Insertion Site Complications Following EVAR
Access site complications occur in 2-6% of EVAR procedures, with the most critical being hemorrhage (including retroperitoneal), pseudoaneurysm, arteriovenous fistula, arterial thrombosis/occlusion, and limb ischemia—all requiring immediate recognition and intervention to prevent limb loss or death. 1, 2
Common Insertion Site Complications and Their Management
Hemorrhage and Hematoma
Access site bleeding is the most frequent complication, presenting as expanding groin hematoma or occult retroperitoneal hemorrhage. 1
- Groin hematoma: Monitor for expansion; stable hematomas can be managed conservatively with observation. 1
- Retroperitoneal hemorrhage: Suspect when patient develops hypotension, suprainguinal tenderness, severe back pain, or lower-quadrant abdominal pain despite stable groin appearance. 1
Pseudoaneurysm
Pseudoaneurysms occur in 0.1-0.2% of diagnostic procedures and 3.5-5.5% of interventional procedures, though physical examination alone misses >60% of cases. 2
- Clinical presentation: Pulsatile mass at puncture site, though can be clinically silent; always palpate for pulsatile mass. 2
- Diagnostic approach: Obtain duplex ultrasound for any clinical suspicion—physical exam is unreliable. 2
- Management algorithm: 2
- <2.0 cm: Conservative management with ultrasound follow-up at 1 month (61% resolve spontaneously within 7-52 days; 90% that will close do so within 2 months)
- ≥2.0 cm or persistent/recurrent: Ultrasound-guided thrombin injection (first-line) or compression therapy
- Failed thrombin injection: Stent-graft deployment, particularly for large arterial defects or accompanying AVF 3
Arteriovenous Fistula
AVF formation occurs when both artery and vein are punctured, detected by continuous murmur over puncture site. 1, 2
- Clinical signs: Continuous bruit, potential high-output heart failure in rare cases. 1
- Management: Stent-graft implantation is highly effective, even when located close to femoral bifurcation. 3
- Critical caveat: Avoid repeat use of same access site—risk of enlarging fistula, inadvertent venous access, and hemostasis complications. 1
Arterial Thrombosis and Limb Occlusion
Limb ischemia complicates 9% of EVAR procedures, with limb occlusions accounting for 71% of these cases. 4
Presentation spectrum: 4
- Severe acute arterial ischemia (most urgent)
- Rest pain
- Intermittent claudication
- Decreased/absent femoral pulse
- Graft limb occlusion (most common—71%)
- Distal embolization (15%)
- Common femoral artery thrombosis (15%)
- Acute severe ischemia: Immediate thrombectomy with stent placement or femorofemoral bypass
- Embolization/CFA injury: Emergent embolectomy followed by femoral endarterectomy and patch angioplasty or interposition graft
- Iliofemoral thrombosis: Catheter-directed thrombolysis followed by prolonged balloon inflation or stent placement 3
- Mild claudication: Expectant management acceptable if symptoms improving 4
Arterial Dissection or Perforation
Vessel injury from delivery system or improper puncture technique can cause dissection or perforation. 1, 5
- Obstructive dissection flaps in CFA: Prolonged balloon inflation; if extending to iliac arteries, deploy self-expanding stents. 3
- Active bleeding/perforation: Prompt stent-graft placement at leakage site is lifesaving. 3
Arterial Closure Device Failure
Device failure contributes to access site complications, potentially causing bleeding or arterial occlusion requiring emergent intervention. 1
- Management: May require emergent endarterectomy to remove device. 1
- Alternative complications: Stenoses and occlusions from closure devices can be treated with balloon angioplasty and catheter-directed thrombolysis. 3
Localized Infection and Ecchymosis
Infection and bruising at access site are less severe but require monitoring. 1
- Simple ecchymosis without swelling: Reassure patient if no pulsatile mass, symmetric pulses, and no expanding hematoma. 2
- Infection: Requires antibiotics; if involving endograft, may necessitate explantation. 6
High-Risk Patient Factors
Your patient population (>65 years, hypertension, atherosclerotic disease, anticoagulation) represents the highest-risk group for access complications. 1, 2
- Age ≥70 years
- Female sex
- Peripheral arterial disease (atherosclerotic disease)
- Renal failure or creatinine ≥2 mg/dL
- Anticoagulation/antiplatelet therapy intensity
- Body surface area ≤1.6 m² or BMI ≥28 kg/m²
- Emergent procedures
- Glycoprotein IIb/IIIa inhibitor use
Critical Post-Procedure Monitoring
Immediate assessment must include: 2
- Bilateral pedal pulse palpation
- Comparison of systolic Doppler blood pressures between legs
- Continuous monitoring until femoral sheath removal for vasovagal responses
- High-risk patients require continuous ECG monitoring ≥24 hours 2
Return precautions for patients: 2
- New swelling at groin
- Pulsatile mass
- Pain, numbness, weakness
- Color changes in leg
- Any signs of limb ischemia
Technical Prevention Strategies
- Proper puncture site location: Avoid "too low" (below CFA bifurcation) or "too high" (above superior pubic ramus—noncompressible) punctures. 1
- Femoral angiogram verification: Standard practice to confirm appropriate puncture location. 1, 2
- Ultrasound-guided access: Consider in high-risk patients to reduce complications. 2
- Operator experience: Meticulous technique cannot be overemphasized. 1
Special Considerations for EVAR-Specific Complications
Female patients experience higher rates of both intraoperative and early postoperative vascular complications due to smaller vessel caliber. 5
Adjunctive vascular procedures to iliofemoral arteries are frequently necessary during EVAR to repair delivery system damage or provide adequate conduit when access arteries are inadequate. 5