title: Limb graft occlusion following EVAR: clinical pattern, outcomes and predictive factors of occurrence.
abstract: BACKGROUND
  We reviewed our experience with limb occlusion after EVAR in order (1) to assess the clinical pattern and treatment options (2) to assess outcomes and (3) to identify predictive factors of occurrence.
  
  
  METHODS
  Between 1995 and 2005, 460 AAA patients were electively treated with a variety of commercially available stent grafts. There were 369 bifurcated and 91 aortouniiliac grafts (829 limbs). Follow-up included physical examination, plain X-ray, Duplex ultrasonography, and spiral computed tomographic scans at 1, 6, 12 months and annually thereafter. All pertinent data were collected prospectively and analysed retrospectively. The follow-up period ranged from Day 0 to 104 months, with a median follow-up of 23.4 months.
  
  
  RESULTS
  36 limbs in 33 patients (7.2%) occluded between Day 0 and 71 months (average: 9.5 months) after EVAR. Presentation was acute ischemia in 11 cases, rest pain in 9, claudication in ten. Four occlusions remained asymptomatic and two occurred intraoperatively. Treatment was femoro-femoral cross-over graft in 19 cases, axillo-femoral bypass in three, thrombectomy and stent in three, thrombolysis and stent in nine, and conservative in two. One patient (3%) died of multiple organ failure after thrombolysis. There was no amputation. Reocclusions occurred in two patients (6.1%). Multivariate logistic regression showed that kinking (odds ratio [OR] 11.9; confidence interval [CI] 3.39-42.1; p=0.0001), first graft generation (OR 2.87; CI 1.25-6.62; p=0.017) and younger age (OR 1.05; CI 1.00-1.09; p=0.034) were independently related to the occurrence of graft limb occlusion.
  
  
  CONCLUSIONS
  Acute graft limb occlusion is not rare after EVAR. The frequency of limb occlusion has declined with current stent grafts generation. Although surgery and endovascular treatments are efficient and safe, development of a graft limb kink should lead to aggressive pre-emptive treatment to prevent occlusion.
authors.affiliation: Department of Vascular Surgery, Henri Mondor Hospital, AP/HP, University Paris Val de Marne, Creteil 94000, Paris, France.
authors.forename: F
authors.initials: F
authors.lastname: Cochennec
authors.forename: J P
authors.initials: JP
authors.lastname: Becquemin
authors.forename: P
authors.initials: P
authors.lastname: Desgranges
authors.forename: E
authors.initials: E
authors.lastname: Allaire
authors.forename: H
authors.initials: H
authors.lastname: Kobeiter
authors.forename: F
authors.initials: F
authors.lastname: Roudot-Thoraval
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D005602:France / Q000453:epidemiology; D006083:Graft Occlusion, Vascular / Q000150:complications / Q000175:diagnosis / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007511:Ischemia / Q000453:epidemiology / Q000209:etiology* / Q000601:surgery; D007866:Leg / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D036542:Tomography, Spiral Computed; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex