• Hélène Wattez, Teresa Martin-Gonzalez, Benjamin Lopez, Rafaëlle Spear, Rachel E Clough, Adrien Hertault, Jonathan Sobocinski, and Stéphan Haulon.
• Université Lille Nord de France, Lille, France; Aortic Center, Hôpital Cardiologique, Lille, France.
• J. Vasc. Surg. 2016 Dec 1; 64 (6): 1595-1601.

BackgroundEndovascular repair of aortic aneurysms involving the visceral segment of the aorta often requires placement of a covered bridging stent in the celiac axis (CA). The median arcuate ligament (MAL) is a fibrous arch that unites the diaphragmatic crura on either side of the aortic hiatus. The ligament may compress and distort the celiac artery and result in difficult cannulation, or stenosis and occlusion of the vessel. This study evaluated the influence of the MAL compression on the technical success and the patency of the celiac artery after branched and fenestrated endovascular aortic repair.MethodsWe retrospectively analyzed a cohort of consecutive patients treated electively for complex aneurysms with branched and fenestrated endovascular aortic repair between January 2007 and April 2014. All data were collected prospectively. Analysis of preoperative computed tomography angiography on a three-dimensional workstation determined the presence of MAL compression. Patency of the CA bridging stent was assessed during follow-up by computed tomography angiography and duplex ultrasound evaluation. Statistical analysis was performed to compare the outcomes of patients with MAL (MAL+) and without MAL (MAL-) compression.ResultsOf 315 patients treated for aortic disease involving the visceral segment during the study period, 113 had endografts designed with a branch (n = 57) or fenestration (n = 56) for the CA. In 45 patients (39.8%), asymptomatic compression of the CA by the MAL was depicted (MAL+). Complex endovascular techniques were required in this group to access the CA in 16 (14.2%) patients (vs none in the MAL- group; P = .003), which lead to a failed bridging stent implantation in seven patients (6.2%). Increased operative time and dose area product were observed in the MAL+ group, but this did not reach statistical significance. In the MAL+ group, no thrombosis of the CA bridging stents were observed during follow-up; an external compression of the CA bridging stent was depicted in six patients but without hemodynamic effect on duplex ultrasound imaging. In the MAL- group, one CA bridging stent occlusion occurred owing to an embolus from a cardiac source.ConclusionsMAL compression is associated with good celiac trunk bridging stent patency during follow-up, but with a higher rate of technical difficulties and failed bridging stent implantation during the procedure.Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

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