Endovascular management of iliac limb occlusion of bifurcated aortic endografts

Endovascular approach to thrombosed limb of aortoiliac endoprosthetic stent graft following abdominal endovascular aneurysm repair

The increasing use of endovascular aneurysm repair to treat abdominal aortic aneurysms has mandated solutions to the limitations of this operation, including the requirement for additional procedures. A 64-year-old man had presented with symptomatic thrombosis of the left iliac limb after endovascular aneurysm repair. We have reported the use of an innovative endovascular repair for our patient.

Tratamento endovascular da oclusão de ramo ilíaco de endoprótese bifurcada de aorta abdominal: trombectomia rotativa e aspirativa seguida de angioplastia com stent primário

A oclusão de ramo ilíaco de endoprótese bifurcada de aorta surge como complicação decorrente da correção endovascular do aneurisma de aorta abdominal e várias abordagens terapêuticas têm sido empregadas para o tratamento dessa complicação em casos de isquemia de membro inferior. Apresentamos dois casos de tratamento totalmente percutâneo da oclusão de ramo ilíaco de endoprótese de aorta abdominal com dispositivo de trombectomia rotativa e aspirativa seguida de angioplastia com stent primário, sem complicações operatórias.

Endovascular management of delayed complete graft thrombosis after endovascular aneurysm repair

Graft thrombosis rates after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms vary widely in published series. When thrombosis does occur, it usually involves a single limb and occurs within 3 months of stent-graft insertion. If the entire endoprosthesis is thrombosed, treatment may be challenging because femoro-femoral crossover graft insertion is not an option and a greater volume of thrombus is present, thus making thrombolysis more difficult. We present two cases of delayed thrombosis after EVAR involving the entire stent-graft. These were successfully treated by a combined surgical and endovascular technique, and patency has been maintained in both cases to date.

Limb Graft Occlusion Following EVAR: Clinical Pattern, Outcomes and Predictive Factors of Occurrence

INTRODUCTION

We reviewed our experience with limb occlusion after EVAR in order (1) to assess the clinical pattern and treatment options (2) to assess outcomes and (3) to identify predictive factors of occurrence.

MATERIALS AND METHOD

Between 1995 and 2005, 460 AAA patients were electively treated with a variety of commercially available stent grafts. There were 369 bifurcated and 91 aortouniiliac grafts (829 limbs). Follow-up included physical examination, plain X-ray, Duplex ultrasonography, and spiral computed tomographic scans at 1, 6, 12 months and annually thereafter. All pertinent data were collected prospectively and analysed retrospectively. The follow-up period ranged from Day 0 to 104 months, with a median follow-up of 23.4 months.

RESULTS

36 limbs in 33 patients (7.2%) occluded between Day 0 and 71 months (average: 9.5 months) after EVAR. Presentation was acute ischemia in 11 cases, rest pain in 9, claudication in ten. Four occlusions remained asymptomatic and two occurred intraoperatively. Treatment was femoro-femoral cross-over graft in 19 cases, axillo-femoral bypass in three, thrombectomy and stent in three, thrombolysis and stent in nine, and conservative in two. One patient (3%) died of multiple organ failure after thrombolysis. There was no amputation. Reocclusions occurred in two patients (6.1%). Multivariate logistic regression showed that kinking (odds ratio [OR] 11.9; confidence interval [CI] 3.39-42.1; p=0.0001), first graft generation (OR 2.87; CI 1.25-6.62; p=0.017) and younger age (OR 1.05; CI 1.00-1.09; p=0.034) were independently related to the occurrence of graft limb occlusion.

CONCLUSION

Acute graft limb occlusion is not rare after EVAR. The frequency of limb occlusion has declined with current stent grafts generation. Although surgery and endovascular treatments are efficient and safe, development of a graft limb kink should lead to aggressive pre-emptive treatment to prevent occlusion.

Complications of Endovascular Repair of Abdominal Aortic Aneurysms: A Review

The endovascular procedure for repair of abdominal aortic aneurysms has had an enormous impact on the treatment of this challenging disease. Complications, however, do occur and it is important to have a thorough understanding of the array of complications and appropriate management strategies. In this review of endovascular complications, we describe early and late complications paying particular attention to preventive, treatment and surveillance strategies.

Endovascular graft limb occlusion

Endovascular aneurysm repair (EVAR) has undergone a tremendous evolution in the nearly 15 years since it was first described. Continual refinement of the technology and techniques associated with EVAR and the respectable short-term results of this procedure led the United States Food and Drug Administration to approve several devices for the endovascular treatment of abdominal aortic aneurysm (AAA). There has been a corresponding rapid dissemination of this technology throughout the vascular surgery community in the United States. Availability and critical analysis of mid- and long-term follow-up data on the increasing number of patients who have undergone EVAR has begun to raise questions about the long-term durability and effectiveness of EVAR. Numerous complications of EVAR are now recognized and well described in the literature. One of these is graft limb dysfunction. Graft limb occlusion occurs in a significant number of patients and it is imperative that physicians who perform EVAR have a thorough understanding of this condition. There are a variety of factors that predispose patients to development of graft limb occlusion. These factors can be classified as either anatomic or graft-related. When patients present with graft limb occlusion, endovascular treatment is usually possible and it is highly effective. Some cases require traditional surgical treatment. Prevention of graft limb occlusion is of paramount importance. It can only be achieved with an aggressive search for graft limb compromise and liberal use of angioplasty and/or stenting at the time of graft implantation.

