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Abstract Acute limb ischemia is a potential complication of open surgical
and endovascular repair of abdominal aortic aneurysms. This complication
may present in the early postoperative period or late in follow-up and may
be related to technical, patient, and/or graft-related factors. For endovascular
aneurysm repair, device-specific factors have been associated with endograft
limb occlusion and consequential limb ischemia.
Keywords Limb occlusion , limb ischemia
Introduction
Both open surgical and endovascular aneurysm repair (EVAR) are effective
forms of treatment for infrarenal abdominal aortic aneurysms (AAAs).
1
Acute
limb ischemia may potentially complicate either treatment modality
2
and may
add considerable morbidity to the patient’s outcome. Arterial occlusion may be
detected intraprocedurally during either form of intervention or it may present
in the postoperative period. Postoperatively, patients with arterial occlusion
may develop classical clinical symptoms of acute limb ischemia. The severity
of these symptoms depends on the degree and level of arterial occlusion, and
this may threaten the viability of the affected lower extremity. Once identified
and if clinically indicated, an operative or endovascular intervention must be
initiated to minimize the potential for tissue loss. Several technical or patient-
related factors may place the patient at risk for this complication. Additionally,
graft or endograft-related factors may result in graft/endograft limb occlusion,
and this complication must be appropriately addressed in order to reestablish
and maintain perfusion to the affected lower extremity. While well-known
factors such as distal arterial stenosis or occlusion enhance the risk for limb
occlusion following open surgery or EVAR, other endograft-specific factors
unique to EVAR should be considered in order to minimize or address this
potential complication.
Chapter 22
Acute Limb Ischemia After Abdominal
Aortic Aneurysm Repair
Paul J. Riesenman and William A. Marston
G. Upchurch and E. Criado (eds.) Aortic Aneurysms, Contemporary Cardiology
DOI: 10.1007/978-1-60327-204-9_22, © Humana Press, a part of
Springer Science + Business Media, LLC 2009
315
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316 P.J. Riesenman and W.A. Marston
Open Surgery
The etiology of acute limb ischemia following open surgical reconstruction
of an AAA is primarily related to the time of presentation. Acute ischemic
events in the early postoperative period usually are related to intraoperative
technical problems, whereas patients who present with acute limb ischemia
during follow-up will most likely have graft-limb occlusion due to inadequate
outflow from progressive atherosclerotic disease of their distal arterial vessels.
In either situation, the potential for a proximal embolic source is a possibility
and should be evaluated if clinically indicated.
Early/Postoperative Limb Ischemia
Early postoperative acute limb ischemia following open AAA repair has an
incidence of 1.7–3%.
2–
4
This complication is one of the most common indica-
tions for an additional intervention following the initial surgical procedure.
3
Many of the causes of acute limb ischemia in this setting may be directly
attributed to the operative procedure including embolization, arterial injury,
and graft-related complications.
Embolization of atheroembolic debris or intramural thrombus mobilized
during operative exposure and vessel clamping may result in distal arterial
occlusion and acute ischemic changes in the lower extremities immediately fol-
lowing open AAA repair. Additionally, embolic material may gain access to the
distal vasculature if a thorough intraluminal irrigation is not performed prior to
completion of the distal anastomosis. The size of these particles will often be
small, and the clinical relevance of these microemboli is variable as ischemic
changes are often transient and do not result tissue loss, although patients with
advanced peripheral arterial disease may be more vulnerable in this setting.
The femoral vessels in patients with aneurismal disease are typically calcified
to a varying degree, and many patients also have significant intraluminal obstruc-
tion leading to challenges in access and closure of these vessels. Technical issues
that may lead to thrombosis and limb ischemia include clamp trauma, raising an
intimal flap, and narrowing of the vessel lumen at the time of closure.
A careful consideration of placement of the surgical graft can minimize
potential graft-related complications which may manifest as acute limb
ischemia. Avoidance of heavily calcified areas of the common femoral artery
by use of the proximal superficial femoral artery (SFA) or profunda femoral
artery (PFA) is a useful alternative. We commonly perform anastomoses to
the distal common femoral artery with profundaplasty to optimize outflow,
particularly in patients with occluded SFAs. In heavily calcified arteries, con-
sideration should be given to the use of intraluminal balloon occlusion of the
inflow from the iliac artery to avoid the use of clamps that may crush the artery
leading to potential embolization or intimal flaps. Patients presenting with
occlusion of the SFA and severe PFA disease should undergo concomitant
procedures to reopen either the SFA or the PFA to provide adequate graft limb
outflow and reduce the risk of early limb thrombosis.
