What are the complications of Abdominal Aortic Aneurysm (AAA) repair?

From the Guidelines

Complications of abdominal aortic aneurysm (AAA) repair include both immediate surgical complications and long-term issues that require vigilant monitoring, with the most recent evidence suggesting that EVAR is associated with a lower 30-day mortality rate compared to open surgical repair, but may have long-term potential harms due to device failure 1.

Common Complications

• Bleeding, which may require transfusion or reoperation
• Infection at the surgical site or graft
• Renal dysfunction from ischemia or contrast exposure
• Ischemic colitis due to interruption of mesenteric blood flow
• Respiratory complications such as pneumonia and atelectasis, particularly in elderly patients with pre-existing pulmonary disease
• Cardiac events including myocardial infarction and arrhythmias, given the high prevalence of coronary artery disease in this population

EVAR-Specific Complications

• Endoleaks, where blood flows outside the graft but within the aneurysm sac, potentially requiring reintervention
• Device migration, component separation, and stent fractures, necessitating lifelong surveillance with imaging

Long-Term Complications

• Graft thrombosis, anastomotic pseudoaneurysms, graft infection, and aortoenteric fistulas
• Sexual dysfunction due to autonomic nerve damage during open repair

Management

• Early recognition through close postoperative monitoring
• Appropriate imaging surveillance, typically CT angiography at regular intervals
• Prompt intervention for complications
• Antiplatelet or anticoagulation therapy as indicated
• Aggressive cardiovascular risk factor modification to improve long-term outcomes, as recommended by the American College of Radiology Appropriateness Criteria 1. The most recent study from 2018 1 highlights the importance of accurate preoperative imaging evaluation for EVAR, and the need for lifelong surveillance with imaging to detect potential complications.

From the Research

Complications of Abdominal Aortic Aneurysm (AAA) Repair

The complications of AAA repair can be categorized into device-related and systemic complications.

• Device-related complications include:
  • Endoleaks
  • Endograft migration or collapse
  • Kinking and/or stenosis of an endograft limb
  • Graft infection
• Systemic complications include:
  • End-organ ischemia
  • Cerebrovascular and cardiovascular events
  • Post-implantation syndrome

Frequency of Complications

The rate of complications after endovascular AAA repair is estimated to range between 16% and 30% 2.

• The complication rate is higher following thoracic EVAR (TEVAR) and is estimated to be as high as 38% 2.
• Secondary re-interventions are required in approximately 19% to 24% of cases following endovascular abdominal and thoracic aortic aneurysm repair respectively 2.

Comparison of Open and Endovascular Repair

Studies have compared the complications of open and endovascular repair of AAA.

• A study found that cardiac and pulmonary complications were less frequent after EVAR, but graft-related complications were more frequent 3.
• Another study found that endovascular surgery was associated with fewer postoperative complications and in-hospital death than open surgery 4.
• A review of the literature found that EVAR is associated with a significant risk of complication in terms of both procedural associated morbidity and operative mortality 5, 6.

Management of Complications

The management of complications after AAA repair includes:

• Surveillance using imaging modalities such as computed tomography, magnetic resonance angiography, and ultrasonography 2.
• Secondary re-interventions using percutaneous techniques such as placement of cuff extension devices, additional endograft components or stents, and embolization techniques 2.