Limb Graft Occlusion Following Endovascular Aneurysm Repair for Infrarenal Abdominal Aortic Aneurysm with the Zenith Alpha, Excluder, and Endurant Devices: a Multicentre Cohort Study

Abstract

WHAT THIS PAPER ADDSThis study provides real world, midterm follow up data on the performance of three major endograft systems currently in routine use, the Zenith Alpha, Excluder, and Endurant, with regards to limb graft occlusion (LGO) after standard endovascular aneurysm repair. The Zenith Alpha device, external iliac artery (EIA) diameter < 10 mm, and landing in EIA were identified as independent risk factors for LGO.Objective: Limb graft occlusion (LGO) is a serious complication after endovascular aneurysm repair (EVAR) and while device development enables treatment of increasingly complex aortic anatomy, little is known about how endograft type affects the risk of occlusion. This observational study aimed to explore the incidence of LGO after EVAR for three major endograft systems. Methods: All patients with standard EVAR as the primary intervention for infrarenal abdominal aortic aneurysm (AAA), between January 2012 and December 2018, at five Swedish vascular surgery centres, were included in this multicentre retrospective cohort study. LGO was defined as a total limb occlusion regardless of symptoms, or a treated significant stenosis. A nested case control (NCC) design with incidence density sampling of 1:3 was used for analysis of potential per-operative and morphological risk factors. Conditional logistic regression was used to estimate multivariable odds ratios (OR) with 95% confidence intervals (CI) Results: A total of 924 patients were included. The majority were male (84%), the mean age was 76 years (AE 7.5 SD), and median AAA diameter was 59 mm (IQR 55, 67). Patients were treated with Zenith Alpha (n ¼ 315, ZISL limbs), Excluder (n ¼ 152, PLC/PXC limbs), and Endurant (n ¼ 457, ETLW/ ETEW limbs). During median follow up of 37 months (IQR 21, 62), 55 occlusions occurred (5.9%); 39 with Zenith Alpha (12.4%), one with Excluder (0.7%), and 15 with Endurant (3.3%). In the NCC analysis, the Zenith Alpha device (OR 5.31, 95% CI 1.97 e 14.3), external iliac artery (EIA) landing (OR 5.91, 95% CI 1.30 e 26.7), and EIA diameter < 10 mm (OR 4.99, 95% CI 1.46 e 16.9) were associated with an increased risk of LGO. Conclusion: Endograft device type is an independent risk factor for LGO after EVAR. Specifically, the Zenith Alpha demonstrated an increased risk of LGO compared with the Endurant and Excluder devices. In addition, a narrow EIA and landing zone in EIA are also risk factors for LGO.

Treatment of recurrent iliac branch occlusion after endovascular repair of abdominal aortic aneurysm diagnosed by contrast- enhanced ultrasound combined with computed tomography angiography: a case report

“…Bogdanovic et al recently reported a multicenter retrospective cohort study that reconfirmed that anchoring in the external iliac artery and narrowed external iliac diameter were risk factors for IBO after EVAR. Their study also revealed that the Zenith Alpha covered stent system is an independent risk factor for IBO ( 9 ). Poor proximal anchoring zone-inflicted IBO is rarely reported.…”

“…Complex anatomical conditions are usually the main cause of related complications, and are associated with a higher rate of surgical revision (5,6). Iliac branch occlusion (IBO) is a common issue post EVAR, with a reported incidence of approximately 1-8% (5,(7)(8)(9). Either unilateral or bilateral sides can be involved in IBO, and the causes are usually complex, including anatomy, equipment, operator factors, and so on.…”

Abdominal Aortic Aneurysm: Can the Anaconda™ Custom-Made Device Deliver? An International Perspective

“…Interestingly, incidence of iliac limb occlusion was 14%, which is still comparable to values reported in studies using other devices in normal circumstances ( 21 ). For example, in their Zenith group, Bogdanovic et al reported a 12.4% rate of limb occlusion ( 26 ).…”

Outcome of endovascular treatment of internal iliac artery aneurysms: a single center retrospective review

“…Re-intervention was also performed in one patient who developed limb graft occlusion after undergoing EVAR for an aortoiliac aneurysm. A recent multicenter study reported a limb graft occlusion rate of 5.9 percent in a retrospective cohort of 924 patients undergoing EVAR for abdominal aortic aneurysms (Bogdanovic et al 2021 ; Cochennec et al 2007 ). The rate is likely to be similar in patients undergoing EVAR for IIA aneurysms that coexist with aortoiliac aneurysms.…”