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140 M.J. Sideman and K.E. Taubman
grafts, and technique for deployment. This group of complications can include
dissection , rupture , embolus , thrombosis , lymphocele , pseudoaneurysm , and
infection .
Arterial Dissection
Arterial dissection may occur in the iliac vessel related to difficulty with the
initial arterial access and placement of the introducer sheath. Several local
factors will increase the risk of these events. This includes a disproportion-
ately large sheath size requirement in relation to the native access vessels,
concomitant occlusive disease of the access vessels, and tortuosity/angulation
of the iliac vessels.
Preoperative imaging in the form of CT angiography and MR angiography
is invaluable to avoid these pitfalls. In these circumstances, potential adjunc-
tive maneuvers to prevent arterial dissection include predilation angioplasty
of the iliac vessels prior to EVAR sheath placement, utilization of smaller
access sheaths when possible, stiffer wires to aid in sheath placement, use of
hydrophobic sheaths, and/or lubrication of the sheath with sterile mineral oil.
Sheath placement should be done under fluoroscopic guidance and insertion
halted for any significant resistance. Consideration should be given to using
the contralateral side for the larger sheath access if amenable or conversion
to an iliac conduit if unable to place the sheath in the native femoral or distal
iliac artery.
If an arterial dissection does occur, it often remains undetected until com-
pletion of the EVAR graft deployment and upon removal of the access sheath.
Also referred to as “iliac on a stick,” large pieces of the dissected intima may
be expelled after the sheath is removed. The dissected intima may also remain
in the aorta or iliac arteries creating either an immediate or a delayed presenta-
tion of a flow-limiting stenosis or distal embolization. From our experience,
we encountered the circumstance of an iliac dissection in the setting of a
thoracic aortic EVAR that presented on the night of surgery with an acutely
ischemic contralateral limb related to this mechanism. Upon exploration, the
intima from the dissection of the right iliac system had embolized to the left
popliteal artery (Fig. 2a and b ).
Diagnosis and treatment of an iliac dissection requires a high index of suspi-
cion. After closure of the access site, if the inflow into the limb is poor or the
Doppler signals in the extremity are diminished in comparison to the preopera-
tive examination, an arterial dissection should be considered. An arteriogram
is indicated for any abnormal vascular examination findings to delineate the
underlying anatomy. If a dissection is identified, the options for repair relate
to the location and extent of the process. This may include endovascular
procedures such as angioplasty and stenting. In the setting of failed endovascular
therapy, an extra-anatomic bypass (e.g. femoral-femoral, axillary-femoral) is
an alternative to reestablish arterial inflow. An arterial dissection that results
in distal emboli should be treated with balloon thromboembolectomy or open
embolectomy as the circumstances dictate.
Arterial Rupture
Rupture of the iliac artery occurs from persistent attempts to place large sheath
access in iliacs that are too small, too diseased, and/or too tortuous. Iliac rupture
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Chapter 8 Complications Secondary Procedures after Elective Endovascular 141
should be suspected when the patient experiences sudden pain or hemody-
namic instability. Arteriogram will confirm retroperitoneal extravasation and
hemorrhage. This should be controlled with inflation of balloons in the iliac
to regain hemodynamic stability with appropriate resuscitation and transfusion
of the patient by the anesthesiologist. Consideration should be given to open
conversion at this time. If the rupture is small and the patient is hemodynami-
cally stable, an endovascular solution can be attempted. This would involve
placement of a covered stent across the perforation if wire access is maintained
through the true lumen. If the hemorrhage is controlled with these maneuvers
and the patient is stable, completion of the EVAR can be done. If the rupture
Fig. 2 ( a ) Arteriogram of left lower leg after distal embolization of iliac intima.
( b ) Iliac intima removed from the popliteal artery after exploration.
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142 M.J. Sideman and K.E. Taubman
is controlled, but the patient remains unstable, the EVAR should be aborted. If
the rupture cannot be repair with covered stenting, open surgical conversion is
necessary to prevent hemorrhagic death.
Embolus
Distal emboli can occur from the access site causing distal limb ischemia.
These emboli can be intima from a dissection (as described above), athero-
emboli from diseased iliac or common femoral arteries, or thrombotic from
formation of clot on the sheath or in situ due to low flow distal to the large
sheath access. It is imperative that the patient’s distal vascular examination be
documented prior to beginning the operation and reexamined after comple-
tion of the EVAR and closure of the access sites. Any significant change from
preoperative baseline warrants further investigation with a runoff arteriogram.
Treatment is then directed by the arteriogram findings but likely would require
balloon thromboembolectomy and/or open thromboembolectomy. Treatment
of distal emboli can be accomplished easily enough with open groin access.
The problem becomes more challenging if percutaneous access is used for
placement of the sheath(s).
Thrombosis
Access site thrombosis can occur acutely at the time of EVAR or subacutely
presenting in the early postoperative period.
