Related Experiment Video
Updated: Nov 10, 2025
Multimodality Diagnosis of Mesenteric Ischemia
Published on: July 21, 2023
Retrograde Catheterization of the Superior Mesenteric Artery and Celiac Axis as a Bailout Technique in a Complex
Fernando Picazo Pineda1, Tishanthan Pathmarajah1, Kishore Sieunarine1,2
1Department of Vascular and Endovascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia.
Insights
Retrograde access via median laparotomy is a viable bailout strategy for complex fenestrated endovascular aortic repair (FEVAR) when standard antegrade catheterization of visceral arteries fails. This approach successfully treated a persistent type 1a endoleak in a challenging case.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Endovascular Aneurysm Repair
Background:
- Fenestrated endovascular aortic repair (FEVAR) aims to treat complex aortic aneurysms.
- Standard antegrade catheterization of visceral arteries (celiac trunk [CT] and superior mesenteric artery [SMA]) can be challenging due to patient anatomy.
- Persistent type 1a endoleak after prior repair complicated FEVAR in this case.
Observation:
- Antegrade catheterization of the CT and SMA failed during FEVAR due to vessel angulation and graft rotation.
- A median laparotomy was performed to establish retrograde access to the CT and SMA.
- Successful catheterization and stenting were achieved via the retrograde approach.
Findings:
- Retrograde access through median laparotomy enabled successful visceral artery catheterization and stenting during FEVAR.
- The patient experienced no major post-operative complications and was discharged after 30 days.
- Follow-up imaging confirmed a stable repair with resolution of the type 1a endoleak.
Implications:
- Retrograde access is a feasible and potentially life-saving bailout option for FEVAR when antegrade approaches fail.
- This technique can prevent conversion to open surgery and reduce patient morbidity in complex cases.
- Median laparotomy for retrograde visceral artery access in FEVAR is a valuable strategy for challenging anatomies.
Introduction:
A retrograde approach of the celiac trunk (CT) and superior mesenteric artery (SMA) to catheterize the visceral vessels during a fenestrated endovascular aortic reparation (FEVAR) is a feasible option when standard access techniques have failed.
Report:
In this report we describe a patient with a previous endoluminal repair of an infrarenal aortic aneurysm, complicated by a persistent type 1a endoleak despite treatment with endoanchor fixation. A decision was made to proceed with a proximal 4 vessel FEVAR to treat the type 1a endoleak. Due to angulation of the mesenteric vessels, and a rotation of the fenestrated stent graft during deployment, the CT and SMA were unable to be catheterized. A decision was made to perform a median laparotomy for retrograde access of the aforementioned vessels, allowing successful catheterization and stenting. The patient was discharged 30 days following the procedure, without any major post-operative complications. Follow up at 6 weeks with a contrasted enhanced computerized tomography scan showed a stable repair with no residual type 1a endoleak.
Discussion:
Catheterization of the target vessels during a FEVAR can be difficult, especially in patients with challenging anatomy. Prolonged surgical time in an attempt to catheterize the vessels can result in increased morbidity for the patient, and ultimately may result in the procedure being abandoned or conversion to an open repair of the aneurysm. Retrograde access of the target vessels as a bailout measure during fenestrated stent graft repair due to failure of an antegrade approach has rarely been reported in the literature. Only a few cases are described in the available literature, however, none of them describe retrograde approach of both the CT and SMA as described in this case. A median laparotomy for retrograde access is a feasible alternative in these situations, and should be considered if the patient is suitable.