Kinks or external compression of the prosthesis by surrounding structures
may impede outflow leading to obstruction and/or thrombosis. Care should be
taken to avoid external compression of the graft during reapproximation of the
aortic wall and periaortic tissues. If the aortic wall or periaortic tissues cannot
adequately cover the graft from adjacent bowel without constriction, an omental
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Chapter 22 Acute Limb Ischemia After Abdominal Aortic Aneurysm Repair 317
flap can be utilized; however, the aortic wall is usually not limiting as this is
redundant in aneurysmal disease. Redundant length in the graft limbs should
also be minimized as this may be a potential source of graft kinking.
The assessment of the limbs immediately after aneurysm repair is a
critical component of the procedure. After reperfusion of the femoral ves-
sels, arteries should be interrogated with a Doppler or duplex scanner for
evidence of adequate flow. Distal pulses and/or Doppler signals should
also be confirmed and the limb must be examined carefully to ensure that
adequate perfusion is present. The optimal time to correct lower extremity
perfusion problems is prior to leaving the operating room in order to mini-
mize the potential for irreversible tissue loss. If any questions concerning
the adequacy of lower extremity perfusion are raised, immediate evaluation
with duplex ultrasound scanning or arteriography should be performed.
The choice of these methods depends on availability and patient related
factors. We favor duplex scanning in patients with contraindications to con-
trast administration and in cases where the question concerning perfusion
arises after closure of the incisions has been completed. Otherwise, we
favor intraoperative angiography as long as this is rapidly available in the
operative suite. Based on the results of the diagnostic study, correction of
the perfusion problem is immediately performed. Consideration should be
given to four compartment fasciotomy based on the duration and extent of
limb ischemia prior to reperfusion.
Late Limb Ischemia
Late acute limb ischemic events following open AAA repair are most likely a
consequence of progressive occlusive processes in the distal arterial vessels.
Distal atherosclerotic disease and intimal hyperplasia at the distal anastomotic
sites may make the graft limbs prone to thrombosis as outflow is impeded.
The incidence of late graft-limb occlusion has been reported to range from
0.1% to 5.3% in long-term durability studies through variable follow-up.
5–
8
Biancari et al. reported on 208 operative survivors of elective and emergent AAA
repair with a mean follow-up of 8 years.
5
Eleven patients (5.3%) developed graft
limb occlusion during follow-up, with four of these cases attributed to distal
occlusive processes. Adam et al. reported on 957 patients treated for nonruptured
AAAs over a mean follow-up of 41 months.
6
Eleven cases (1.1%) of limb occlu-
sion necessitating a secondary intervention were reported, with only one of these
occurring during the patient’s initial hospitalization for their AAA repair. In a
review of 1047 cases performed at the Cleveland Clinic by Hertzer et al., only
one case (0.1%) of late limb occlusion was identified during a mean follow-up
of 57 months.
7
Additionally, Hallet et al. reported on 307 patients treated at
the Mayo clinic and found a 2% ( n = 6) incidence of graft thrombosis with the
majority of these cases occurring at more than 30 days.
8
Both of these later stud-
ies were strengthened by their efforts to establish long-term follow-up.
Late graft limb occlusion can potentially be minimized by clinically moni-
toring patients for symptoms of peripheral arterial disease. Routine graft scan-
ning with duplex ultrasound is not warranted given the low incidence of late
problems, so further evaluation is only recommended when symptoms develop
at follow-up. Areas of stenosis at the anastomotic sites or distal arterial vessels
may require operative or endovascular intervention to ensure adequate distal
runoff from the graft limbs.
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318 P.J. Riesenman and W.A. Marston
Endovascular Aneurysm Repair
As with open surgery, acute limb ischemia following EVAR is a recognized
complication of this form of intervention, and has been reported to occur in
1.3–6.8% of patients.
4,
9
Although limb ischemia is largely attributed to endog-
raft limb occlusion, similar etiologies as those describe for open repair may be
the cause of this complication following EVAR.
9
The potential risk of endog-
raft limb occlusion has been associated with endograft design-specific factors,
as well as technical considerations at the time of EVAR (Fig. 1 ).
Endograft Limb Occlusion
Endograft limb occlusion has been reported to be a common complication
necessitating intervention following EVAR.
10
This complication tends to be
detected intraoperatively or in the early postoperative period, with approxi-
mately half of reported cases occurring within approximately 30 days.
11,
12
Early studies reporting high rates of endograft limb occlusion involved endog-
rafts with an unsupported configuration.
13–
15
Additionally, some anatomic
characteristics and procedure-related risk factors have been associated with
this complication (Fig. 2 ).
Anatomic Considerations
Proper preoperative evaluation and consideration of the patient’s vascular
anatomy are essential for minimizing the potential of endograft limb occlu-
sion. Patients with clinical symptoms or physical examination findings con-
cerning for peripheral arterial disease should undergo further evaluation as
distal arterial outflow stenoses or occlusions are risk factors for graft occlusion.
Although the iliac arterial system is routinely interrogated for luminal diameter
Fig. 1 Abdominal radiograph in a patient presenting with acute onset claudication
3 months after endovascular repair of an abdominal aortic aneurysm with extensive
bilateral iliac involvement necessitating endograft limb deployment in the external iliac
artery. A kink is appreciated in the distal endograft limb ( arrow )
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Chapter 22 Acute Limb Ischemia After Abdominal Aortic Aneurysm Repair 319
and tortuosity in order to assess delivery sheath accommodation, these
characteristics also affect the patency of endograft limbs. As opposed to open
repair, where the surgeon has the advantage of constructing an unimpeded
course for the graft limbs, endograft limbs must conform to the tortuosity,
tapering, and intraluminal compressive forces of the iliac arteries.
Several anatomic characteristics of the aortoiliac system have been associ-
ated with endograft limb occlusion. At the aortic bifurcation, risk factors asso-
ciated with limb occlusion include angulation of the iliac origin in relation to
the course of the iliac artery, abrupt luminal transition from the aorta to the iliac
system, and extrinsic compression from thrombus within the aneurysm or from
the contralateral endograft limb.
15
A limiting aortic diameter at this level may
potentially be overcome through the use of a kissing endovascular balloon tech-
nique during limb deployment, or use of an aortomonoiliac endograft design.
Tortuosity and regions of stenosis secondary to atherosclerotic disease encoun-
tered throughout the course of the iliac system may also contribute to endograft
limb occlusion as these may result in limb kinks and extrinsic compression.
Additionally, extension of the endograft limb into the external iliac artery has
also been associated with endograft limb occlusion.
11,
16
Although this associa-
tion may be a consequence of the smaller arterial diameters encountered in the
external iliac artery, it has been suggested that the loss of hypogastric artery
outflow may contribute to endograft limb occlusion in this setting.
16
Although angiographic evaluation may reveal an optimal technical result at
the conclusion of the initial endovascular procedure, endograft limb patency
remains at risk due to conformational changes in the endograft as it adapts to
aneurysmal remodeling over time. Reductions in aneurysm sac length have
been associated with endograft buckling and kinking.
17
Additional observations
have noted that late endograft kinking may be more likely, and present earlier,
when the arterial vessels are more tortuous at the time of EVAR.
18
Fig. 2 ( a ) Arteriogram of a left endograft iliac limb following catheter-directed thrombolysis for acute limb
thrombosis. A distal kink and luminal filling defect is observed in the distal endograft limb ( arrow ). ( b )
Completion arteriogram following placement of a 12 × 60 mm Luminexx stent (C.R. Bard, Inc., Murray Hill, NJ)
and balloon angioplasty
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320 P.J. Riesenman and W.A. Marston
D evice-Specific Considerations and Outcomes
General conclusions about the anticipated frequency endograft limb occlu-
sion are difficult to make, given the variability in endograft design. Several
single-institution studies describing the frequency of endograft limb occlu-
sion have been reported with this complication occurring in 0.6–45.6% of all
patients who have undergone EVAR
9,
11–
16,
18–
22
(Table 1 ). Conclusions from
these studies are difficult to make, given different definitions of limb compli-
cations (kinking, stenosis, occlusion, and/or thrombosis), variable follow-up,
Table 1 Studies reporting endograft limb complications following EVAR.
Study Year Patients Limbs at risk Endograft(s)
Limb complications
a
(%)
Follow-up
(months) Patients Limbs
Umscheid et al.
18
1999 264 528 14.0 7.8
124 248 Vanguard
81 162 Stentor
41 82 Talent
18 36 AneuRx
Tillich et al.
19
1999 33 66 Vanguard 9.1 4.5 8.8
Baum et al.
