Since the advent of endovascular repair of aortic aneurysms (EVAR), clinical focus has been on preventing loss of sealing at the level of the infrarenal neck, which leads to type I endoleak and repressurization of the aneurysm sac. Enhanced mechanisms for central fixation and seal have consequently lowered the incidence of migration and endoleaks. However, endograft limb thrombosis and its causal mechanisms have not been addressed adequately in the literature. This article reviews the pathophysiological mechanisms associated with limb thrombosis in order to facilitate better clinical judgment to prevent iliac adverse effects.
DonasKPTorselloGBisdasT. New EVAR devices: pros and cons. J Cardiovasc Surg (Torino). 2012;53:559–569.
2.
TroisiNTorselloGDonasKP. Endurant stent-graft: a 2-year, single-center experience with a new commercially available device for the treatment of abdominal aortic aneurysms. J Endovasc Ther. 2010;17:439–448.
3.
AvgerinosEDDalainasIKakisisJ. Endograft accommodation on the aortic bifurcation: an overview of anatomical fixation and implications for long-term stent-graft stability. J Endovasc Ther. 2011;18:462–470.
4.
ChiesaRRiambauVCoppiG; ADVANCE Investigational Study Investigators. The Bolton Treovance abdominal stent-graft: European clinical trial design. J Cardiovasc Surg (Torino). 2012;53:595–604.
5.
VerziniFIserniaGDe RangoP. Abdominal aortic endografting beyond the trials: a 15-year single-center experience comparing newer to older generation stent-grafts. J Endovasc Ther. 2014;21:439–447.
6.
PropperBWAbularrageCJ. Long-term safety and efficacy of endovascular abdominal aortic aneurysm repair. Vasc Health Risk Manag. 2013;9:135–141.
7.
FransenGADesgrangesPHarrisPL. Frequency, predictive factors, and consequences of stent-graft kink following endovascular AAA repair. J Endovasc Ther. 2003;10:913–918.
8.
BecqueminJPPilletJCLescalieF. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg. 2011;53:1167–1173.
9.
LederleFAFreischlagJAKyriakidesTC.; OVER Veterans Affairs Cooperative Study Group. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med. 2012;367:1988–1997.
10.
De BruinJLBaasAFButhJ.; DREAM Study Group. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1881–1889.
11.
United Kingdom EVAR Trial Investigators, GreenhalghRMBrownLC. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1863–1871.
12.
van ZeggerenLBastos GonçalvesFvan HerwaardenJA. Incidence and treatment results of Endurant endograft occlusion. J Vasc Surg. 2013;57:1246–1254.
13.
CarpenterJPBaumRABarkerCF. Impact of exclusion criteria on patient selection for endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2001;34:1050–1054.
14.
TaudorfMJensenLPVogtKC. Endograft limb occlusion in EVAR: iliac tortuosity quantified by three different indices on the basis of preoperative CTA. Eur J Vasc Endovasc Surg. 2014;48:527–533.
15.
WyssTRDickFBrownLC. The influence of thrombus, calcification, angulation, and tortuosity of attachment sites on the time to the first graft-related complication after endovascular aneurysm repair. J Vasc Surg. 2011;54:965–971.
16.
CochennecFBecqueminJPDesgrangesP. Limb graft occlusion following EVAR: clinical pattern, outcomes and predictive factors of occurrence. Eur J Vasc Endovasc Surg. 2007;34:59–65.
17.
CarroccioAFariesPLMorrisseyNJ. Predicting iliac limb occlusions after bifurcated aortic stent grafting: anatomic and device-related causes. J Vasc Surg. 2002;36:679–684.
18.
MaleuxGKoolenMHeyeS. Limb occlusion after endovascular repair of abdominal aortic aneurysms with supported endografts. J Vasc Interv Radiol. 2008;19:1409–1412.
19.
WuMSBoyleJR. Commentary: Strategies that minimize the risk of iliac limb occlusion after EVAR. J Endovasc Ther. 2012;19:86–87.
20.
