Lower Extremity Complications Following Endovascular Abdominal Aortic Aneurysm Repair: Midterm Results from a Concurrent Series

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Christopher J. LeCroy, MD, Mark A. Patterson, MD, Steve M. Taylor, MD, Gilberto C. Russo, MD, PhD, Bart R. Combs, MD, William D. Jordan, Jr., MD.
University of Alabama at Birmingham, Birmingham, AL, USA.

BACKGROUND:
Endovascular aneurysm repair (EVAR) is being utilized with increasing frequency and success. As midterm results accumulate considerable attention has focused upon management of temporal and procedural complications related to EVAR. The present study details our experience in managing arterial complications which have arisen in relation to EVAR - specifically involving the access and lower extremity arteries.

METHODS:
Review of a prospectively maintained vascular surgery database identified 490 patients undergoing EVAR for aneurysmal disease (aortic and iliac) between October 1, 1999 and December 31, 2004. Patients found to have experienced arterial complications involving the access arteries or lower extremities in relation to EVAR, were identified and data analysis performed using Fisher’s exact test.
RESULTS:
Between October 1, 1999 and December 31, 2004, 490 patients underwent EVAR for abdominal aortic (450), thoracic aortic (5), or iliac (35) aneurysmal disease. Mean aneurysm diameter at operation was: AAA = 5.59cm + 0.96 (standard deviation = SD), IAA = 4.07cm + 1.37 (SD), and TAA = 6.65cm + 1.34 (SD). Implanted stent graft devices included: Ancure (Guidant) = 195, AneuRx (Medtronic) = 179, Excluder (Gore) = 83, Zenith (Cook) = 21, Custom made = 7, Talent = 3, and Cordis = 2. Thirty three (6.7%) arterial complications were identified among the study group. Complications included - intraoperative iliac or femoral artery dissection (17), intraoperative iliac or femoral artery avulsion (5), lower extremity arterial embolization (6), post-operative stent graft limb thrombosis (acute (2), remote (2)), and common femoral artery false aneurysm (1). Techniques used to manage intraoperative events included: interposition graft (16), covered stent placement (7), thrombectomy (6), local repair/ patch angioplasty (2). One remote graft limb thrombosis was salvaged with thrombolysis, while a second required cross femoral bypass. One patient required extremity amputation. Thirty day mortality and major complication rate were increased among patients experiencing arterial complications, compared to those not experiencing access artery or lower extremity events: 8.8% vs 0.9% (p=.0088) and 17.6% vs 7.0% (p=.038), respectively. Length of hospital stay was likewise increased in the arterial complication group: 5.3 d (mean), range (2-20), compared to 3.0 d (mean), range (1-25) (p=.015).
CONCLUSIONS:
EVAR continues to provide a suitable alternative to open repair of aortic and iliac aneurysms. While relatively rare in frequency, access artery and lower extremity complications when present, are associated with increased perioperative morbidity, mortality, and length of stay. While various techniques are required to successfully manage these complications, overall extremity amputation rate remains low. In addition, access artery and lower extremity complications may prove to be a surrogate marker for high risk patients who undergo aneurysm repair.

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