Clinical Patterns, Predictors, and Results of Endograft Limb Occlusion After Endovascular Aneurysm Repair
Nahirniak P, Morton K, and Hans SS. Clinical Patterns, Predictors, and Results of Endograft Limb Occlusion After Endovascular Aneurysm Repair. Journal of Vascular Surgery 2020; 72(1):e82.
Journal of Vascular Surgery
Objective: The objective was to assess the incidence and outcome of endograft limb occlusion (ELO) after endovascular aneurysm repair (EVAR) with midterm and late follow-up.
Methods: Data of consecutive patients undergoing EVAR from 2000 to 2017 were retrospectively analyzed with clinical examination, computed tomography angiography, and duplex ultrasound imaging at regular intervals. Ipsilateral and contralateral aorta-common iliac artery (CIA) angle and CIA to external iliac artery (EIA) angle and diameter of CIA and EIA were determined using IntelliX (Columbus, Ohio) EndoSize software program. Graft extension to ipsilateral EIA at index operation was recorded. Multivariant logistic regression analysis with odds ratio was used for statistical analysis.
Results: Of 369 patients treated with EVAR, complete data were available in 319 patients (mortality, 4; lost to follow-up, 40; incomplete imaging data, 6). Twenty-two patients (6.9%) had ELO with occlusion of both limbs in two, with mean follow-up of 7 ± 2.3 years. Four patients had unsupported (Ancure; Guidant, Menlo Park, Calif) grafts with occlusion in two. The remaining 315 patients had supported grafts with ELO in 20 (P =.03): AneuRx (Medtronic, Santa Rosa, Calif), 98; Talent (Medtronic), 54; Excluder (W. L. Gore & Associates, Flagstaff, Ariz), 8; Zenith (Cook Medical, Bloomington, Ind), 8; and Endurant (Medtronic), 147. Age, sex, and risk factors including hypertension, diabetes, coronary artery disease, chronic obstructive pulmonary disease, renal failure, hyperlipidemia, and nicotine abuse were similar in patients who had ELO and those who did not. Of 22 patients with ELO, 3 occluded within 1 month of EVAR (treated with thrombectomy in 3 and associated axillofemoral graft in 2). Twelve had ELO (1-12 months), with three requiring thrombectomy with fasciotomy in one and crossover femorofemoral graft in one. Seven patients had ELO between 1 and 5 years; four required crossover femorofemoral graft and one required thrombectomy with graft extension to EIA, with no intervention in the remaining two patients. In all seven patients, late occlusion was due to disease progression in the ipsilateral EIA and femoral artery. There was one operative death (4.5%) after a delayed diagnosis of bilateral limb thrombosis. A left above-knee amputation at 3 years after occlusion of the axillofemoral graft occurred in one patient.
Conclusions: Small-diameter CIA at the landing zone, graft extension into EIA, and use of unsupported grafts are the primary predictors of ELO. Graft limb occlusion is a serious complication after EVAR with significant morbidity and mortality.