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Graft Limb Occlusion Following Endovascular And Open Repair Of Abdominal Aortic Aneurysm
Sachinder Singh Hans1, *Kevin Morton2, *Phillip Nahirniak1
1Henry Ford Health System, clinton township, MI;2Ascension St. John Macomb-Oakland, Warren, MI

OBJECTIVE(S): To assess the incidence, clinical patterns and outcomes of graft limb occlusion (GLO) following endovascular (EVAR) and open aneurysm repair (OAR).
METHODS: A retrospective study of patients undergoing EVAR and OAR from 1997-2017. In patients undergoing EVAR, ipsilateral and contralateral aorto-common iliac artery angle (A-CIA) and common iliac- external iliac artery angle (CIA-EIA) was determined. Diameter of EIA, graft extension to the EIA, prior CIA stent was recorded.
RESULTS: Of 973 patients, 604 had OAR and 369 EVAR, with mean follow up 9.1 +/- 2.1 years. Four patients (0.7%) following OAR had graft limb occlusion (GLO) as compared to 22 following EVAR (6.9%, p=<0.0001). Mean age, gender, size of AAA, and risk factors like HTN, CAD, DM and COPD were similar in patients with GLO and those without. A-CIA, CIA-EIA angle were similar in both groups. Small diameter EIA (6mm or less), graft extension to EIA, prior CIA stenting were significant predictors of GLO (Table). In the EVAR group 4 had unsupported grafts with GLO in 2 and remaining 315 had supported grafts with GLO in 20 (p=0.02). Three patients had GLO (within 1 month), all treated with thrombectomy and simultaneous axillo-femoral graft (2), 12 occurred (1-12 months) treated with thrombectomy (3) and fasciotomy (1), and crossover femoral-femoral graft (2) and 1 had open thrombectomy with graft extension to EIA. Seven patients had GLO (1-5 years) with crossover femoral-femoral graft (4), open thrombectomy with graft extension to EIA (1). One patient (4.5%) died following bilateral GLO (EVAR). One patient had AKA 3 years following axillo-femoral graft occlusion. All four patients with GLO following OAR had successful thrombectomy with simultaneous femoral-popliteal bypass graft in two.
CONCLUSIONS: Graft limb occlusion following EVAR is more common as compared to patients undergoing OAR with significant morbidity and mortality. Predictors of GLO following EVAR include unsupported graft, small diameter EIA, prior CIA stenting and graft limb extension to EIA. GLO following OAR presents acutely requiring emergent revascularization.

Table showing potential predictor contribution for graft limb thrombosis in EVAR
PredictorsNo Thrombosis (N=297)Thrombosis (N=22)P-valueOdds Ratio (95% C.I.)
Aorta-CIA Angle Left (<120)54 (18.2)3 (13.6)0.781.41 (0.40-4.93)
Aorta-CIA Angle Right (<120)48 (16.2)2 (9.1)0.551.93 (0.44-8.52)
CIA-EIA Angle Left (<120)147 (50.2)12 (54.5)0.830.84 (0.35- 2.00)
CIA-EIA Angle Right (<120)158 (53.9)11 (50.0)0.831.17 (0.49-2.78)
Small Diameter EIA Left (<6)2 (0.7)3 (13.6)0.00323.2 (3.64- 142.9)
Small Diameter EIA Right (<6)4 (1.4)4 (18.2)0.00113.0 (3.71-71.4)
Graft Extension (EIA)4 (1.4)4 (18.2)<0.00118 (4.1-78.6)
Prior CIA stenting5 (1.6)2 (9.1)0.00047.2 (1.3-40.0)


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