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Complications of endovascular abdominal aortic repair

Rabih A Chaer, MD
Section Editors
Joseph L Mills, Sr, MD
John F Eidt, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


The technical success rate for abdominal aortic endografting is high, and the overall rate of severe perioperative complications is lower compared with open surgical repair. However, the endograft remains a dynamic entity, and late complications are more likely. Complications associated with endovascular abdominal aortic repair are usually related to some technical aspect of endograft placement, such as problems with vascular access, or to the structural integrity and stability of the endograft, such as endoleak, endograft migration, or endograft collapse.

Endograft complications rarely lead to a need to convert to open surgery at the time of placement and when they occur late can usually be managed using endovascular means [1]. Device-related complications are the main reason for reintervention (including late conversion), which is required in up to 30 percent of patients. The overall incidence of conversion is approximately 2 percent [2]. Ischemic complications are often related to embolism but may also be due to positioning the endograft and can affect the extremities, intestine, pelvic organs, spinal cord, or kidneys. Renal insufficiency can also be caused by the administration of intravenous contrast (eg, allergic reaction, contrast-induced nephropathy). The risk of ischemic complications increases with more complex endovascular repairs.

The complications associated with abdominal aortic endografting will be reviewed here. The indications for abdominal aortic endografting and technical aspects of endograft placement are discussed elsewhere. (See "Endovascular repair of abdominal aortic aneurysm" and "Surgical and endovascular repair of ruptured abdominal aortic aneurysm" and "Management of asymptomatic abdominal aortic aneurysm", section on 'Introduction'.)


The aorta is the major arterial conduit conveying blood from the heart to the systemic circulation. The abdominal aorta lies slightly left of the midline to accommodate the inferior vena cava, which is in close apposition. The branches of the aorta (superior to inferior) include the left and right inferior phrenic arteries, left and right middle suprarenal arteries, the celiac axis, superior mesenteric artery, and left and right renal arteries in addition to occasional accessory renal arteries, left and right gonadal arteries, the inferior mesenteric artery, left and right common iliac artery, middle sacral artery, and paired lumbar arteries (L1-L4) (figure 1).

The common iliac arteries most often arise at the level of the fourth lumbar vertebra. The common iliac artery bifurcates into the external iliac and internal iliac arteries at the pelvic inlet (figure 2). The internal iliac artery gives off branches to the pelvic viscera and also supplies the musculature of the pelvis. The external iliac artery passes beneath the inguinal ligament to become the common femoral artery [3].

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Literature review current through: Nov 2017. | This topic last updated: Jul 31, 2017.
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  1. Gabrielli L, Baudo A, Molinari A, Domanin M. Early complications in endovascular treatment of abdominal aortic aneurysm. Acta Chir Belg 2004; 104:519.
  2. Moulakakis KG, Dalainas I, Mylonas S, et al. Conversion to open repair after endografting for abdominal aortic aneurysm: a review of causes, incidence, results, and surgical techniques of reconstruction. J Endovasc Ther 2010; 17:694.
  3. Sandhu RS, Pipinos II. Isolated iliac artery aneurysms. Semin Vasc Surg 2005; 18:209.
  4. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351:1607.
  5. Nordon IM, Karthikesalingam A, Hinchliffe RJ, et al. Secondary interventions following endovascular aneurysm repair (EVAR) and the enduring value of graft surveillance. Eur J Vasc Endovasc Surg 2010; 39:547.
  6. United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular repair of aortic aneurysm in patients physically ineligible for open repair. N Engl J Med 2010; 362:1872.
  7. Brown LC, Greenhalgh RM, Powell JT, et al. Use of baseline factors to predict complications and reinterventions after endovascular repair of abdominal aortic aneurysm. Br J Surg 2010; 97:1207.
  8. Karthikesalingam A, Holt PJ, Hinchliffe RJ, et al. Risk of reintervention after endovascular aortic aneurysm repair. Br J Surg 2010; 97:657.
  9. Golledge J, Parr A, Boult M, et al. The outcome of endovascular repair of small abdominal aortic aneurysms. Ann Surg 2007; 245:326.
  10. Drury D, Michaels JA, Jones L, Ayiku L. Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm. Br J Surg 2005; 92:937.
