stent-graft kinking (Fig. 3C).
Postoperative, color-coded duplex sonography of patient 3. Power mode demonstrates patent, regular side branch to the IMA (white arrow) without kinking or stenosis.
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Postoperatively and after 12 months, CT scan and ultrasound examination showed regular results with a patent IMA branch (Figure 3, Figure 4).