title: Initial management and outcome of aortic endograft limb occlusion.
abstract: OBJECTIVE
  The purpose of this study was to determine the differences in outcome related to initial management of aortic endograft limb occlusion (ELO).
  
  
  METHODS
  During a 7-year period, 823 endovascular aneurysm repairs (EVARs) resulted in 25 ELOs in 22 patients. The initial management and outcome of these ELOs were reviewed. Median follow-up after ELO was 24.2 +/- 16.8 months.
  
  
  RESULTS
  Initial EVARs included both unsupported unibody (n = 5) and supported modular (n = 17) devices. ELO was significantly more common in the unsupported unibody graft design (P <.024) and with extension of the graft limb to the external iliac artery (P <.001). ELO was managed with an endovascular approach (EVA), including some combination of mechanical thrombectomy (n = 8), angioplasty with or without stenting (n = 8), and thrombolysis (n = 2) in 12 patients and bypass procedures (femoral-femoral bypass, n = 11; axillofemoral bypass, n = 1; and aortofemoral bypass, n = 1) in 13. At 12-month follow-up, freedom from secondary procedures with EVA was 80.2 +/- 17.7% versus 53.2 +/-17.1% with extra-anatomic bypass (EB) (P = NS). Secondary patency was 100% with EVA and 80.6 +/- 14.4% with EB (P = NS). Of the 12 EVAs, there was 1 (8.3%) perioperative mortality with EVA and none with EB. EB failure was directly attributed to donor limb occlusion in 4 of 6 EVAs (67%), and when this occurred it resulted in bilateral lower extremity ischemia. Amputation was required in 2 of 12 (16.7%) EBs versus none of the 12 EVAs (P = NS). EVA never resulted in graft dislodgement or endoleak but did identify an underlying treatable cause in 8 of 12 (67%).
  
  
  CONCLUSIONS
  Both EVA and EB are acceptable management strategies for ELO. The potential risk of graft dislodgement was not observed with an EVA. If EB is employed, assessment of the donor limb and treatment of any underlying lesions is advisable in an attempt to minimize future donor limb occlusion.
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Foundation, Ohio 44120, USA. vzerzurum@yahoo.com
authors.forename: Victor Z
authors.initials: VZ
authors.lastname: Erzurum
authors.forename: Ellis S K
authors.initials: ES
authors.lastname: Sampram
authors.forename: Timur P
authors.initials: TP
authors.lastname: Sarac
authors.forename: Sean P
authors.initials: SP
authors.lastname: Lyden
authors.forename: Dan G
authors.initials: DG
authors.lastname: Clair
authors.forename: Roy K
authors.initials: RK
authors.lastname: Greenberg
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: O'Hara
authors.forename: Vikram S
authors.initials: VS
authors.lastname: Kashyap
authors.forename: Kenneth
authors.initials: K
authors.lastname: Ouriel
mesh_terms: D017130:Angioplasty; D001011:Aorta / Q000601:surgery*; D001014:Aortic Aneurysm / Q000601:surgery; D001366:Axillary Artery / Q000601:surgery*; D001807:Blood Vessel Prosthesis / Q000009:adverse effects*; D005263:Femoral Artery / Q000601:surgery*; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000628:therapy*; D006801:Humans; D012189:Retrospective Studies; D015607:Stents; D017131:Thrombectomy; D015912:Thrombolytic Therapy; D016896:Treatment Outcome