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.

Broadening the applicability of endovascular aneurysm repair: the use of iliac conduits.

OBJECTIVE: Suboptimal iliac anatomy has sometimes precluded endovascular repair of abdominal aortic aneurysm (AAA). In an effort to increase the applicability of endovascular repair, a limited retroperitoneal approach and iliac conduit was used in some patients with unsuitable iliac anatomy at high risk for open repair. METHODS: Charts and imaging studies of 312 patients who underwent endovascular (AAA) repair at the Cleveland Clinic Foundation between June 1999 and November 2000 were reviewed. Among these, 22 patients with complex iliac anatomy had an iliac conduit placed. Seventeen of these procedures were planned, but five were unplanned and placed after an iliac artery injury. A group of 17 patients who underwent a standard endovascular repair without conduits was selected and matched to the 17 patients in the planned conduit group by baseline comorbidities. The conduits were 8-mm or 10-mm polyester grafts sewn proximally to the common iliac artery and provided unobstructed access to the aneurysm. After insertion of the endograft device through the conduit, the distal end of the conduit was anastomosed to the external iliac or common femoral vessels. RESULTS: Operative time and estimated blood loss were higher among patients in whom conduits were performed, especially when performed urgently as an unplanned procedure. Although operative time and intensive care unit and hospital stays were longer for the group of patients with iliac conduits, the cardiac pulmonary and renal complication rates were similar for the conduit and the standard endovascular repair group. CONCLUSION: The use of a limited retroperitoneal approach and iliac conduit for patients with difficult iliac anatomy increases the applicability of the endovascular repair of AAA. This technique should be considered when an open surgical approach is inadvisable on the basis of medical comorbidities.