Impact of Post-EVAR Graft Limb Kinking in EVAR Limb Occlusion: Aetiology, Early Diagnosis, and Management

Abstract

The aim of this study was to review preventive and treatment management of one of the most common complications of endovascular aneurysm repair, which surprisingly, is little described in the literature. This study aimed to objectively identify high risk patients for kinking and make recommendations for intra-operative diagnosis and management, as well as management of limb occlusion.Objective/background: Endograft limb occlusion is a potential complication of endovascular aneurysm repair (EVAR), being one of the major causes of secondary interventions and rehospitalisation. The aim of this review is to report on the impact of endograft kinking in endograft limb occlusion, as well as on risk factors, prevention, early diagnosis, and management. Methods: A systematic review and meta-analysis was conducted according to the recommendations of the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. Results: After a MEDLINE and Scopus search, 55 articles (27,509 patients) were included in the qualitative analysis and eight in the quantitative analysis. In this meta-analysis, 179 at risk limbs were treated by preemptive stenting, which significantly reduced the risk of limb occlusion: not pre-emptively stenting limbs at risk had a negative impact on graft limb patency (odds ratio 4.30, 95% confidence interval 1.45e12.78). Postoperatively, a kink was identified in 422 patients (1.5%), contributing to 42.8% of all limb occlusions. Relevant data support that completion angiography is an inadequate means of diagnosing high risk limbs, proposing cone beam computed tomography and intravascular ultrasound as adjuncts. The post-operative limb occlusion rate ranged from 0% to 10.6%, affecting 984 patients. Several risk factors for limb occlusion have been identified. Regarding treatment, most patients were submitted to femorofemoral bypass (52.3%) or to deployment of a bare metal stent, either alone or associated with catheter directed thrombolysis or mechanical thrombectomy (26.4%). Complications and outcome after re-intervention for limb occlusion are described infrequently in the literature, but single studies have reported on re-occlusion, major amputation, and limb occlusion related mortality rates. Conclusion: Pre-EVAR planning should focus on identification of risk factors for kinking. Adjunctive stenting is an effective prophylaxis for selected high risk limbs, yet intra-operative identification remains problematic. Also, it is noteworthy that most limb occlusions occur in the first year after EVAR, emphasising the importance of careful early follow up of high risk patients.

Stentgraft Limb Occlusion After Endovascular Aneurysm Repair: Incidence and Risk Factors

“…Extension to EIA was a predictor for occlusion reported in many studies. 6,8,9,13 In our study, there were also more extensions to the EIA in occluded limbs (27.3%) than in patent limbs (9.4%), however, not statistically significant (P .108).…”

“…This is in contrast to our study, in which distal aortic diameter was larger in occluded limbs (3.3 ± 1.1 cm) than in patent limbs (2.7 ± .8 cm), however, not statistically significant (p .312). Several studies demonstrated iliac artery tortuosity and calcification as risk factors for SLO; 6,11,12 in our study, there were no major differences. Faure et al 8 noted that if the diameter of the external iliac artery (EIA) was ≤1.0 cm, there was a higher risk of occlusion (P .001).…”

“…In literature, occlusions were sometimes found in asymptomatic patients during routine follow-up imaging. 6,7,10 Three patients worked on their knees or cycled frequently before the moment of occlusion. This suggests that incorrect movements of the hip joint may influence the development of occlusion.…”

“…Similar to Cochennec et al, 7 our study could not identify any characteristic of the arterial anatomy as predictor for SLO. Coelho et al 6 identified narrow distal aorta as risk factor. This is in contrast to our study, in which distal aortic diameter was larger in occluded limbs (3.3 ± 1.1 cm) than in patent limbs (2.7 ± .8 cm), however, not statistically significant (p .312).…”

Acute occlusion of aortic endovascular aneurysm repair stent graft with bilateral limb ischemia

“…Usually, the kinking of an AAA EVAR stent graft will occur at the level of the iliac artery limbs, with incidence of 1.5%, and contributes to lower extremity occlusion. 5 In the present case report, however, we have addressed a unique complication of AAA EVAR stent graft kinking at the level of the mid-body, which led to acute occlusion of the stent graft and bilateral iliac arteries. The graft in the present patient seemed to have migrated >5 mm from its original position, meeting the definition of stent displacement.…”