Initial management and outcome of aortic endograft limb occlusion

OBJECTIVE

The purpose of this study was to determine the differences in outcome related to initial management of aortic endograft limb occlusion (ELO).

METHODS

During a 7-year period, 823 endovascular aneurysm repairs (EVARs) resulted in 25 ELOs in 22 patients. The initial management and outcome of these ELOs were reviewed. Median follow-up after ELO was 24.2 +/- 16.8 months.

RESULTS

Initial EVARs included both unsupported unibody (n = 5) and supported modular (n = 17) devices. ELO was significantly more common in the unsupported unibody graft design (P <.024) and with extension of the graft limb to the external iliac artery (P <.001). ELO was managed with an endovascular approach (EVA), including some combination of mechanical thrombectomy (n = 8), angioplasty with or without stenting (n = 8), and thrombolysis (n = 2) in 12 patients and bypass procedures (femoral-femoral bypass, n = 11; axillofemoral bypass, n = 1; and aortofemoral bypass, n = 1) in 13. At 12-month follow-up, freedom from secondary procedures with EVA was 80.2 +/- 17.7% versus 53.2 +/-17.1% with extra-anatomic bypass (EB) (P = NS). Secondary patency was 100% with EVA and 80.6 +/- 14.4% with EB (P = NS). Of the 12 EVAs, there was 1 (8.3%) perioperative mortality with EVA and none with EB. EB failure was directly attributed to donor limb occlusion in 4 of 6 EVAs (67%), and when this occurred it resulted in bilateral lower extremity ischemia. Amputation was required in 2 of 12 (16.7%) EBs versus none of the 12 EVAs (P = NS). EVA never resulted in graft dislodgement or endoleak but did identify an underlying treatable cause in 8 of 12 (67%).

CONCLUSION

Both EVA and EB are acceptable management strategies for ELO. The potential risk of graft dislodgement was not observed with an EVA. If EB is employed, assessment of the donor limb and treatment of any underlying lesions is advisable in an attempt to minimize future donor limb occlusion.

Aortic endograft thrombosis after colorectal surgery in lithotomy position

Aortic endograft limb occlusion is a serious complication after endovascular abdominal aortic aneurysm repair. We describe a yet unreported cause of endograft limb occlusion, the lithotomy position. Two patients with abdominal aortic aneurysm and colorectal cancer underwent an initial endovascular repair followed by cancer resection in the lithotomy position. Aortic endograft limb occlusion occurred in both patients immediately after the cancer operation. Percutaneous rheolytic thrombectomy was performed successfully in both patients. Pelvic surgery requiring the lithotomy position should be performed with caution in patients with aortic endografts, because it can result in endograft occlusion.

Durability of femorofemoral bypass grafting after aortouniiliac endovascular aneurysm repair

INTRODUCTION

Endovascular aneurysm repair (EVAR) with aortouniiliac prostheses extends the morphologic range of aneurysms that can be treated and is potentially a more rapid and simple operation than bifurcated endovascular repair. It may, however, be limited by durability of the femorofemoral extra-anatomic bypass graft required to revascularize the contralateral lower limb. Previous studies of femorofemoral bypass grafts were performed almost exclusively in patients with occlusive disease. An 8-year single center experience with use of the femorofemoral bypass graft in aneurysmal disease is reported.

METHODS

All patients undergoing EVAR with an aortouniiliac endovascular stent graft over eight years (1994-2002) at a single institution were included in a retrospective study. Patient data were collected from a prospectively maintained local endovascular database. All patients gave informed consent and were part of an endovascular program approved by the local ethics committee.

RESULTS

Over the 8 years, 231 patients underwent EVAR with an aortouniiliac endovascular stent-graft. Median follow-up was 22 months. Localized wound complications were observed in 25 patients (11%). Cumulative 3-year patency rate for the femorofemoral bypass graft was 91%. At the end of 5 years 83% of grafts remained patent.

CONCLUSIONS

The femorofemoral bypass graft used during EVAR with aortouniliac stent grafts offers encouraging medium and long-term patency. When graft occlusion occurs, it is usually directly attributable to inadequate inflow from the endovascular stent graft itself or to endoluminal damage of the external iliac artery. Awareness and early detection of stent-graft distortion or complications in the external iliac artery may result in improved patency rates.

A new endovascular approach to treatment of acute iliac limb occlusions of bifurcated aortic stent grafts with an exoskeleton

Endovascular aneurysm repair continues to become increasingly popular. As the number of implanted endografts increases, complications will increase as well. We report a new approach to endovascular treatment in two patients with acute iliac limb occlusions of a bifurcated aortic endograft with an endoskeleton. Neither patient required femoral-femoral bypass grafting because of unilateral limb ischemia. We believe this is the optimal primary approach in patients with a bifurcated stent graft with an endoskeleton.