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 2002-2017 at two mid-sized suburban teaching hospitals. The ipsilateral and contralateral aorto-common iliac artery angle (A-CIA) and common iliac-external iliac artery angle (CIA-EIA) was 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 one bilateral) with a mean follow up of 9.1 +/- 2.1 years. 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 one month of EVAR, only open thrombectomy was performed in 2 limbs, open thrombectomy with simultaneous axillo-femoral graft in one limb, and open thrombectomy with self-expandable stent placement in one limb. 12 limbs had GLO within 1-12 months treated with only open thrombectomy in three limbs, open thrombectomy with fasciotomy in one limb, open thrombectomy with graft extension to EIA in one limb, and crossover femoral-femoral graft performed in three limbs. Seven limbs had GLO within 1-5 years with a crossover femoral-femoral graft performed in four limbs and open thrombectomy with graft extension to EIA was performed in one limb. Six limbs with GLO following EVAR did not undergo any intervention. One patient had an above the knee amputation 3 years following occlusion of the axillo-femoral graft and one patient returned in 4 years with an increase in size of the excluded aneurysm leading to acute rupture and death.
Graft limb occlusion 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.
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Accepted: February 3, 2023
Received in revised form: January 2, 2023
Received: September 27, 2022
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