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Complications - Interventional management of type Ia endoleak after endoluminal repair of bilateral internal iliac artery aneurysms - Vascular Surgery

vascular surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Intraoperative complications

    • Injury to access vessels with or without acute thrombosis; bleeding complications; later also pseudoaneurysms and arteriovenous fistulae
    • Dissection, occlusion of the access vessel, vascular rupture → conversion to open surgery, possibly stent implantation
    • Bleeding complication at puncture site (5-8%) → mostly nonsurgical; surgical hematoma evacuation and suturing of the vessel required in <3% of cases
    • Procedural failure → switch to a different procedure (e.g. endoluminal Y-graft)

  2. Postoperative complications

    Limb ischemia  

    • Peripheral embolism (< 2%) → Balloon extraction

    Systemic complications

    • Cardiopulmonary and cerebrovascular complications and contrast-media induced nephrotoxicity
    • Acute coronary syndrome; myocardial infarction; pneumonia; cerebrovascular events; kidney failure→ adequate multidisciplinary management
    • Preoperative assessment: cardiac status, lung function, retention parameters

    Access vessel pseudoaneurysms

    • Percutaneous puncture site pseudoaneurysms more common than following surgical exposure of the access vessel.
    • Incidence of pseudoaneurysms requiring treatment: 3–6%
    • Management: ultrasound-guided thrombin injection into the aneurysm, possibly surgical repair, esp. in aneurysms >1.5 cm diameter

    Repeated endograft migration

    • Endograft displacment by more than 5–10 mm from its original position, usually in a caudad direction
    • Incidence: 1–10% (1-year follow-up after EVAR)
    • Repeated endoleak → switch to a different procedure

    Material fatigue

    • Cause: fractures of the stent struts, tears in the endograft material, loosening of prolene sutures attaching the endograft material to the stent struts
    • Sequelae: type I or type III endoleaks (see below)

    Endograft infection

    • Mortality 20–50%!
    • Risk factors: age; diabetes; obesity; malnutrition; gangrene/ulcer; duration of preop. hospitalization; operating time; inguinal access; blood loss; reinterventions; lymphocele; hematoma; seroma; wound healing disorders; wound infections
    • Varied clinical signs: rather unremarkable findings (elevated inflammation markers); back pain; febrile infections including dramatic courses with active hemorrhage/perforation; erosion of adjacent organs with fistula formation
    • Management: broad-spectrum antibiotics immediately after diagnosis; in the absence of pathogen presence in blood culture → vancomycin + anti-gram-negative preparations (e.g., ceftriaxone, fluroquinolone, or piperacillin-tazobactam), otherwise according to antimicrobial susceptibility testing; in case of persistent or recurrent infection after/or despite antibiotic regimen-> open surgical graft explantation.