  11. Peppelenbosch N, Buth J, Harris PL, et al. Diameter of abdominal aortic aneurysm and outcome of endovascular aneurysm repair: does size matter? A report from EUROSTAR. J Vasc Surg 2004; 39:288.
  12. Schermerhorn ML, O'Malley AJ, Jhaveri A, et al. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008; 358:464.
  13. Powell JT, Greenhalgh RM. Clinical practice. Small abdominal aortic aneurysms. N Engl J Med 2003; 348:1895.
  14. FDA Public Health Notification www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/default.htm (Accessed on June 10, 2010).
  15. Schanzer A, Greenberg RK, Hevelone N, et al. Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair. Circulation 2011; 123:2848.
  16. Karthikesalingam A, Vidal-Diez A, De Bruin JL, et al. International validation of a risk score for complications and reinterventions after endovascular aneurysm repair. Br J Surg 2015; 102:509.
  17. Feezor RJ, Huber TS, Martin TD, et al. Perioperative differences between endovascular repair of thoracic and abdominal aortic diseases. J Vasc Surg 2007; 45:86.
  18. Gargiulo M, Gallitto E, Wattez H, et al. Outcomes of endovascular aneurysm repair performed in abdominal aortic aneurysms with large infrarenal necks. J Vasc Surg 2017; 66:1065.
  19. Oliveira NFG, Bastos Gonçalves FM, Van Rijn MJ, et al. Standard endovascular aneurysm repair in patients with wide infrarenal aneurysm necks is associated with increased risk of adverse events. J Vasc Surg 2017; 65:1608.
  20. Blankensteijn JD, Prinssen M. Does fresh clot shrink faster than preexistent mural thrombus after endovascular AAA repair? J Endovasc Ther 2002; 9:458.
  21. Harris P, Brennan J, Martin J, et al. Longitudinal aneurysm shrinkage following endovascular aortic aneurysm repair: a source of intermediate and late complications. J Endovasc Surg 1999; 6:11.
  22. Umscheid T, Stelter WJ. Time-related alterations in shape, position, and structure of self-expanding, modular aortic stent-grafts: a 4-year single-center follow-up. J Endovasc Surg 1999; 6:17.
  23. Blankensteijn JD, de Jong SE, Prinssen M, et al. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 2005; 352:2398.
  24. Malkawi AH, Hinchliffe RJ, Holt PJ, et al. Percutaneous access for endovascular aneurysm repair: a systematic review. Eur J Vasc Endovasc Surg 2010; 39:676.
  25. Görich J, Rilinger N, Sokiranski R, et al. Treatment of leaks after endovascular repair of aortic aneurysms. Radiology 2000; 215:414.
  26. Chaikof EL, Blankensteijn JD, Harris PL, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg 2002; 35:1048.
  27. Moll FL, Powell JT, Fraedrich G, et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011; 41 Suppl 1:S1.
  28. Laheij RJ, Buth J, Harris PL, et al. Need for secondary interventions after endovascular repair of abdominal aortic aneurysms. Intermediate-term follow-up results of a European collaborative registry (EUROSTAR). Br J Surg 2000; 87:1666.
  29. Wilt TJ, Lederle FA, Macdonald R, et al. Comparison of endovascular and open surgical repairs for abdominal aortic aneurysm. Evid Rep Technol Assess (Full Rep) 2006; :1.
  30. Tonnessen BH, Sternbergh WC 3rd, Money SR. Mid- and long-term device migration after endovascular abdominal aortic aneurysm repair: a comparison of AneuRx and Zenith endografts. J Vasc Surg 2005; 42:392.
  31. England A, McWillians R. Migration and dislocation of aortic devices during follow-up. In: Endovascular aortic repair: the state of the art, Branchereau A, Jacobs M (Eds), Minerva Medica, 2008.
  32. EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005; 365:2179.
  33. Fransen GA, Desgranges P, Laheij RJ, et al. Frequency, predictive factors, and consequences of stent-graft kink following endovascular AAA repair. J Endovasc Ther 2003; 10:913.
  34. Blom AS, Troutman D, Beeman B, et al. Duplex ultrasound imaging to detect limb stenosis or kinking of endovascular device. J Vasc Surg 2012; 55:1577.
  35. Murphy EH, Szeto WY, Herdrich BJ, et al. The management of endograft infections following endovascular thoracic and abdominal aneurysm repair. J Vasc Surg 2013; 58:1179.