ConwayAMModaraiBTaylorPR. Stent-graft limb deployment in the external iliac artery increases the risk of limb occlusion following endovascular AAA repair. J Endovasc Ther. 2012;19:79–85.
21.
SampramESKarafaMTMaschaEJ. Nature, frequency, and predictors of secondary procedures after endovascular repair of abdominal aortic aneurysm. J Vasc Surg. 2003;37:930–937.
22.
GeorgakarakosEGeorgiadisGSIoannouCV. Aneurysm sac shrinkage after endovascular treatment of the aorta: beyond sac pressure and endoleaks. Vasc Med. 2012;17:168–173.
23.
FigueroaCATaylorCAYehV. Effect of curvature on displacement forces acting on aortic endografts: a 3-dimensional computational analysis. J Endovasc Ther. 2009;16:284–294.
24.
RoosHGhaffariMFalkenbergM. Displacement forces in iliac landing zones and stent graft interconnections in endovascular aortic repair: an experimental study. Eur J Vasc Endovasc Surg. 2014;47:262–267.
25.
GeorgakarakosEXenakisAManopoulosC. Studying the flow dynamics in an aortic endograft with crossed-limbs. Int J Artif Organs. 2014;37:81–87.
26.
GeorgakarakosEXenakisAGeorgiadisGS. The hemodynamic impact of misalignment of fenestrated endografts: a computational study. Eur J Vasc Endovasc Surg. 2014;47:151–159.
27.
BisdasTWeissKEisenackM. Durability of the Endurant stent graft in patients undergoing endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2014;60:1125–1131.
28.
ChenHYSinhaAKChoyJS. Mis-sizing of stent promotes intimal hyperplasia: impact of endothelial shear and intramural stress. Am J Physiol Heart Circ Physiol. 2011;301:H2254–H2263.
29.
van KeulenJWMollFLArtsJ. Aortic neck angulations decrease during and after endovascular aneurysm repair. J Endovasc Ther. 2010;17:594–598.
30.
KrämerSCSeifarthHPamlerR. Geometric changes in aortic endografts over a 2-year observation period. J Endovasc Ther. 2001;8:34–38.
31.
CoulstonJBaigentASelvachandranH. The impact of endovascular aneurysm repair on aortoiliac tortuosity and its use as a predictor of iliac limb complications. J Vasc Surg. 2014;60:585–589.
32.
DemangetNDupreyABadelP. Finite element analysis of the mechanical performances of 8 marketed aortic stent-grafts. J Endovasc Ther. 2013;20:523–535.
33.
ZandvoortHJGonçalvesFBVerhagenHJ. Results of endovascular repair of infrarenal aortic aneurysms using the Endurant stent graft. J Vasc Surg. 2014;59:1195–1202.
34.
DoughertyGJohnsonMJ. Clinical validation of three-dimensional tortuosity metrics based on the minimum curvature of approximating polynomial splines. Med Eng Phys. 2008;30:190–198.
35.
DoughertyGVarroJ. A quantitative index for the measurement of the tortuosity of blood vessels. Med Eng Phys. 2000;22:567–574.
36.
KristmundssonTSonessonBReschT. A novel method to estimate iliac tortuosity in evaluating EVAR access. J Endovasc Ther. 2012;19:157–164.
37.
JohnsonMJDoughertyG. Robust measures of three-dimensional vascular tortuosity based on the minimum curvature of approximating polynomial spline fits to the vessel mid-line. Med Eng Phys. 2007;29:677–690.
38.
DowsonNBoultMCowledP. Development of an automated measure of iliac artery tortuosity that successfully predicts early graft-related complications associated with endovascular aneurysm repair. Eur J Vasc Endovasc Surg. 2014;48:153–160.
39.
KleinstreuerCLiZBascianoCA. Computational mechanics of nitinol stent grafts. J Biomech. 2008;41:2370–2378.
40.
GeorgakarakosEGasserTCXenosM. Applying findings of computational studies in vascular clinical practice: fact, fiction, or misunderstanding?J Endovasc Ther. 2014;21:434–438.
