Lumbar Artery Branch in Treatment of Thoracoabdominal Aortic Aneurysm to Prevent Spinal Cord Ischemia

PURPOSE: This article describes the modification of an iliac limb to incorporate a lumbar artery branch to decrease risk of spinal cord ischemia (SCI) in a patient with a symptomatic extent III thoracoabdominal aortic aneurysm (TAAA). CASE REPORT: dissection with 6.5 cm aneurysmal degeneration presented with sudden onset chest and abdominal pain. Imaging revealed rapid growth to 9.8 cm with a new stent graft-induced entry tear and associated fat stranding. Not medically fit for open repair, the patient was taken for an emergent fenestrated/branched endovascular aortic repair (F/BEVAR). A 32×24×150 TX2 Zenith thoracic tube graft was modified with 4 fenestrations. A 13×11×56 Z SLE Cook iliac limb was modified to create a custom iliac fenestrated endoprosthesis, as this patient's right iliac anatomy was not suitable for off-the-shelf products. After deployment of the custom iliac fenestrated device and fenestrated thoracic device, an aortogram revealed a large L5 lumbar artery we felt was amenable to fenestration to help preserve spinal perfusion. A 13×16×39 Z SLE Cook iliac limb was modified with a branch for an L5 lumbar artery. Post-operative course was uneventful without ischemic-related complications. One-month follow-up imaging reveals stable sac size with type II endoleak and patent hypogastric and lumbar artery stents. CONCLUSION: Preservation of collateral pathways is understood to be critical in prevention of SCI, although the precise branches necessary are not clear. Lumbar fenestration and hypogastric preservation to reduce risk of SCI is a feasible and valid technique that should be considered when anatomy allows.Clinical ImpactThis case validates the efficacy and safety of using a physician-modified iliac limb to salvage an L5 lumbar artery after endovascular exclusion of a symptomatic extent III thoracoabdominal aortic aneurysm (TAAA). This interventional approach allows for the maintenance of perfusion to the spine and preservation of potentially hemodynamically significant collateral pathways. Our results suggest that this technique to mitigate the risk of spinal cord ischemia is safe and effective and thus may be considered for appropriately-selected cases.