Clinical and anatomical variables associated in the literature to limb graft occlusion after endovascular aneurysm repair compared to the experience of a tertiary referral center

Introduction: Limb graft occlusion (LGO) is the third reason for hospital readmission after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm. We reviewed the clinical features, incidence, anatomical and devices related predictive factors for LGO after EVAR, and compared them with our experience. Evidence acquisition: EVAR between 2010-2017 were included. Patients with LGO (LGO group) were matched for age and type of endograft with the rest of the entire cohort without LGO (control group). Clinical, anatomical, operative, outcome, and follow-up data were collected. Evidence synthesis: Two hundred seventy-six EVAR, (30 aorto-uniliac), 276 patients. The incidence of LGO was 2.5% (seven limbs, seven patients) at 27±24.6 days. Symptomatic patients were successfully treated. No mortality, limb loss, critical limb ischemia or residual claudication due to LGO was observed. Fifty patients resulted from the matching. Among the predictive factors of LGO between the two groups, significant differences were observed in graft limb oversizing ≥15% (57.1% vs. 8%, P=0.005), or kinking (42.9% vs. 2%, P=0.01), and diameter of the aortic bifurcation <20 mm (71.4% vs. 20%, P=0.01). Logistic regression analysis showed that these three variables increased the risk of LGO (P=0.003, P=0.006, and P=0.01, respectively). Conclusions: The strongest predictive factors of LGO issued from our review were: extension in the external iliac artery, or small diameter; tortuous, angled, and calcific iliac axis; excessive oversizing of the limb graft, or kinking; use of old generation devices; EVAR performed outside the instructions for use. Limb graft oversizing >15%, or kinking, and aortic bifurcation <20 mm appear to be independent predictive factors of LGO.