Treatment of thoracoabdominal aortic aneurysms (TAAA) by thoracic (TEVAR) and fenestrated or branched endovascular aortic repair (f/bEVAR) has become an attractive option. We describe an uncommon case of acute occlusion of all four branches after bEVAR with severe reno-visceral ischemia.

Case report of a 58-year-old male patient who had been treated urgently for a Crawford type II TAAA using TEVAR and off-the-shelf bEVAR (E-nside, Jotec, Germany).

Three months after bEVAR, the patient was referred by air ambulance after acute onset of severe abdominal pain and absence of diuresis. Computed tomography revealed occlusion of all four bEVAR branches. Beside a stenosis of the celiac trunk due to compression by the arcuate ligament, no stenosis or stentgraft fracture as cause for branch occlusion was identified. In addition, the patient was under rivaroxaban due to atrial fibrillation as well as acetylsalicylic acid. Urgent laparotomy and iliaco-mesenteric bypass with bypass grafts to the superior mesenteric (SMA) and both renal arteries was performed. After mesenteric revascularization, the bowel recovered. No bowel resection was necessary. Intraoperative doppler examination showed good retrograde perfusion of the distal celiac trunk via collaterals and macroscopically, liver and stomach were well perfused. Therefore, no celiac trunk revascularization was performed. During the second postoperative week, the patient’s general condition worsened and stomach cramps and gastroparesis occurred. Gastroscopy revealed ischemic gastritis. Revision laparotomy and revascularization of the celiac trunk with a retro-pancreatic bypass from the iliaco-SMA-bypass to the proper hepatic artery was performed. Thereafter, patient recovered slowly. Hemodialysis had been necessary since admission. Due to an anastomotic stenosis of the bypass to the right renal artery, stenting was performed with recovery of renal function. The patient was discharged with phenprocoumon and acetylsalicylic acid.

Acute occlusion of all bEVAR branches is a rare but life-threatening complication necessitating immediate revascularization. In acute visceral ischemia with all visceral arteries occluded, SMA vascularization alone may not be sufficient. High clinical alertness is mandatory to detect stomac or liver malperfusion, and secondary revascularization of the celiac trunk may become necessary.