1. Ischemic Complications
Visceral Ischemia
- due to malpositioning of the endograft covering the celiac trunk
- Treatment: open removal of the endograft and, depending on the situation, open correction of the PAU
Spinal Ischemia and Paraplegia (“ischemic spinal cord injury” – SCI)
- Cause: Reduced blood flow to the spinal cord due to endovascular overstenting of spinal cord-relevant arteries in combination with other risk factors such as perioperative hypotension, larger blood losses/anemia; especially in thoracic/thoracoabdominal procedures
If at least two territories of spinal perfusion are compromised, the likelihood of spinal ischemia increases.
- Clinical presentation: ranges from small transient sensory impairments to functional disorders of continence organs to complete paraplegia with lifelong bedriddenness and need for care
- Treatment: Increase in spinal perfusion pressure, e.g. pharmacological elevation of mean arterial pressure and placement of a cerebrospinal fluid drain to reduce the counterpressure of arterial perfusion in the cerebrospinal fluid spaces
Prophylaxis:
- Avoid intra- and postoperative hypotensive phases and, after segmental artery occlusion, maintain a mean arterial pressure of 80–90 mm Hg for at least 48 h
- Placement of a prophylactic spinal cerebrospinal fluid drain if at least two territories of spinal blood flow (see above) are impaired and cannot be reopened by revascularizing measures
- perioperatively sufficient central venous saturation (ScvO2) of ≥70 % as well as intraoperatively a central venous pressure (CVP) of ≤10 mm Hg, hemoglobin value ≥ 8 mg/dl or keep intraoperative blood loss as low as possible, cell saver
- postop. prompt extubation to assess neurological status, follow-up checks
Limb Ischemia
- peripheral emboli (< 2 %) → resolution through combination of thrombolysis, catheter aspiration, angioplasty/stent as well as Fogarty maneuver
2. Systemic Complications
- cardiopulmonary and cerebrovascular complications as well as contrast-induced nephrotoxicity
- acute coronary syndrome, myocardial infarction, pneumonia, cerebrovascular events, renal insufficiency → adequate, interdisciplinary treatment
- preoperative evaluation: cardiac status, lung function, retention values
3. Post-Implantation Syndrome
- Incidence: 13 – 60 %
- Cause: inflammatory immune response with release of cytokines due to endothelial activation by the endograft material
- Clinical presentation: transient, acute, flu-like symptoms, fever
- Laboratory: elevation of C-reactive protein (CRP), interleukin-6 and TNF-α during the first week after implantation; typically no leukocytosis and no pathogen detection
- Treatment: symptomatic (antipyretic measures, antibiotics are not indicated)
4. Pseudoaneurysms of Access Vessels
- at the puncture site after percutaneous approach more common than after surgical exposure of the access vessel
- Incidence of pseudoaneurysms requiring treatment: 3 - 6 %
- Treatment: ultrasound-guided thrombin injection into the aneurysm, if necessary operative repair, esp. in aneurysms > 1,5 cm
5. Endoprosthesis Migration
- Displacement of the endoprosthesis by more than 5–10 mm from the original position, usually caudally
- Incidence: 1 – 10 % (1-year follow-up after TEVAR)
- Main cause of reinterventions in type I endoleaks (see below)
7. Material Fatigue
- Cause: fractures of stent struts, tears in endograft material, loosening of Prolene sutures that attach the endograft material to the stent struts
- Consequence: Type I or Type III endoleaks (see below)
8. Endograft Infection
- Incidence after TEVAR: 0.4 – 3 %
- Lethality 20 – 50 %!
- Risk factors: age, diabetes, obesity, malnutrition, gangrene/ulcer, duration of preop. hospitalization, op duration, inguinal access, blood loss, reinterventions, lymphoceles, hematomas, seromas, wound healing disorders, wound infections
- variable clinical presentation: relatively mild findings (elevation of inflammatory parameters), febrile infections up to dramatic courses with active bleeding/perforation, erosions of neighboring organs with fistula formations
- Treatment: immediately after diagnosis broad-spectrum antibiotics; no pathogen detection in blood culture → vancomycin + agent against gram-negative pathogens (e.g. ceftriaxone, fluoroquinolone or piperacillin-tazobactam), otherwise according to resistogram; in case of infection persistence or recurrence after/or despite antibiotics → open surgical prosthesis explantation
9. Endoleaks
- Definition: persistent blood flow in the aneurysm sac after complete endograft placement
- Classification using the example of abdominal aortic aneurysms:
- Type I and Type III endoleaks are associated with a higher risk of aneurysm rupture → timely intervention recommended
- Diagnostics: CT, MRI, contrast-enhanced color-coded duplex sonography
- Treatment:
