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LETTER TO EDITOR
Year : 2022 | Volume
: 32
| Issue : 3 | Page : 187-190
Endovascular management of acute postprocedural abdominal aortic – Iliac limb endograft occlusions: A case series
Cataldo Palmieri1, Francesco Sbrana2, Antonio Rizza1
1 Division of Interventional Cardiology, Fondazione Toscana “Gabriele Monasterio”, Massa – 54100, Italy
2 Lipoapheresis Unit - Reference Center for Diagnosis and Treatment of Inherited Dyslipidemias, Fondazione Toscana “Gabriele Monasterio”, Pisa – 56124, Italy
Correspondence Address:
Francesco Sbrana
Fondazione Toscana Gabriele Monasterio, Via Moruzzi 1, Pisa - 56124
Italy
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jcecho.jcecho_28_22
Since the 1990s, endovascular aneurysm repair (EVAR) has surpassed open surgery as the primary choice for treating abdominal aortic aneurysms (AAAs).[1] Despite an early mortality benefit over open surgery, EVAR patients have a long-term higher re-intervention rate due to limb graft occlusion (LGO) and thrombotic obstruction of blood flow in one or both endograft limbs, and these complications are the major cause of rehospitalization after EVAR.[1],[2] LGO clinical presentation ranges from no symptoms to severe acute limb ischemia and may have a fatal outcome due to the risks involved with treatment.[2] Nowadays, procedure-related risk factors for developing LGO have been reported as hostile aortoiliac anatomy with calcification, severe angulation of the iliac arteries, kinking or excessive limb oversizing, and a narrow distal landing zone including the external iliac artery.[3]
Acute ischemic complications after EVART are rare,[4] usually caused by a blood clot, and could lead to irreversible damage to muscles and nerves if blood flow is not restored in a few hours. Once irreversible damage occurs, amputation will be necessary and the condition can be life-threatening. Usually, the clinical approach includes surgically management with, as bridge, infusion of clot-busting drugs,[5] but the endovascular approach could play an important role.
In this report, we describe the endovascular management of patients with acute post procedural abdominal aortic iliac limb endograft occlusions.
Case #1 – A 67-year-old man, with a history of arterial hypertension, familial hypercholesterolemia, current smoker, and previous aortic root replacement with a valved duct Carbomedics “Valsalva” for bicuspid aortic valve disease and previous EVAR for AAA, was admitted for acute aortic dissection type B. At the admission, patients presented a sudden onset of lumbar pain associated with weakness of the lower limbs. The computed tomography (CT) angiography reveals collapse and occlusion of the endoprosthesis with extensive thrombosis of the femoral–popliteal axis. Due to the increscent symptoms, the patient underwent to endovascular procedures. Under ultrasound guidance, the right common femoral artery was cannulated to advance the high support guide and perform, after an ineffective thrombus aspiration procedure, multiple dilations with the Reliant balloon (5.0 mm × 80 mm) on the iliac-femoral axis. No protective methods to avoid peripheral embolization were used. The angiographic outcome was satisfactory [Figure 1]. Furthermore, after the procedure was administered endovascular urokinase (500000 UI) undergoing iv therapy with sodium heparin. During the postprocedural period, the patient maintaining clinical stability but developed contrast-induced nephropathy which required dialysis sessions.
Figure 1: Case #1 – (a) type B intimal dissection (red asterisk) with ostial flap (orange arrow-the blue circle identifies the true lumen) in correspondence of the renal arteries with collapse and occlusion of the endoprosthesis (yellow arrowheads). (b) Angiographic documentation of extensive thrombosis of the femoral-popliteal axis (yellow arrowheads) was treated with multiple dilations of the right superficial femoral artery and the right common femoral artery. (c) Final angiography whit restoration of the antegrade flowCase #2 – A 75-year-old man, with a history of arterial hypertension, former smoker, previous lung cancer, and previous EVAR for AAA, was admitted for acute and worsening claudication in the right limb. Physical examination showed the absence of arterial pulses in the right lower limb. The patient was undergoing to endovascular procedures: Common femoral arteries were cannulated bilaterally; after angiographic evidence of thrombotic occlusion of the right leg of the endoprosthesis, mechanical thrombectomy was performed with a Rotarex device; subsequent was positioning two “extra stiff” guides (0.035 mm) in the aorta, to perform aorto-bi-ilic relining with excluder iliac leg (16 mm × 12 mm × 140 mm on the right −16 mm × 18 mm × 100 mm on the left); the angiographic outcome was satisfactory [Figure 2] and the postprocedural period was uncomplicated.