20
2000 89 149 14.6 12.1 10.6
74 122 Talent 6.8 4.9
15 27 Ancure 53.0 44.0
Amesur et al.
13
2000 68 130 Ancure 45.6 36.2
Carpenter et al.
15
2001 173 310 7.7 9.7
111 189 Talent 3.7
31 59 Ancure 28.8
25 50 AneuRx 0.0
4 8 Lifepath 0.0
2 4 Zenith 0.0
Krajcer et al.
21
2002 40 80 Ancure 15.0 8.8
Parent et al.
14
2002 67 125 Ancure 23.8 11.2 15.9
Carroccio et al.
16
2002 351 702 7.4 3.7 20
255 510 Talent 7.8 3.9
35 70 AneuRx 2.8 1.4
25 50 Excluder 0.0 0.0
18 36 Vanguard 22.2 11.1
10 20 Teramed 0.0 0.0
8 16 Ancure 12.5 6.3
Erzurum et al.
11
2004 823 2.7
373 746 Zenith 2.4 1.2
230 460 AneuRx 2.6 1.3
68 136 Ancure 10.3 5.1
61 Other 0.0
39 78 Talent 5.1 2.6
30 60 Excluder 0.0 0.0
22 44 Quantum 4.5 2.3
Maldonado et al.
9
2004 311 4.8 22.5
238 Ancure 5.9
30 Excluder 0.0
28 AneuRx 3.6
15 Zenith 0.0
Sivamurthy et al.
12
2006 248 486 Zenith 5.2 2.7 24.0
Hiramoto et al.
22
2007 325 650 Zenith 0.6 0.3 27.5
a
Kinking, stenosis, occlusion, and/or thrombosis
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Chapter 22 Acute Limb Ischemia After Abdominal Aortic Aneurysm Repair 321
inclusion or exclusion of adjunctive limb procedures at the time of EVAR,
and inclusion of multiple endograft designs. It is more instructive to look at
each device design and its associated incidence of limb thrombosis, including
some devices no longer in the market to consider design issues related to this
complication.
The Ancure endograft (Guidant, Menlo Park, CA) was the first commer-
cially manufactured device to be placed into clinical trials in the United States
and is no longer available on a commercial basis. This device was constructed
as an unsupported bifurcated or aortomonoiliac configured endograft. This
unsupported design was initially employed due to its smaller size, conform-
ability, and ability to traverse tortuous iliac anatomy at the time of deployment.
The lack of structural support made it prone to external compression, as well
as developing folds in the graft material secondary to size mismatch between
graft and vessel. High rates of endograft limb occlusion led to the practice
of reinforcing these limbs with intravascular stents as both an intraoperative
therapeutic
15
and a prophylactic measure.
23
Amesur et al. reported on a series of patients treated with the Ancure device
and noted that 47 of 130 limbs treated (36%) required reinforcement with
stents due to luminal compromise at the time of deployment or during follow-
up.
13
They noted that none of the patients who underwent limb reinforcement
with adjunctive limb stenting experienced endograft limb occlusion through a
mean follow-up of 14 months.
Parent et al. reported an overall incidence of endograft limb stenosis or
occlusion of 23% in 67 patients using the Ancure endograft.
14
Nine patients
(13%) underwent endograft limb stenting for abnormalities noted upon com-
pletion angiography, and none developed endograft limb complications dur-
ing a mean follow-up of 15.9 months. The remaining 58 patients had normal
appearing endograft limbs at the conclusion of EVAR and did not undergo
adjunctive stenting. Seven (12%) of these patients developed limb stenosis or
occlusion during follow-up; three of which presented with acute lower extremity
ischemia necessitating operative intervention.
In a study including 823 patients treated with either the Ancure device or
one of several supported endograft designs, Erzurum et al. reported a median
time to limb occlusion of 34.9 days. They found that endograft configuration
was significantly associated with endograft limb occlusion with this complica-
tion occurring in 5.1% of Ancure limbs and 0–2.6% of supported endograft
limbs.
11
Carroccio et al. reported an endograft limb occlusion rate of 3.7% in 702
at-risk limbs during a mean follow-up of 20 months.
16
Half of the cases of
limb occlusion occurred within 30 days of surgery, and 69% required an
intervention to reestablish blood flow to the affected extremity. No association
between endograft limb occlusion and any of the six commercially manufac-
tured devices was demonstrated, although the cohort was dominated by the
Talent (Medtronic, Santa Rosa, CA) device (73% of at-risk limbs).