37
This is more likely to happen
when accessing and then closing heavily diseased arteries. Whether using
open arteriotomies or percutaneous access, if there is significant disease
present at the access site, the lumen can be compromised with the repair.
The artery should be examined if doing open access for disease after removal
of the sheath. If it is extensive, consideration should be given to performing
a local endarterectomy to prevent narrowing of the artery after closure. In
extreme cases, replacement of the access artery with an interposition graft
is necessary. For percutaneous access, closure devices can narrow the access
vessel leading to thrombosis. Careful evaluation of the preoperative imaging
should be undertaken before choosing to puncture an access artery percuta-
neously and use a closure device. Any heavily diseased or calcified arteries
should be exposed surgically for sheath placement. If thrombosis occurs after
percutaneous access and closure, the groin should be explored surgically and
repaired as needed.
False Aneurysms
False aneurysms (FAs), or pseudoaneurysms, are defined by the absence of
involvement of all three histological layers of the arterial wall. They may occur
after EVAR regardless of whether the access is obtained via an open or percu-
taneous technique. However, the incidence is more common after percutaneous
access and with newer generation devices of a size now capable of performing
EVAR with percutaneous delivery, the occurrence may increase. Newer arterial
closure systems may help to reduce this risk. A recent report of one device sug-
gested a late complication rate of only 2% related to access closure.
38
Risk factors for the development of these complications relate to access
sheath size ( ³ 7 FR), obesity, female gender, periprocedural anticoagulation,
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Chapter 8 Complications Secondary Procedures after Elective Endovascular 143
high/low femoral access entry sites, and perivascular infection. Diagnosis
is made by either contrast-enhanced helical CT or MR angiography, Duplex
sonography, or in some cases selective angiography.
Although there are a number of options for treating this complication
including percutaneous thrombin and endovascular stenting, FAs detected
after EVAR are likely best treated by open surgical exploration and repair.
Typically, the defect in the artery is large related to either the percutaneous
access sheath or the result of suture-line bleeding in open access circum-
stances. In the face of a wide-neck FA, thrombin injection may carry a prohibi-
tive risk of native vessel thrombosis.
39
Lymphocele
A lymphocele is a rare complication of open groin exposures. It is the result
of a persistent lymphatic leak into the surgical site causing an accumulation
of lymph. Often poor healing of the wound will result. There has been some
debate as to whether the occurrence of this complication is higher in the set-
ting of transverse/oblique versus vertical incisions.
40
Aggressive treatment
of this complication in the setting of vascular procedures has been shown to
reduce the subsequent wound infection rate.
41
Local Wound (Surgical Site) Infections
Wound infections account for approximately 3% of the morbidity of
EVAR, and when further examining for the occurrence of severe infection,
this risk further diminishes to less than 1%.
19,
20
Typical skin flora such as
Staphylococcus and Streptococcus species are common offending organisms.
Infection may range from mild cellulitis to wound dehiscence with purulent
drainage. Treatment involves surgical debridement of devitalized tissue and
culture-directed antibiotics. Rarely does the extent of infection require arte-
rial reconstruction. However, if encountered to this level of severity, the same
principles practiced in the setting of graft infections should be applied in terms
of both in situ and extra-anatomic revascularization.
Strict adherence to sterile technique and judicious administration of appro-
priate perioperative antibiotics are necessary to decrease the incidence of
surgical site infections. Tight control of blood glucose in the postoperative
period has also been shown to substantially reduce the incidence of surgical
site infections in cardiovascular surgery.
42
Uncommon Complications
Spinal Cord, Colonic, and Pelvic Ischemia
The occurrence of pelvic, spinal, and colonic ischemia following EVAR of the
infrarenal aorta is uncommon. Paraplegia following EVAR in the infrarenal
aorta remains low with an estimated occurrence of 0.21%.
43,
44
However,
when present, this complication carries significant morbidity and mortality.
This may occur in the setting of postgraft deployment or as a complication
of secondary interventions to treat endoleak. Several papers have described
an increased association between the appearances of this complication
in the setting of perioperative embolization of the hypogastric arteries.
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144 M.J. Sideman and K.E. Taubman
Preservation of one or both of the internal iliac arteries is typically
recommended.
Similarly, the occurrence of colon and pelvic ischemia also remains accept-
ably low, but again when manifested may lead to a higher risk of death and
disability. Based upon several trials, clinically significant colon ischemia only
appears in 0.6–1.4% of cases.
19,
20,
44,
45
Patients clinically presenting with aneu-
rysm rupture and those requiring extended procedures appear to have elevated
risk even in the setting of EVAR.
45
Mechanisms in colon ischemia appear to
extend beyond interruption of formerly patent hypogastric vessels or the infe-
rior mesenteric artery and may also relate to a complication of both macro- and
microembolization to the capillary bed. Mortality in this setting was correlated
with the amount of embolized material.