Figure 2: Case #2 – (a) Abdominal aortography with evidence of thrombotic occlusion of the right leg of the endoprosthesis. (b) Advancement of Rotarex device (yellow arrowhead) through the right femoral artery. (c) Positioning of two 0.035 mm “extra stiff” guides to perform aorto-bi-iliac relining by positioning Excluder 16 mm × 12 mm × 140 mm on the right common femoral artery and Excluder 16 mm × 18 mm × 100 mm on the left common femoral artery. (d) Final angiography whit restoration of the antegrade flowCase #3 – A 79-year-old man, with a history of arterial hypertension, atrial fibrillation, and previous carotid artery thrombendarterectomy was admitted, due to AAA (Ø 57 mm × 66 mm), for EVAR procedure. EVAR (Medtronic Endurant) placement procedure was performed regularly and final angiography showed no signs of endoleak. Six hours after the procedure, the patient presented acute left leg pain; on physical examination was present thermal step in the absence of arterial pulses of the lower limb. After the CT angiography with evidence of endoprosthesis left leg thrombotic occlusion, the patient was undergoing to endovascular procedures: With left brachial arterial access, after angiography confirmatory, an Indigo Penumbra 6F suction catheter was advanced. After thrombus aspiration, multiple endoprosthesis dilations with subsequent Medtronic Endurant endoprosthesis placement were performed. Due to the persistence of clots was performed a surgical Fogarty in the left iliac-femoral axis was to remove thrombotic material. The angiographic outcome was satisfactory [Figure 3] and the postprocedural period was uncomplicated.
Figure 3: Case #3 – (a) CT angiography with evidence of endoprosthesis left leg thrombotic occlusion (yellow arrowhead-red asterisk) and patency of the right leg (blue circle). (b) Angiographic confirmation of endoprosthesis left leg thrombotic occlusion (yellow arrowhead). (c) Indigo Penumbra 6F suction catheter placement. (d) Multiple endoprosthesis dilations with subsequent Medtronic Endurant endoprosthesis placement. (e) Surgical Fogarty (red asterix) to remove thrombotic material. (f) Final angiography whit restoration of the antegrade flow. CT: Computed tomographyWe describe three cases of acute ischemic complications after EVAR secondary to blood clots. These conditions are time-dependent urgency that leads, if not restored in a few hours, to irreversible damage.
EVAR procedures can be extremely complex and therefore require operators with endovascular experience and refined technical skills. To note that our own Institute, Fondazione Toscana Gabriele Monasterio, is a cardiopulmonary tertiary-level institute (123 beds; more than 5000 hospital admissions per year), with cath-lab hub for the acute coronary syndrome, and expertise in endovascular procedures.
As in other case series,[6] a major problem faced by interventional cardiology is the available vascular access site to treat the occlusion, because in the early postoperative period, the percutaneous access to the femoral artery carries a high risk of hemorrhage and, to performed “kissing balloon” procedure is necessary two vascular access. Today interventional cardiologists benefit from technological innovations, but sometimes their procedural creativity serves to stem the technical problems.[7]
In the present cases, the interventional cardiologists were faced with several technical challenges to ward off, as extremely consequence, leg amputation. Furthermore, in these cases, the endovascular procedures were imbricated with clot-busting drugs infusion or surgical intervention.[5]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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