  36. Cernohorsky P, Reijnen MM, Tielliu IF, et al. The relevance of aortic endograft prosthetic infection. J Vasc Surg 2011; 54:327.
  37. O'Connor S, Andrew P, Batt M, Becquemin JP. A systematic review and meta-analysis of treatments for aortic graft infection. J Vasc Surg 2006; 44:38.
  38. Vogel TR, Symons R, Flum DR. The incidence and factors associated with graft infection after aortic aneurysm repair. J Vasc Surg 2008; 47:264.
  39. Heyer KS, Modi P, Morasch MD, et al. Secondary infections of thoracic and abdominal aortic endografts. J Vasc Interv Radiol 2009; 20:173.
  40. Sharif MA, Lee B, Lau LL, et al. Prosthetic stent graft infection after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2007; 46:442.
  41. Ducasse E, Calisti A, Speziale F, et al. Aortoiliac stent graft infection: current problems and management. Ann Vasc Surg 2004; 18:521.
  42. Phade SV, Keldahl ML, Morasch MD, et al. Late abdominal aortic endograft explants: indications and outcomes. Surgery 2011; 150:788.
  43. Smeds MR, Duncan AA, Harlander-Locke MP, et al. Treatment and outcomes of aortic endograft infection. J Vasc Surg 2016; 63:332.
  44. Capoccia L, Speziale F, Menna D, et al. Preliminary Results from a National Enquiry of Infection in Abdominal Aortic Endovascular Repair (Registry of Infection in EVAR--R.I.EVAR). Ann Vasc Surg 2016; 30:198.
  45. Brown LC, Thompson SG, Greenhalgh RM, et al. Incidence of cardiovascular events and death after open or endovascular repair of abdominal aortic aneurysm in the randomized EVAR trial 1. Br J Surg 2011; 98:935.
  46. Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009; 302:1535.
  47. Becquemin JP, Pillet JC, Lescalie F, et al. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg 2011; 53:1167.
  48. Ju MH, Keldahl ML, Pearce WH, et al. Stepwise age-related outcomes of elective endovascular abdominal aortic aneurysm repair: 11-year institutional review. Perspect Vasc Surg Endovasc Ther 2011; 23:280.
  49. Wahlgren CM, Malmstedt J, Swedish Vascular Registry. Outcomes of endovascular abdominal aortic aneurysm repair compared with open surgical repair in high-risk patients: results from the Swedish Vascular Registry. J Vasc Surg 2008; 48:1382.
  50. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463.
  51. Cuypers PW, Gardien M, Buth J, et al. Randomized study comparing cardiac response in endovascular and open abdominal aortic aneurysm repair. Br J Surg 2001; 88:1059.
  52. Brown LC, Greenhalgh RM, Thompson SG, et al. Does EVAR alter the rate of cardiovascular events in patients with abdominal aortic aneurysm considered unfit for open repair? Results from the randomised EVAR trial 2. Eur J Vasc Endovasc Surg 2010; 39:396.
  53. Fonseca R, Rockman C, Pitti A, et al. Intermediate-term EVAR outcomes in octogenarians. J Vasc Surg 2010; 52:556.
  54. Moore NN, Lapsley M, Norden AG, et al. Does N-acetylcysteine prevent contrast-induced nephropathy during endovascular AAA repair? A randomized controlled pilot study. J Endovasc Ther 2006; 13:660.
  55. Mills JL Sr, Duong ST, Leon LR Jr, et al. Comparison of the effects of open and endovascular aortic aneurysm repair on long-term renal function using chronic kidney disease staging based on glomerular filtration rate. J Vasc Surg 2008; 47:1141.
  56. Surowiec SM, Davies MG, Fegley AJ, et al. Relationship of proximal fixation to postoperative renal dysfunction in patients with normal serum creatinine concentration. J Vasc Surg 2004; 39:804.
  57. Mehta M, Veith FJ, Lipsitz EC, et al. Is elevated creatinine level a contraindication to endovascular aneurysm repair? J Vasc Surg 2004; 39:118.
  58. Parmer SS, Fairman RM, Karmacharya J, et al. A comparison of renal function between open and endovascular aneurysm repair in patients with baseline chronic renal insufficiency. J Vasc Surg 2006; 44:706.
  59. Maldonado TS, Rockman CB, Riles E, et al. Ischemic complications after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2004; 40:703.