Although adjunctive stenting for unsupported endograft limbs appears to be
beneficial in preventing limb occlusion, this practice may also be beneficial
when utilizing endograft limbs with a supported configuration. Sivamurthy et
al. compared patients who underwent adjunctive primary stenting of endograft
limbs at the time of EVAR with the Zenith AAA endovascular graft (Cook,
Inc., Bloomington, IN).
12
Indications for adjunctive stenting were endograft
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322 P.J. Riesenman and W.A. Marston
limb angulation, compression, and kinking. After a mean follow-up of 2 years,
no cases of limb occlusion occurred in 85 at-risk stented limbs, while occlu-
sion was observed in 3.6% (13 of 361) of unstented limbs. Approximately half
the cases of obstruction occurred within 30 days of EVAR and 73% occurred
at ≤ 6 months. This higher rate of occlusion in unstented endograft limbs
occurred despite more favorable vascular anatomy and more favorable initial
EVAR results.
Interventions for Endograft Limb Occlusion
Following endograft limb occlusion, the severity of the patient’s symptoms
may necessitate an emergent intervention to restore and maintain limb pat-
ency to the affected vascular territory. A less invasive endovascular interven-
tion would be preferable and is often technically successful. Endovascular
options depend on the etiology of the occlusion and include angioplasty,
stenting, AngioJet thrombectomy, and thrombolysis. Krajcer et al. reported
on six patients with symptomatic thrombosis, all of whom underwent success-
fully treatment with AngioJet thrombectomy (Possis Medical, Minneapolis,
MN).
21
Erzurum et al. reported on 25 patients treated endovascularly ( n = 12)
and with extra-anatomic bypass ( n = 13) for endograft limb occlusion.
11
Nine
(75%) of the initial endovascular approaches were successful at resolving the
occlusion and none of these patients experienced recurrent endograft limb
occlusion.
When the patient’s extremity is acutely threatened secondary to endograft
limb occlusion and an endovascular revision is technically unsuccessful or pro-
hibitive, extra-anatomic bypass is indicated. When a femoral–femoral bypass
is to be performed, care should be taken to evaluate the contralateral endograft
limb supplying the donor vessel, as contralateral endograft limb obstruction
has been responsible for extra-anatomic bypass failure in this setting.
11
O ther Causes of Limb Ischemia Fowllowing EVAR
Although lower extremity ischemia following EVAR is largely attributed to
endograft limb occlusion, cases of atheroembolization necessitating inter-
vention have been reported
9,
24
Operative dissection and obtaining vascular
control of the femoral or iliac vessels may release atheroembolic debris.
Additionally, wire and sheath manipulation may further disrupt atheroscle-
rotic plaques or intraaneurysmal material. The evaluation for distal occlu-
sion and need for intervention should be similar to that described for open
surgical repair.
In addition to disruption of atheroembolic debris, wire and sheath manipula-
tion has been reported to result in arterial access vessel injury in 4.8–8% of
patients undergoing EVAR.
4,
25
This iatrogenic trauma may result in rupture,
dissection, or pseudoaneurysms which may give rise to thromboembolic proc-
esses and vessel occlusion. Care should be taken to assess the iliofemoral
anatomy at the time of evaluation for EVAR candidacy. Patients with access
vessels that are found to be tortuous and severely atherosclerotic may be better
served with a more proximal level of arterial access. At the conclusion of each
EVAR procedure, device limb and iliac vessel anatomy should be evaluated
to identify any luminal irregularity for consideration for treatment in order to
avoid potential limb occlusion.
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Chapter 22 Acute Limb Ischemia After Abdominal Aortic Aneurysm Repair 323
Conclusion
Acute limb ischemia is a recognized complication of both open surgical repair
of AAAs and EVAR. Early acute limb ischemic events following open repair
are most commonly due to technical factors of the repair, while late events are
often secondary to progressive atherosclerotic disease. Acute limb ischemia
following EVAR has mainly been associated with endograft limb occlusion
and this complication tends to be present in the early postoperative period.
Early reports of high rates of limb ischemia following EVAR were associated
with the use of unsupported endografts limbs which were inherently prone to
occlusion. Adjunctive stenting of unsupported limbs greatly reduced the inci-
dence of this complication and the present use of supported endograft limbs
has been associated with a lower incidence of endograft limb obstruction.
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