How to deal with a limb occlusion after EVAR?

This presentation deals with three important issues:
(1) What is the real incidence of limb occlusion post-EVAR?
(2) Which are the key points and risk factors behind limb occlusion?
(3) How to manage different clinical scenarios?


    July 28, 2018

    Hi Fernando,

    thank you very much for this nice presentation. Often people publish success stories, but rather rarely problems they have to manage. This is very much appreciated as it gives direct impact into learning how to get out of trouble in different situations. It also demonstrates how important is the initial planning process and the choice of stentgrafts.

    In one case you mentioned thrombolysis, intra-aortic, with a PigTail catheter. Did this work? No distal embolisation?

    Also how do you manage intraoperative ACT measurement? What is your target ACT? Do you think some occlusions may occur in the context of Heparin-resistance or even HIT? (I had 2 in the past 2 1/2 years over a volume of 170)
    Very Best, P

    Hi Philipe,
    Thanks for your comments and questions.
    Yes, I have realized that is when you are performing high volumen of aortic procedures when problems appear, and the importance of review carefully the planning, not just saying “it was just a limb occlusion due to bad stentgrafts limbs” as I have heard many many times…and it is also our responsibility remain educational and share with other colleagues our experience and failures.
    1. Yes, at this case we observed the immediate occlusion of the limb, with a pigtail we delivered a bolus of 300000 UI urokinase inside the aorta and the beginning of the occluded limb, and it worked. No distal embolization was observed, as probably it was a very recent thrombus it was totally disolved. Anyway we assumed this risk.
    2. About ACT measurements, I have to be honest with you and our colleagues, I don’t use it for standard infrarenal EVAR, usually less 90 mins procedures, I use a 5000 UI doses after proglide deployment (pre-closure), (about 60UI/kg). And sometimes 20 UI Protamine when closing access.
    For complex EVAR/ FEVAR, we measure ACT with a target pick value <250 sc.
    3. Yes It could happen, thrombosis due to heparin-resistance, but in my humble experience there is usually a mechanical cause during the deployment or a failure in the planning or graft selection that could explain the limb occlusion. HIT is quite unfrequent, about 0.3%, in this publication (J Cardiothorac Vasc Anesth. 2017 Oct;31(5):1751-1757. Incidence and Outcomes of Heparin-Induced Thrombocytopenia in Patients Undergoing Vascular Surgery. Chaudhry R1 et all), but at other reports (1-5%).
    Best regards,

    September 18, 2018

    Aortic Disease Awareness Day

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