Gastrointestinal complications and visceral circulation changes after intentional celiac artery embolization during complex endovascular aortic repair

Objective: Intentional celiac artery embolization (CAE) is an oft-used strategy to extend proximal or distal seal during complex endovascular aortic repair. Prior reports document a wide range of gastointestinal-related complications. However, associated changes in collateral circulation are poorly defined. We sought to report the long-term outcomes and adaptive changes in collateral visceral circulation following CAE during complex endovascular aortic repair.

Methods: All patients undergoing complex endovascular aortic procedures (endovascular aortic repair [EVAR] and thoracic EVAR) with CAE at a single institution over a 12-year period were included. Pre- and postoperative clinical, radiologic, and laboratory data were reviewed to identify mesenteric complications related to CAE and to assess long-term survival and radiologic changes in collateral anatomy. Multivariable logistic regression was used to determine the association between collateral vessel diameter change and mesenteric complications.

Results: From 2011 to 2023, 70 patients underwent planned CAE during complex EVAR. With regards to mesenteric complications not attributable to the superior mesenteric artery (SMA) stent, 11.4% had 30-day mesenteric complications, including upper gastrointestinal bleed or perforated ulcer (n = 3), cholecystitis (n = 2), pancreatitis (n = 2), and ischemic hepatitis (n = 1). During 31 to 90 days after CAE, two additional patients (2.9%) had upper gastrointestinal bleed. With regards to 90-day mesenteric complications related to the SMA stent, four additional patients (5.7%) had SMA stent complications leading to mesenteric ischemia. On Kaplan-Meier analysis, patients with any 90-day mesenteric complication had significantly lower overall 2-year survival (42.5% vs 75.0%; P = .002). On preoperative imaging, 20% of patients had variant SMA anatomy with the gastroduodenal artery as the dominant SMA-celiac collateral pathway in 68.6%. Postoperatively, patients without mesenteric complications had a greater increase in the collateral diameter at both SMA and celiac junctions at 1, 3 to 6, 12, and 24 months, with a statistically significant difference in diameter at 1 month compared with patients with complications (median: 16.2% vs -2.1% at celiac; P = .006 and 20.8% vs 7.7% at SMA; P = .021). On adjusted multivariate regression, increase in collateral diameter at the SMA junction on first postoperative computed tomography was significantly protective of 90-day mesenteric complications (odds ratio, 0.93; 95% confidence interval, 0.87-0.96; P = .046).

Conclusions: CAE during complex EVAR is a useful adjunct to increase seal zone in select patients; however, mesenteric complications occur in 14% of the patients over a 90-day postoperative period, and patients with mesenteric complications have a higher long-term all-cause mortality. CAE should be a technique within the toolbox of vascular surgeons for urgent circumstances that do not allow for celiac preservation. Careful selection of candidates for CAE and early postoperative surveillance of collateral pathways may help with prevention and early identification of long-term visceral complications.