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Factors Associated With Limb Occlusion In The Long-term After Endovascular Aortic Repair
Jayne Raven Rice, M.D
1, Grace Wang, MD
1, Olamide Alabi, MD
2, Naveen Balasundaram, MD
1.
1University of Pennsylvania, Philadelphia, PA, USA,
2Emory University School of Medicine, Atlanta, GA, USA.
OBJECTIVES: Limb occlusion after endovascular aortic aneurysm repair (EVAR) is an uncommon but serious complication leading to possible need for reintervention. It is unclear which factors are predictors of limb occlusion in the long-term followup (LO-LTFU) after EVAR.
METHODS:We examined the long-term followup dataset of the Endovascular AAA registry in the Vascular Quality Initiative from 2014-2023. Endovascular aortobi-iliac grafts were coded twice, once for each limb, while aorto-uni-iliac grafts were coded once. Aorto-aortic grafts were excluded. Patients who did not have postoperative imaging documented were excluded. Sociodemographic, comorbidities, operative factors before the index surgery were analyzed. Bivariate log-rank test and stepwise multivariable cox analysis were used.
RESULTS: Among 33,064 EVARs performed with 65,421 limbs, there were 498 (0.79%) LO-LTFU captured in the dataset. Mean followup was 453 days for the dataset, and there was a mean of 390 days till the first occlusion for LO-LTFU patients
. Nonwhite patients (p=0.007) along with patients on Medicare/Medicaid or self-pay patients (p<0.001), had higher than expected rates of LO-LTFU. Patients who did not have the COVID vaccine (p=0.006) before their index procedure had higher rates of LO-LTFU. LO-LTFU patients were more likely to have iliac aneurysms (p<0.001) and required iliac adjunctive such as angioplasty or endoconduit placement for delivery of the device during the index procedure (p=0.003). They were more likely to have a femoral endarterectomy (p=0.049) and/or a femoral-femoral bypass (p=0.020) during the index procedure. For cox regression, smoking, prior peripheral arterial disease (PAD) surgery, requiring an urgent repair, having open access, use of suprarenal fixation graft, placing multiple iliac limb grafts/extensions and covering/coiling the internal iliac were significant for increased risk of LO-LTFU (Table 1). Overall, there was no difference in long-term mortality for the two groups (p=0.975).
CONCLUSIONS: In patients with risk factors of smoking, prior PAD surgery, urgent repair, suprarenal fixation, use of multiple iliac limb grafts/extensions and coiling/covering the internal iliac artery more frequent surveillance should be considered, and the utility of interventions to identify and address issues to prolong primary assisted and secondary patency should be investigated.
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