POST-EVAR LIMB GRAFT KINKING — INTRA-OPERATIVE DIAGNOSIS
Introduction: Endograft limb kinking remains one of the major causes of secondary interventions and rehospitalisation after Endovascular aneurysm repair (EVAR). However, the importance of improving limb patency has received little focus. Endograft limb kinking also remains ill-defined, with considerable variability in the literature concerning its clinical presentation and natural history. The purpose of this paper is to search for an appropriate definition for limb graft kinking as well as intra-operative and follow-up approaches for a timely diagnosis.
Methods: A literature review was performed in the MEDLINE database.
Results: Several imaging methods have been reviewed, and they all present advantages and drawbacks. Completion Angiography (CA) is routinely performed after removal of stiff guidewires, but it is considered an inadequate means of determining high-risk limb grafts. Cone Beam Computed Tomography (CBCT) has been shown to be feasible both in EVAR planning and as completion imaging to detect complications missed by CA. Duplex Ultrasound, pressure measurement and intravascular ultrasound have also been proposed as adjuncts for intraoperative evaluation of limb grafts.
Discussion: Standardizing criteria for hemodynamically significant kinking diagnosis is necessary in order to define patients that may benefit from re-interventions to reduce the risk of limb occlusion. Further studies are necessary in order to raise awareness for this complication which can lead to limb graft thrombosis and limb loss and in order to establish an appropriate diagnosis and follow up protocol.
2. Ronsivalle S, Faresin F, Franz F, Pedon L, Rettore C, Zonta L, et al. A new management for limb graft occlusion after endovascular aneurysm repair adding a vollmar ring stripper: the unclogging technique. Ann Vasc Surg. 2013;27(8):1216-22. doi: 10.016/j.avsg.2013.02.018. Epub Sep 5.
3. van Zeggeren L, Bastos Goncalves F, van Herwaarden JA, Zandvoort HJ, Werson DA, Vos JA, et al. Incidence and treatment results of Endurant endograft occlusion. J Vasc Surg. 2013;57(5):1246-54; discussion 54. doi: 10.016/j.jvs.2012.11.069. Epub 3 Feb 6.
4. Hallett JW, Jr., Marshall DM, Petterson TM, Gray DT, Bower TC, Cherry KJ, Jr., et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. Journal of vascular surgery. 1997;25(2):277-84; discussion 85-6.
5. Hertzer NR, Mascha EJ, Karafa MT, O'Hara PJ, Krajewski LP, Beven EG. Open infrarenal abdominal aortic aneurysm repair: the Cleveland Clinic experience from 1989 to 1998. Journal of vascular surgery. 2002;35(6):1145-54.
6. Coulston J, Baigent A, Selvachandran H, Jones S, Torella F, Fisher R. Lack of Iliac Engagement Correlates With Iliac Limb Complications Following Standard EVAR. Vasc Endovascular Surg. 2015;49(7):201-5. doi: 10.1177/1538574415614403. Epub 2015 Oct 29.
7. Koutouzi G, Pfister M, Breininger K, Hellstrom M, Roos H, Falkenberg M. Iliac artery deformation during EVAR. Vascular. 2019:1708538119840565.
8. Bianchini Massoni C, Gargiulo M, Giovanetti F, Freyrie A, Faggioli G, Gallitto E, et al. Adjunctive stenting of endograft limbs during endovascular treatment of infrarenal aortic and iliac aneurysms according to 3-projection completion angiography. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists. 2011;18(4):585-90.
9. Oshin OA, Fisher RK, Williams LA, Brennan JA, Gilling-Smith GL, Vallabhaneni SR, et al. Adjunctive iliac stents reduce the risk of stent-graft limb occlusion following endovascular aneurysm repair with the Zenith stent-graft. J Endovasc Ther. 2010;17(1):108-14. doi: 10.1583/09-2854.1.
10. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2007;33 Suppl 1:S1-75.
