LAUSR

BACKGROUND Primary mycotic aneurysm of the aorta (MAA) is a rare and potentially life threatening disease. Endovascular aneurysm repair (EVAR) of MAAs involving the paravisceral has been rarely reported. The purpose of this study is to report our experience with Chimney EVAR (CHEVAR) in patients with MAAs involving the paravisceral aorta. METHODS We performed a retrospective review of all patients treated with EVAR at our institution during the years 2009-2019. Of those, we identified patients who were treated with CHEVAR for MAAs. Diagnosis of MAAs was based on clinical presentation, abnormal laboratory results and a computer tomography (CT) scan suggestive of a MAA. Data collected included patient demographics, clinical presentation, and antibiotic regimen before and after the surgery, preoperative imaging, surgical details and perioperative and long term morbidity and mortality. RESULTS During the study period we performed 54 cases of CHEVARs for aortic aneurysms. Of those, 8 (15%) were performed for mycotic aneurysms involving the visceral segment. Six (75%) were males, and mean age was 68 (range 59-76). All patients were symptomatic at time of diagnosis, presenting with either back or abdominal pain. A total of 16 visceral vessels (Celiac trunk, 2; Superior mesenteric artery (SMA), 7; right renal artery, 4; left renal artery, 3) were revascularized with parallel grafts (PGs). Six patients required 2 PGs, one required 3 PGs and one patient had a single PG inserted. Fifteen (94%) PGs were upward pointing chimneys stent grafts, and 1 was placed in downward pointing "periscope" configuration. Eight visceral arteries in 6 patients were sacrificed, either by preoperative occlusion or intentional coverage with the endograft during the procedure. Vessels sacrificed included 4 Celiac trunks and 4 renal arteries (3 main branches, 1 accessory renal artery). Technical success, was achieved in all patients. One patient expired in the perioperative period. One patient developed an infectious related complication. One patient experienced worsening of his renal function and eventually required dialysis. Of the 4 patients who underwent intentional sacrifice of a kidney, all experienced a moderate decrease in renal function from baseline (mean preoperative and postoperative serum creatinine 0.76 mg/dl and 1.2 mg/dl respectively, increase of 43%). Mean follow up was 8 months (range 3-28 months). During this period 2 patients expired, one from an aneurysm related cause. No stent occlusion of the PGs occurred and no reintervention due to endoleaks was required. No patient required explanation of the stent grafts or conversion to an open repair. CONCLUSION CHEVAR is a feasible and safe treatment modality for MAAs involving the visceral segment. Occasionally, intentional occlusion of selected visceral arteries may be required in order to minimize the risk of gutter endoleaks in this urgent setting. Further follow up is needed to accurately assess the durability of this repair.