Limb occlusion following endovascular aortic repair

Abstract

Limb occlusion following endovascular aortic repair (EVAR) is one of the most common complications requiring secondary interventions and is associated with a relevant morbidity and mortality. This review article describes the risk factors for limb occlusion, highlights strategies for prevention and provides a treatment algorithm involving current open and endovascular modalities. A selective literature search for risk factors and treatment modalities of limb occlusion after EVAR was carried out. A total of five risk factors for limb occlusion after EVAR were identified: (1) iliac angulations >60°/high iliac tortuosity (odds ratio, OR 5.76), (2) severe iliac calcification (OR 5.8), (3) excessive oversizing >15% (OR 5.54), (4) graft placement in the external iliac artery (EIA) with (5) EIA diameter <10 mm. While there are multiple treatment modalities (e.g. open, endovascular and hybrid procedures) for treating limb occlusion after EVAR, recommendations concerning treatment selection are diverse. Even in the endovascular era, open surgical repair with an iliacofemoral or femorofemoral crossover bypass is frequently used. Reocclusion still occurs in up to 30% of cases after initially successful treatment with endovascular and/or hybrid repair. Patients with tortuous iliac arteries, significant iliac vessel calcification that require endograft limb placement in small diameter EIAs have the highest risk for limb occlusion. During planning and implantation a special focus should be on strategies to prevent this complication. The suggested treatment algorithm represents a practical tool in clinical decision-making processes concerning treatment of limb occlusion.