Limb occlusion rate after EVAR with individualized graft limb selection and a liberal protocol of primary relining.

PURPOSE This study analyses limb occlusion rates after endovascular aneurysm repair (EVAR) with a strategy including stent-graft limb selection and liberal primary stenting (relining) in anatomies at higher risk for occlusion with uncovered self-expandable or balloon-expandable stents. MATERIALS AND METHODS All patients undergoing elective EVAR with a bifurcated stent-graft between January 2010-August 2018 were included. A protocol involving personalized stent-graft selection and liberal primary relining based on preoperative imaging was followed during the whole period. Primary endpoints were technical success and primary limb patency during follow-up. Secondary endpoints included mortality and limb reintervention rates. Risk factors associated to limb patency and reintervention rates were analysed. RESULTS 615 patients (548 males; mean age 72.9±9 years) were included. Overall technical success was 98.5% (606/615). One (0.16%) patient died during the first 30 days. Of the 1230 limbs, 96 (8%) were deemed at risk for occlusion in view of the anatomy, and primarily relined in 62 patients. Estimated primary limb patency at 6 months, 1 year and 3 years was 99.5±0.2%, 99.2±0.3% and 98.5±0.5%, respectively. Freedom from limb-related reintervention at 6 months, 1 year and 3 years was 98.1±0.4%, 97.4±0.5% and 95.6±0.7%, respectively. Only one (1%) of the ninety-six relined limbs occluded during follow-up. No differences were found in terms of patency or freedom from reintervention between limbs at risk that were primary stented and limbs without adjunctive stents. Gore Excluder stent-grafts presented better patency (Breslow p=.005) and lower reintervention rates (Breslow p=.001) than other devices during follow-up. Peripheral artery disease was also a risk factor for reintervention (Breslow p=.015). CONCLUSION Liberal use of primary limb relining in patients with iliac anatomy at higher risk for occlusion appears to be a safe and effective strategy to preserve limb patency after EVAR. Gore Excluder graft limbs present better patency and lower reintervention rates than other stent-graft types.