  60. Chang CK, Chuter TA, Niemann CU, et al. Systemic inflammation, coagulopathy, and acute renal insufficiency following endovascular thoracoabdominal aortic aneurysm repair. J Vasc Surg 2009; 49:1140.
  61. Brown LC, Brown EA, Greenhalgh RM, et al. Renal function and abdominal aortic aneurysm (AAA): the impact of different management strategies on long-term renal function in the UK EndoVascular Aneurysm Repair (EVAR) Trials. Ann Surg 2010; 251:966.
  62. Saratzis A, Melas N, Mahmood A, Sarafidis P. Incidence of Acute Kidney Injury (AKI) after Endovascular Abdominal Aortic Aneurysm Repair (EVAR) and Impact on Outcome. Eur J Vasc Endovasc Surg 2015; 49:534.
  63. Wald R, Waikar SS, Liangos O, et al. Acute renal failure after endovascular vs open repair of abdominal aortic aneurysm. J Vasc Surg 2006; 43:460.
  64. Hedayati N, Lin PH, Lumsden AB, Zhou W. Prolonged renal artery occlusion after endovascular aneurysm repair: endovascular rescue and renal function salvage. J Vasc Surg 2008; 47:446.
  65. Noorani A, Walsh SR, Boyle JR. Long-term effects of EVAR. Suprarenal versus infrarenal fixation. J Cardiovasc Surg (Torino) 2011; 52:199.
  66. Mehta M, Cayne N, Veith FJ, et al. Relationship of proximal fixation to renal dysfunction in patients undergoing endovascular aneurysm repair. J Cardiovasc Surg (Torino) 2004; 45:367.
  67. Greenberg RK, Chuter TA, Lawrence-Brown M, et al. Analysis of renal function after aneurysm repair with a device using suprarenal fixation (Zenith AAA Endovascular Graft) in contrast to open surgical repair. J Vasc Surg 2004; 39:1219.
  68. Zettervall SL, Soden PA, Deery SE, et al. Comparison of Renal Complications between Endografts with Suprarenal and Infrarenal Fixation. Eur J Vasc Endovasc Surg 2017; 54:5.
  69. Miller A, Marotta M, Scordi-Bello I, et al. Ischemic colitis after endovascular aortoiliac aneurysm repair: a 10-year retrospective study. Arch Surg 2009; 144:900.
  70. Becquemin JP, Majewski M, Fermani N, et al. Colon ischemia following abdominal aortic aneurysm repair in the era of endovascular abdominal aortic repair. J Vasc Surg 2008; 47:258.
  71. Faure EM, Becquemin JP, Cochennec F, ENGAGE collaborators. Predictive factors for limb occlusions after endovascular aneurysm repair. J Vasc Surg 2015; 61:1138.
  72. Taudorf M, Jensen LP, Vogt KC, et al. Endograft limb occlusion in EVAR: iliac tortuosity quantified by three different indices on the basis of preoperative CTA. Eur J Vasc Endovasc Surg 2014; 48:527.
  73. Mantas GK, Antonopoulos CN, Sfyroeras GS, et al. Factors Predisposing to Endograft Limb Occlusion after Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2015; 49:39.
  74. Simonte G, Parlani G, Farchioni L, et al. Lesson Learned with the Use of Iliac Branch Devices: Single Centre 10 Year Experience in 157 Consecutive Procedures. Eur J Vasc Endovasc Surg 2017; 54:95.
  75. Bosanquet DC, Wilcox C, Whitehurst L, et al. Systematic Review and Meta-analysis of the Effect of Internal Iliac Artery Exclusion for Patients Undergoing EVAR. Eur J Vasc Endovasc Surg 2017; 53:534.
  76. Mehta M, Veith FJ, Ohki T, et al. Unilateral and bilateral hypogastric artery interruption during aortoiliac aneurysm repair in 154 patients: a relatively innocuous procedure. J Vasc Surg 2001; 33:S27.
  77. Casey K, Al-Khatib WK, Zhou W. Hypogastric artery preservation during aortoiliac aneurysm repair. Ann Vasc Surg 2011; 25:133.e1.
  78. Lin PH, Chen AY, Vij A. Hypogastric artery preservation during endovascular aortic aneurysm repair: is it important? Semin Vasc Surg 2009; 22:193.
