Iatrogenic Injuries of the Common Femoral Artery (CFA) and External Iliac Artery (EIA) During Endograft Placement: An Underdiagnosed Entity

Objective: Early limb occlusions following endovascular treatment of aorto-iliac aneurysmal disease is not uncommon (4-13%). To assess whether the femoral artery entry site could potentially cause this complication, we prospectively evaluated the ipsilateral CFA and distal EIA with intraoperative duplex scans (IDS).
Methods: There were 134 patients with infrarenal nonruptured abdominal aorto-iliac aneurysms treated with endografts since 2002 at our institution. Age ranged from 65 to 89 years (mean 77±7 years). Aneuryx (n=41), Zenith (n=50) Excluder (n=43) endografts were used for repair. All procedures were performed via open exposure of the CFA. Introducer diameter varied from 12 mm to 22 mm. All patients underwent IDS of the CFA and distal EIA after repair of the arteriotomies.
Results:. In 34 patients (25%), we documented intimal dissections causing severe stenoses (>80%) stenoses. These were repaired with flap excision, tacking sutures revision or patch angioplasty. Repeat IDS confirmed the adequacy of the repair. No statistical difference was noted if the site of larger introducer sheath and the incidence of flap formation. In addition, 10 small flaps or plaques were visualized but not creating significant stenosis. No differences was noted in the incidence of positive duplex exams between each type graft (p=0.4). No early or late iliac limb occlusions were noted. 94 % follow-up was obtained.
Conclusions: Completion arterial duplex scans are helpful in detecting a substantial number of clinically unsuspected technical defects caused by introducer sheaths. Timely diagnosis and repair of these defects may decrease the incidence of early limb occlusion following endograft placement.