Lysis and covered endovascular reconstruction of the aortic bifurcation (LA CERAB) technique for chronic juxtarenal aortic occlusions.

Abstract

Background: The purpose of this study was to review early experience with catheter directed thrombolysis in the setting of chronic juxtarenal aortic occlusion as an initial therapy to allow safe definitive management with placement of aorto-iliac endografts.

Methods: A retrospective review was performed of all patients with a diagnosis of chronic juxtarenal aortic occlusion treated by the author with initial catheter directed thrombolysis. In all, six patients (five males and one female, average age of 57 years) treated between 2019 and 2022 met criteria. Total duration of symptoms prior to thrombolysis ranged from 2 to 54 months (average 23 months.) Four patients (67%) had progressed to tissue loss 2 to 5 months prior to the initiation of thrombolysis (average 3.25 months). Radiographic confirmation of aortic occlusion on preoperative imaging was noted 7 to 846 days prior to the initiation of thrombolysis (average 190 days).

Results: Five of six patients (83%) had near complete resolution of aorto-iliac thrombus after 12 to 72 hours of thrombolysis to reveal underlying stenoses. The remaining patient's thrombolysis therapy was cut short at 48 hours due to behavioral issues, but had enough clearing of juxtarenal thrombus to undergo placement of aorto-iliac endografts. There were no perioperative deaths, myocardial infarctions, strokes or major complications. Temporary laboratory abnormalities (coagulopathy and/or increase in serum creatinine) were seen in four patients (67%), but all resolved by discharge without clinical sequelae. The primary patency is 100% at early follow-up of up to 15 months.

Conclusions: In the setting of chronic juxtarenal aortic occlusions, thrombolysis can provide effective clearing of the juxtarenal aortic thrombus to allow safe definitive therapy with aorto-iliac endografts. The approach deserves consideration in patients at high risk for open reconstruction.