  79. Farahmand P, Becquemin JP, Desgranges P, et al. Is hypogastric artery embolization during endovascular aortoiliac aneurysm repair (EVAR) innocuous and useful? Eur J Vasc Endovasc Surg 2008; 35:429.
  80. Zander T, Baldi S, Rabellino M, et al. Bilateral hypogastric artery occlusion in endovascular repair of abdominal aortic aneurysms and its clinical significance. J Vasc Interv Radiol 2007; 18:1481.
  81. Lin PH, Bush RL, Chaikof EL, et al. A prospective evaluation of hypogastric artery embolization in endovascular aortoiliac aneurysm repair. J Vasc Surg 2002; 36:500.
  82. Rayt HS, Bown MJ, Lambert KV, et al. Buttock claudication and erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair. Cardiovasc Intervent Radiol 2008; 31:728.
  83. Angiletta D, Marinazzo D, Guido G, et al. Spinal cord, bowel, and buttock ischemia after endovascular aneurysm repair. Ann Vasc Surg 2011; 25:980.e15.
  84. Freyrie A, Testi G, Gargiulo M, et al. Spinal cord ischemia after endovascular treatment of infrarenal aortic aneurysm. Case report and literature review. J Cardiovasc Surg (Torino) 2011; 52:731.
  85. Setacci F, Sirignano P, De Donato G, et al. Endovascular thoracic aortic repair and risk of spinal cord ischemia: the role of previous or concomitant treatment for aortic aneurysm. J Cardiovasc Surg (Torino) 2010; 51:169.
  86. Djavani Gidlund K, Wanhainen A, Björck M. Intra-abdominal hypertension and abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2011; 41:742.
  87. Kakisis JD, Moulakakis KG, Antonopoulos CN, et al. Volume of new-onset thrombus is associated with the development of postimplantation syndrome after endovascular aneurysm repair. J Vasc Surg 2014; 60:1140.
  88. Moulakakis KG, Alepaki M, Sfyroeras GS, et al. The impact of endograft type on inflammatory response after endovascular treatment of abdominal aortic aneurysm. J Vasc Surg 2013; 57:668.
  89. Voûte MT, Bastos Gonçalves FM, van de Luijtgaarden KM, et al. Stent graft composition plays a material role in the postimplantation syndrome. J Vasc Surg 2012; 56:1503.
  90. Blum U, Voshage G, Lammer J, et al. Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms. N Engl J Med 1997; 336:13.
  91. Velázquez OC, Carpenter JP, Baum RA, et al. Perigraft air, fever, and leukocytosis after endovascular repair of abdominal aortic aneurysms. Am J Surg 1999; 178:185.
  92. Bölke E, Jehle PM, Storck M, et al. Endovascular stent-graft placement versus conventional open surgery in infrarenal aortic aneurysm: a prospective study on acute phase response and clinical outcome. Clin Chim Acta 2001; 314:203.
  93. Odegård A, Lundbom J, Myhre HO, et al. The inflammatory response following treatment of abdominal aortic aneurysms: a comparison between open surgery and endovascular repair. Eur J Vasc Endovasc Surg 2000; 19:536.
  94. Akin I, Nienaber CA, Kische S, et al. Effect of antibiotic treatment in patients with postimplantation syndrome after aortic stent placement. Rev Esp Cardiol 2009; 62:1365.
  95. Sartipy F, Lindström D, Gillgren P, Ternhag A. The role of procalcitonin in postimplantation syndrome after EVAR: a pilot study. Ann Vasc Surg 2014; 28:866.
  96. Galle C, De Maertelaer V, Motte S, et al. Early inflammatory response after elective abdominal aortic aneurysm repair: a comparison between endovascular procedure and conventional surgery. J Vasc Surg 2000; 32:234.
  97. Brewster DC, Jones JE, Chung TK, et al. Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade. Ann Surg 2006; 244:426.
  98. Ultee KH, Soden PA, Zettervall SL, et al. Conversion from endovascular to open abdominal aortic aneurysm repair. J Vasc Surg 2016; 64:76.
  99. Brinster CJ, Fairman RM, Woo EY, et al. Late open conversion and explantation of abdominal aortic stent grafts. J Vasc Surg 2011; 54:42.
  100. Scali ST, Runge SJ, Feezor RJ, et al. Outcomes after endovascular aneurysm repair conversion and primary aortic repair for urgent and emergency indications in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2016; 64:338.