46
Graft Enteric Fistula
An uncommon complication that was originally thought to only occur after
open AAA repair is graft enteric fistula. This complication occurs approxi-
mately 1% of the time after open repair.
47
It is a catastrophic condition where
the graft material erodes through an overlying segment of bowel. This results
in bacterial contamination of the graft material and potentially massive GI
bleeding. This has now been reported to occur after EVAR as well.
48,
49
The
presence of graft enteric fistula mandates explantation of the graft, repair of
the enteric fistula, and either extra-anatomic bypass or reconstruction of the
aorta with autogenous tissue. As described above, surgical treatment of this
problem carries significantly high morbidity and mortality for the patient.
Traditional therapy involves intestinal resection and explantation of the graft
with either extra-anatomic or in-line reconstruction.
Conclusion
Although EVAR has expanded treatment of AAA to patients who were previ-
ously unfit for open repair with lower overall morbidity and mortality, these
procedures are not without their complications. The responsible treating phy-
sician should be familiar with all possible complications, counsel their patients
extensively on their causes, implications, and treatment, and be prepared to
treat any complication that arises.
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Chapter 8 Complications Secondary Procedures after Elective Endovascular 147
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Abstract Fenestrated stent-grafts are designed to treat short-neck abdominal
aortic aneurysms. Thanks to customized fenestrations, patency of side branches
such as the renal arteries and the superior mesenteric artery can be maintained,
whilst positioning the graft across these aortic branches.
Stent-graft design improvement and technical refinements advanced the
technique from experiment to a clinical application. In addition, further develop-
ments made it possible to treat juxtarenal, suprarenal, and some thoraco-
abdominal aortic aneurysms (TAAA).
This chapter discusses the principles of the technique, the refinements in
recent years, and the resulting applications. In addition, our results with this
technique are here summarized.
Keywords
Aortic aneurysm , Endovascular , Stent-graft , Fenestration , Branch
Introduction
During the last decade, endovascular aortic aneurysm repair (EVAR) has
become an accepted alternative to open repair. Two prospective randomized
trials have demonstrated short-term benefits compared to open surgery.
1,
2
Although mid-term results of these two trials were disappointing due to a
greater number of late complications and reinterventions in the endovas-
cular group, the technique has continued to evolve with a clear trend towards
increased durability and less reinterventions.
3,
4
However, EVAR is still limited
by certain aortic anatomical conditions: the technique is applicable only
to infrarenal aneurysms with suitable proximal and distal landing zones to
achieve a proper sealing. Sufficient calibre access vessels are mandatory to
allow device insertion. Distally, adverse anatomy can usually be overcome
with adjunct techniques, but a proximal neck is essential to achieve sealing
and a long-lasting result. The Eurostar registry has demonstrated that EVAR
in proximal necks shorter than 15 mm is associated with a higher risk of
complications.
5
Consequently, an important number of aneurysms still have to
Chapter 9
Fenestrated Endovascular
Stent-Grafts: Current Applications
E.L.G. Verhoeven, C.J. Zeebregts , I.F.J. Tielliu , T.R. Prins, W.T.G.J. Bos,
A.O. Sondakh , and J.J.A.M. van den Dungen
G. Upchurch and E. Criado (eds.) Aortic Aneurysms, Contemporary Cardiology
DOI: 10.1007/978-1-60327-204-9_9, © Humana Press, a part of
Springer Science + Business Media, LLC 2009
149
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150 E.L.G. Verhoeven et al.
be classified as unsuitable for standard EVAR. On the other side, open repair
of these short-necked and pararenal aneurysms is also associated with higher
mortality and morbidity rates.
6,
7
The fenestrated stent-graft technique was developed in order to provide a solu-
tion to a neck unsuitable for standard EVAR. By using customized fenestrations
to incorporate both renal and the superior mesenteric arteries, it is possible to
treat these complex aneurysms by endovascular means.
This chapter discusses the basic principles of the fenestrated technique. Then,
important changes in stent-graft design and technical refinements will be high-
lighted, and the current applications will be elaborated. To conclude, limitations
of the technique will be addressed, followed by a summary of our results.
Principles and Technique
The fenestrated technique aims at achieving a durable seal in a short neck by posi-
tioning the first sealing stent proximal to the renal arteries or beyond the superior
mesenteric artery, if necessary. Custom-made fenestrations are designed to maintain
the patency of these vital side branches. The fenestrations allow positioning of the
proximal sealing stent inside the suprarenal aorticneck, to provide a stable and dura-
ble anchoring of the graft. The different types of fenestrations have been described
before.
8
A “standard” fenestrated graft usually involves two small fenestrations
for the renal arteries and a scallop for the superior mesenteric artery, but other con-
figurations are possible to conform to each patient's anatomy (Fig. 1 ).
Fig. 1 A standard fenestrated stent-graft including two small fenestrations for the renal
arteries and a scallop for the superior mesenteric artery
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