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J Vasc Surg Cases Innov Tech
J Vasc Surg Cases Innov Tech
Journal of Vascular Surgery Cases, Innovations and Techniques
2468-4287
Elsevier

S2468-4287(24)00186-2
10.1016/j.jvscit.2024.101602
101602
Case report
Management of acute aortic occlusion in the setting of necrotizing pancreatitis with covered endovascular reconstruction of the aortic bifurcation
Marleau Eastan MD eastan.marleau@usd.edu
∗
Bacharach Thekla MD
Dayama Anand MD
Vascular Surgery, Sanford USD Medical Center, Sioux Falls, SD
∗ Correspondence: Eastan Marleau, MD, Sanford USD Medical Center, 1305 W 18th St, Sioux Falls, SD, 57105 eastan.marleau@usd.edu
20 8 2024
12 2024
20 8 2024
10 6 10160210 6 2024
2 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Acute aortic occlusion represents a rare, life-threatening condition associated with significant morbidity and mortality. Here, we present a case of acute aortic occlusion in the setting of necrotizing pancreatitis, successfully managed with covered endovascular reconstruction of the aortic bifurcation. Traditionally, treatment options for acute aortic occlusion have included thromboembolectomy, aortobifemoral bypass, and axillary bifemoral bypass. Our report demonstrates covered endovascular reconstruction of the aortic bifurcation as a viable in-line treatment option for acute aortic occlusion, particularly in patients with challenging concomitant abdominal pathology.

Keywords

Acute aortic occlusion
CERAB
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pmcAcute aortic occlusion typically presents as bilateral acute limb ischemia and has a mortality rate of 35% and morbidity of 74%.1 The incidence is reported at 3.8 per 1 million person-years, and the most common etiologies include in situ thrombosis, saddle embolus of the aortic bifurcation, and occluded grafts or stents.2 Treatment interventions include thromboembolectomy, axillary-bifemoral bypass, aortobifemoral bypass, and endovascular revascularization2, 3, 4 Endovascular revascularization is an uncommonly used treatment modality.4 This report demonstrates a case of acute aortic occlusion in a patient with necrotizing pancreatitis, successfully treated with covered endovascular reconstruction of the aortic bifurcation (CERAB). The patient has provided written informed consent for the procedure and the report of their case details and imaging studies.

Case report

A 41-year-old man was transferred to our institution for further management of necrotizing pancreatitis. He had a medical history significant for a 90 pack-year smoking history and alcohol abuse complicated by two prior episodes of pancreatitis. He had no prior vascular workup or interventions. At the outside hospital, he had reported 1 day of epigastric abdominal pain, nausea, and vomiting. A computed tomography (CT) scan had shown significant peripancreatic inflammation and hypoenhancement of the pancreatic head and body. There was no aortic thrombus at that time, but there was right inferior renal artery occlusion and chronic appearing occlusion of the left iliac artery (Fig 1).Fig 1 (Left) Diffusely edematous pancreas with hypoenhancement of the pancreatic head and body. (Right) Occlusion of the left common iliac artery.

Upon arrival at our institution, he was in acute distress, tachycardic to 140 and hypertensive with a blood pressure of 179/109 mm Hg. On examination, he had altered mental status, a diffusely tender abdomen, and bilateral cold lower extremities with absent lower extremity pulses. The remainder of his pulse examination was normal. His mental status prevented a thorough motor examination. His laboratory tests revealed a lipase of 1161, troponin 0.238, and lactate 4.2. CT angiography of the abdomen and pelvis was obtained and showed occlusion of the infrarenal aorta and bilateral common and internal iliac arteries with reconstitution of the bilateral femoral arteries via the inferior epigastric arteries (Fig 2). The left inferior epigastric artery was dilated, concerning for chronic occlusion of the left common iliac artery, as seen in the initial CT scan. The inferior mesenteric artery origin was occluded with distal reconstitution. The pancreas was again noted to be diffusely edematous with significant peripancreatic inflammation, free fluid, and hypoenhancement of the pancreatic head and body. There was also an occluded accessory right renal artery.Fig 2 (Left) Axial view of acute infrarenal aortic occlusion. (Right) Acute infrarenal aortic occlusion on three-dimensional reconstruction.

A heparin infusion was started, and the patient was taken to the hybrid operating room emergently for revascularization. Bilateral femoral cutdowns were performed, a transverse arteriotomy was made in the right common femoral artery (CFA), a flush catheter was inserted over a wire into the aorta, and an aortogram was performed, showing an acute infrarenal aortic occlusion (Fig 3). The celiac and superior mesenteric artery origins were patent and without thrombus. The inferior mesenteric artery was occluded, consistent with preoperative imaging.Fig 3 (Left) Aortogram demonstrating infrarenal acute aortic occlusion. (Right) Completion aortogram showing patent stents with excellent flow.

