Clinical Patterns, Predictors, and Results of Graft Limb Occlusion following Endovascular Aneurysm Repair

Abstract

To assess the incidence, clinical patterns, and outcomes of graft limb occlusion (GLO) following endovascular aneurysm repair (EVAR). A retrospective study of patients undergoing EVAR from 2002 to 2017 at 2 mid-sized suburban teaching hospitals. The ipsilateral and contralateral aorto-common iliac artery (A-CIA) angle and common iliac artery-external iliac artery (CIA-EIA) angle were determined. The diameter of the EIA, graft extension to the EIA, and prior CIA stenting was recorded. Of the 373 patients who underwent EVAR, 319 were analyzed. 22 patients had 23 limbs with GLO (21 unilateral and 1 bilateral) with a mean follow-up of 9.1±2.1years. There were no statistically significant differences in mean age, gender, size of the abdominal aortic aneurysm, and risk factors of hypertension, coronary artery disease, diabetes mellitus, and chronic obstructive pulmonary disease in patients with and without GLO. There was no statistically significant difference in A-CIA and CIA-EIA angles. A smaller diameter EIA (6mm or less), graft extension to EIA, and prior CIA stenting were significant predictors of GLO. Four limbs had GLO within 1month of EVAR, only open thrombectomy was performed in 2 limbs, open thrombectomy with simultaneous axillo-femoral graft in 1 limb, and open thrombectomy with self-expandable stent placement in 1 limb. 12 limbs had GLO within 1-12months treated with only open thrombectomy in 3 limbs, open thrombectomy with fasciotomy in 1 limb, open thrombectomy with graft extension to EIA in 1 limb, and crossover femoral-femoral graft performed in 3 limbs. Seven limbs had GLO within 1-5years with a crossover femoral-femoral graft performed in 4 limbs and open thrombectomy with graft extension to EIA was performed in 1 limb. Six limbs with GLO following EVAR did not undergo any intervention. One patient had an above the knee amputation 3years following occlusion of the axillo-femoral graft and 1 patient returned in 4years with an increase in size of the excluded aneurysm leading to acute rupture and death. GLO leads to significant morbidity and mortality following EVAR. Predictors of GLO following EVAR include a small diameter EIA, prior CIA stenting and graft limb extension to the EIA.