VESS11 - Gastrointestinal Complications and Visceral Circulation Changes after Intentional Celiac Artery Embolization during Complex EVAR

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

Methods: All patients undergoing complex EVAR with CAE at our single-institution over a 12-year period were included. Pre- and post-operative, clinical, radiologic and laboratory data were reviewed to identify mesenteric complications related to CAE, survival, and radiologic changes to collateral anatomy. Multivariable logistic regression was used to determine the association between collateral diameter change and mesenteric complications.

Results: From 2011 to 2023, 70 patients underwent CAE during complex EVAR (Table 1). Of these, 11.4% had 30-day mesenteric complications, including upper gastrointestinal bleed (UGIB) or perforated ulcer (n=3), cholecystitis (n=2), pancreatitis (n=2) and shock liver (n=1). During 31-90 days after CAE, 2 additional patients (2.86%) had UGIB. Additionally, in the 90-day post-operative period, 4 other patients (5.7%) had SMA stent complications leading to mesenteric ischemia. On Kaplan-Meier analysis, patients with 90-day mesenteric complications had a worse 2-year survival rate (42.5% vs 75%; P=.002).

Based on pre- and post-operative imaging, 20% of patients had variant SMA anatomy, and the dominant SMA-celiac collateral pathway was 69.6% GDA. Compared to patients with mesenteric complications, patients without complications had a greater increase in the collateral diameter at both the SMA and celiac junctions at 1, 3-6, 12 and 24 months (Figure 1), with a statistically significant difference in diameter at 1 month (median: -2.1% vs 16.2% at celiac, P=.006 and 7.7% vs 20.8% at SMA, P=.021).

On adjusted multivariate regression analysis, increase in collateral diameter at the SMA junction on first post-operative CT was independently associated with 90-day freedom-from mesenteric complications (OR: 0.93, 95% CI: 0.87-0.96; P=.046).

Conclusions: CAE during complex EVAR is a useful adjunct to increase seal zone in select patients, but mesenteric complications occur in 10-15% of the patients over a 90-day post-operative period. Patients with mesenteric complications have a higher long-term all-cause mortality. Patients without mesenteric complications have greater increase in their collateral diameter at both SMA and celiac junctions. 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.