Analysis of Complex Endovascular Aneurysm Repair in Patients with Median Arcuate Ligament Compression

OBJECTIVE: Treating abdominal aortic aneurysms with fenestrated or branched endovascular aneurysm repair in the presence of a median arcuate ligament (MAL) compression of the celiac trunk presents special challenges. This study aimed to investigate whether compressed celiac trunks can be safely stented or left unstented. It also aimed to assess the durability of bridging stent grafts (BSGs) of new generation in patients with compression of the celiac trunk. METHODS: A single-center retrospective analysis of 187 consecutive patients treated with fenestrated or branched endovascular aneurysm repair was performed. The study population was divided into three groups: patients whose MAL compression was stented with a BSG (MAL+ stented), patients whose MAL compression was not stented (MAL+ unstented), and patients without MAL compression (MAL-). Celiac trunk compression was evaluated in consecutive computed tomography angiography (CTA) scans. RESULTS: Of 187 patients, 76 patients (41%) had a MAL compression in the preoperative CTA scan. Of those, 46 patients (25%) were in the MAL+ stented group, and 30 patients (16%) were in the MAL+ unstented group. Six of 30 patients (20%) from the MAL+ unstented group developed mesenteric ischemia compared with zero of 46 patients (0%) from the MAL+ stented group (P ≤ .001). One of MAL+ stented patients (2%) developed target vessel instabilities, compared with one of MAL- patients (3%) and three of MAL- patients (3%) (P=.960). No BSG fracture was observed. CONCLUSIONS: BSGs of new generation are capable of withholding the pressure of MAL compression of the celiac trunk. Patients with unstented celiac trunk compression are significantly more likely to develop mesenteric ischemia. In accordance with present data, BSG deployment, including cases with high-grade stenosis, should be considered for maintenance of celiac blood flow.