Long-Term Outcomes of Percutaneous Stenting of Aortic Endograft Limb Occlusion

Predictive Modeling of Endograft Limb Occlusion after Endovascular Aneurysm Repair: A Propensity Score Matching Analysis

BACKGROUND

Endovascular aneurysm repair (EVAR) is widely used to treat abdominal aortic aneurysm (AAA). However, it carries the risk of complications that often require further interventions. Endograft limb occlusion (ELO), though relatively rare, significantly affects patient outcomes. This study investigates factors influencing and predicting ELO risk after EVAR.

METHODS

All patients who underwent EVAR for AAA between 2013 and 2023 at the First Affiliated Hospital of Guangxi Medical University were examined. Patients were followed up and categorized into ELO and non-ELO groups. The groups were made comparable using propensity score matching. A prediction model was constructed using Lasso regression analysis.

RESULTS

The study included 425 AAA patients. After propensity score matching, the analysis involved 23 patients with ELO and 69 patients without ELO. All patients with the stent positioned distally in the external iliac artery were exclusively in the ELO group, indicating that the stent position variable perfectly predicted the outcome within our matched cohort. A predictive model was constructed using Lasso regression analysis, incorporating 3 variables: double iliac sign, surgical approaches, and iliac artery stent oversizing. Validation of the predictive model using the Hosmer-Lemeshow test demonstrated its excellent predictive capability, achieving an area under the curve of 0.91.

CONCLUSION

Double iliac sign, open surgical approaches, and iliac artery stent oversizing (>50%) emerged as independent risk factors for ELO occurrence in AAA patients undergoing EVAR. The position of the stent in the external iliac artery independently predicts ELO and directly indicates a high-risk situation. Our predictive model aids in risk stratification and clinical decision-making, thereby improving patient outcomes.

Penumbra Indigo Percutaneous Aspiration Thrombectomy System in the treatment of Aortic Endograft Iliac Limb Occlusion: Results from an Italian Multicentre Registry

OBJECTIVE

This study aimed to evaluate the safety and effectiveness of the Penumbra Indigo percutaneous aspiration thrombectomy (PAT) system in the clinical presentation of iliac limb occlusion (ILO) after endovascular aortic repair (EVAR).

METHODS

A retrospective, observational, multicentre study conducted in eight Italian vascular centres. Consecutive patients presenting with ILO after EVAR were eligible. To assess vessel revascularisation, Thrombo-aspiration In Peripheral Ischaemia (TIPI) classification (score 0-3) was used at presentation (t1), after PAT (t2), and after adjunctive procedures (t3). Successful revascularisation was considered TIPI 2-3 (near complete or complete). Primary intra-operative outcomes were technical success (TS) of Indigo PAT and combined TS of PAT associated with adjunctive procedures when needed. Primary follow up outcomes were safety and effectiveness at one, six, and 12 months.

RESULTS

From September 2019 to December 2021, there were 48 ILO and 17 patients (35%) [median age 75 years, IQR 71, 83 years; male, 14 (82%); urgent, 8 (47%)] were treated and enrolled. The median time after primary EVAR was 24 months (IQR 0, 42 months). The median clot age from ILO diagnosis to PAT was three days (IQR 1, 12 days). Ten patients (59%) presented with limb threatening ischaemia. At t1, TIPI 0 and 1 was present in 13 (76%) and four (24%) cases, respectively. At t2, primary TS (TIPI 2-3) was achieved in 14 cases (82%) after Indigo PAT (p < .001). Fifteen patients (88%) required adjunctive procedures (14 re-linings, one surgical patch angioplasty). At t3, combined TS was achieved in 16 cases (94%). Intra-operative complication included one (6%) distal embolisation, treated successfully. The 30 day mortality was one case (6%) due to pneumonia. At one, six, and 12 months, clinical success was 100% without ILO recurrence. The median follow up was 23 months (IQR 11, 41 months): at 18 months, survival and freedom from re-intervention were 91 ± 8% and 90 ± 9%, respectively.

CONCLUSION

This study reports for the first time the efficacy and safety of Penumbra Indigo PAT for ILO after EVAR, with promising technical and clinical success up to one year.

Endovascular recanalization and remodeling of abdominal aorta stent graft chronic total occlusion after failed extra-anatomic bypass surgery

OBJECTIVES

Chronic total occlusion (CTO) of the EVAR graft is a rare and serious complication. Traditionally, surgical intervention with prosthetic graft replacement or bypass graft implantation is performed. However, there are limited data in endovascular era.

METHODS

We present a case of a 68-year-old male with a history of late EVAR graft occlusion treated with multiple surgical interventions (femorofemoral crossover, extra-anatomic bypass surgery, and thrombectomy) five years ago. Color Doppler ultrasound (CDUS) and computed tomography (CT) angiography revealed thrombosis of the entire bypass graft. Endovascular recanalization and remodeling of the abdominal stent graft CTO was performed with a combination of bare stents and stent grafts. Rupture of the stent graft occurred on the right limb. A second covered stent was placed.

RESULTS

At 12-month follow-up, the patient was symptom free. Color Doppler ultrasound surveillance showed patent aortic stent graft and downstream arteries.

CONCLUSIONS

Endovascular recanalization of aortic stent graft CTO is a viable option in patients with failed bypass graft.

Results of adjunctive stenting with high-radial force stents to prevent or treat limb occlusion after EVAR

BACKGROUND

The aim of this study was to report the results of a multicenter experience on the use of adjunctive stents deployed inside abdominal aortic endografts with the purpose to prevent or treat limb occlusion after endovascular aneurysm repair (EVAR).

METHODS

Between 2010 and 2018, there were 35 patients with aorto-iliac aneurysm presenting one or more risk factors for endograft limb occlusion (narrow aortic bifurcation and/or stenotic, highly angulated or occluded iliac arteries), who were treated with standard bifurcated stent graft reinforced by the means of a single model of balloon-expandable platinum/iridium bare stent (CP Stent; NuMED, Inc., Hopkinton, NY, USA). Technical success, mortality, limb patency and reintervention rate during follow-up were the main endpoints assessed.

RESULTS

Technical success was 100%. No patients died perioperatively and no major complication was registered. During a mean follow-up of 48 months (range 1-87), neither aortic-related death nor secondary intervention was registered. At a mean follow-up imaging of 39.4 months (range 1-81) no endograft limb lost its patency.

CONCLUSIONS

The use of high-radial force balloon-expandable stents deployed inside bifurcated endografts to prevent or treat limb occlusion is a safe and effective adjunctive procedure, with outstanding long-term outcomes in terms of patency and reinterventions.