Over-the-wire thrombectomy was performed with a #6 embolectomy balloon with adequate anterograde bleeding after thrombectomy. We then made a transverse arteriotomy in the left CFA and attempted wire access, but the wire would not proceed past the external iliac artery, again raising concern for chronic occlusion at this level. We upsized the right CFA sheath to a 6.5F steerable sheath and the left common iliac artery was selected. The chronic occlusion was crossed anterograde until the wire was externalized through the left CFA arteriotomy. Using a Trailblazer (Medtronic, Minneapolis, MN) catheter, we were able to redirect a guidewire from the left CFA into the aorta. Intravascular ultrasound (IVUS) examination was performed and showed significant residual aortic thrombus despite thrombectomy.

We decided to proceed with CERAB. The 6.5F sheath was upsized to 8F and IVUS examination was performed with measurements of the aorta and right iliac artery. An 11 × 79-mm balloon-expandable VBX (W. L. Gore & Associates, Newark, DE) stent was deployed just below the renal arteries and post dilated with a 16-mm balloon. We covered the inferior mesenteric artery as it was occluded. An 8 × 79-mm balloon expandable VBX kissing iliac stents were deployed and post dilated to 9 mm. We then extended into the bilateral external iliac arteries with 8 × 100-mm Viabahn (W. L. Gore & Associates) stents owing to residual disease and occlusion of the bilateral internal iliac arteries. Completion angiogram demonstrated excellent flow (Fig 3).

We then performed bilateral superficial femoral artery and profunda femoris artery thrombectomies with #4 and #3 embolectomy balloons. We retrieved a moderate amount of thrombus and back bleeding was appropriate after the thrombectomy. The bilateral CFA arteriotomies were repaired with Prolene suture. Bilateral lower compartment fasciotomies were performed.

The patient was admitted to the cardiovascular intensive care unit postoperatively. His course was complicated by sigmoid perforation on postoperative day 16, requiring exploratory laparotomy, sigmoid resection, and end colostomy. The delayed sigmoid perforation was likely owing to ischemia from an occluded inferior mesenteric artery, occluded bilateral hypogastric arteries, and low flow state owing to shock, although the patient had been stable for several days before the perforation. He also developed peripancreatic abscesses, which were treated with multiple percutaneous drains. His fasciotomy sites were treated with skin grafting and healed well. He was discharged home on postoperative day 49. On follow-up, he was doing well, walking without difficulty, and a CT scan demonstrated widely patent aortoiliac stents. At the 6-month follow-up, an aortoiliac duplex examination showed patent aortic and iliac stents without endoleak or limb stenosis. Yearly follow-up with aortoiliac duplex was scheduled.

Discussion

Acute aortic occlusion in the setting of necrotizing pancreatitis is a unique and challenging problem. Emergent treatment is necessary, with classic management options including thromboembolectomy, aortobifemoral bypass, and axillary bifemoral bypass.

In this patient, thromboembolectomy alone was unsuccessful, as demonstrated by persistent thrombus present on IVUS examination. Given the patient's critical illness and hostile abdomen from necrotizing pancreatitis, management with aortobifemoral bypass posed significant technical difficulty, increased operative time for a critically ill patient, and increased risk of perioperative complications. Although axillary bifemoral bypass would have also avoided this patient's hostile abdomen, he was likely going to require multiple percutaneous interventions, as well as potential retroperitoneal and abdominal surgeries for his necrotizing pancreatitis.

Owing to the patient's concurrent abdominal pathology, we determined endovascular revascularization with CERAB would provide him with in-line flow and the lowest risk of complications. CERAB is a well-described technique used for chronic aortoiliac occlusive disease, allowing for a smooth transition to use in patients with acute aortic occlusion. One consideration while performing CERAB for acute aortic occlusion is that care must be taken to avoid displacement of the aortic thrombus into the renal arteries while deploying the aortic stent. The risk of iatrogenic embolization during stent deployment can be mitigated through balloon occlusion of the renal arteries via brachial artery access before stent placement. We decided against balloon occlusion of the renal arteries because our patient had infrarenal aortic thrombus on angiogram and IVUS examination, and we felt that the risk of embolization to the renal arteries during stent deployment was low.

Conclusions

This is a case of a patient with acute aortic occlusion in the setting of necrotizing pancreatitis who was successfully managed with CERAB. We demonstrate that CERAB serves as a viable alternative to open reconstruction or extra-anatomic bypass in patients with acute aortic occlusion, especially those with hostile abdominal pathology. Although it is not a standard technique, this application of the existing CERAB procedure has the potential to benefit patients with acute aortic occlusion.

Disclosures

None.

The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
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