11. Sivamurthy N, Schneider DB, Reilly LM, Rapp JH, Skovobogatyy H, Chuter TA. Adjunctive primary stenting of Zenith endograft limbs during endovascular abdominal aortic aneurysm repair: implications for limb patency. J Vasc Surg. 2006;43(4):662-70. doi: 10.1016/j.jvs.2005.11.044.
12. Schulz CJ, Schmitt M, Bockler D, Geisbusch P. Intraoperative contrast-enhanced cone beam computed tomography to assess technical success during endovascular aneurysm repair. Journal of vascular surgery. 2016;64(3):577-84.
13. Tornqvist P, Dias N, Sonesson B, Kristmundsson T, Resch T. Intra-operative cone beam computed tomography can help avoid reinterventions and reduce CT follow up after infrarenal EVAR. Eur J Vasc Endovasc Surg. 2015;49(4):390-5. doi: 10.1016/j.ejvs.2015.01.009. Epub Feb 27.
14. White RA, Donayre C, Kopchok G, Walot I, Wilson E, de Virgilio C. Intravascular ultrasound: the ultimate tool for abdominal aortic aneurysm assessment and endovascular graft delivery. J Endovasc Surg. 1997;4(1):45-55.
15. Amesur NB, Zajko AB, Orons PD, Makaroun MS. Endovascular treatment of iliac limb stenoses or occlusions in 31 patients treated with the ancure endograft. Journal of vascular and interventional radiology : JVIR. 2000;11(4):421-8.
16. Mazzaccaro D, Farina A, Petsos K, Nano G. The Role of Duplex Ultrasound in Detecting Graft Thrombosis and Endoleak after Endovascular Aortic Repair for Abdominal Aneurysm. Annals of vascular surgery. 2018;52:22-9.
17. Harrison GJ, Oshin OA, Vallabhaneni SR, Brennan JA, Fisher RK, McWilliams RG. Surveillance after EVAR based on duplex ultrasound and abdominal radiography. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2011;42(2):187-92.
18. Coulston J, Baigent A, Selvachandran H, Jones S, Torella F, Fisher R. The impact of endovascular aneurysm repair on aortoiliac tortuosity and its use as a predictor of iliac limb complications. Journal of vascular surgery. 2014;60(3):585-9.
19. Blom AS, Troutman D, Beeman B, Yarchoan M, Dougherty MJ, Calligaro KD. Duplex ultrasound imaging to detect limb stenosis or kinking of endovascular device. J Vasc Surg. 2012;55(6):1577-80. doi: 10.016/j.jvs.2011.12.058. Epub 2 Feb 16.
20. Karthikesalingam A, Kumar S, Anandarajah JJ, Hinchliffe RJ, Poloniecki JD, Thompson MM, et al. Predictive value of peak systolic velocity for the development of graft limb complications after endovascular aneurysm repair. J Endovasc Ther. 2012;19(3):428-33. doi: 10.1583/11-3739MR.1.
21. Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. Journal of vascular surgery. 2009;50(4 Suppl):S2-49.
22. Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, et al. European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2018.
23. Cochennec F, Becquemin JP, Desgranges P, Allaire E, Kobeiter H, Roudot-Thoraval F. Limb graft occlusion following EVAR: clinical pattern, outcomes and predictive factors of occurrence. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2007;34(1):59-65.
24. Torsello G, Troisi N, Tessarek J, Torsello GF, Dorigo W, Pulli R, et al. Endovascular aortic aneurysm repair with the Endurant stent-graft: early and 1-year results from a European multicenter experience. Journal of vascular and interventional radiology : JVIR. 2010;21(1):73-80.
25. Carpenter JP, Neschis DG, Fairman RM, Barker CF, Golden MA, Velazquez OC, et al. Failure of endovascular abdominal aortic aneurysm graft limbs. J Vasc Surg. 2001;33(2):296-302; discussion -3. doi: 10.1067/mva.2001.112700.
26. Fairman RM, Baum RA, Carpenter JP, Deaton DH, Makaroun MS, Velazquez OC, et al. Limb interventions in patients undergoing treatment with an unsupported bifurcated aortic endograft system: a review of the Phase II EVT Trial. Journal of vascular surgery. 2002;36(1):118-26.