Part 3/Chapter 12/26-min read

Local Complications, Graft Thrombosis, Anastomotic Aneurysm, and Endovascular/Access Complication Rescue

Local vascular complications named by failure mode before rescue is chosen: graft thrombosis, anastomotic aneurysm, infection, pseudoaneurysm, and endovascular access disasters. The chapter frames the least morbid rescue that restores durable flow or seal for each failure pattern.

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Consult corner: A bedside consult-style discussion focused on what the clinician should decide next and what not to overinterpret.

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Failure modes before rescue choices

Local vascular complications are best approached by first naming the failure mode, then choosing the least morbid rescue that restores durable flow or seal. In chronic limb-threatening ischemia, the starting point is not the thrombosed graft or the access complication in isolation, but the limb: rest pain or tissue loss must be linked to confirmed peripheral artery disease, staged with WIfI, and mapped anatomically with GLASS before a new revascularization plan is selected. GLASS standardises infrainguinal anatomic complexity, but it does not replace judgment about conduit, comorbidity, prior groin surgery, infection, and patient goals.

Failure analysis should separate three recurring problems: a failing but still patent reconstruction, an occluded reconstruction with threatened limb, and a local structural complication such as pseudoaneurysm, wound breakdown, lymphatic complication, or endograft leak. The first is a surveillance and pre-emptive revision problem; the second is an acute limb rescue problem; the third is a local-control problem in which bleeding, infection risk, and future access often matter as much as lumen restoration. Duplex surveillance, symptom review, and attention to hemodynamic deterioration are therefore not administrative follow-up tasks; they are the mechanism by which thrombosis is prevented rather than treated after the fact.

Adults with chronic limb-threatening ischemia being considered for revascularization vs Patients with acute lower extremity bypass graft occlusion
  • Population
    Adults with chronic limb-threatening ischemia being considered for revascularization.
    Intervention
    Apply WIfI staging at presentation and use GLASS to plan infrainguinal revascularization; align graft-thrombosis salvage decisions with the same anatomic framework.
    Key result
    The 2019 Global Vascular Guidelines on chronic limb-threatening ischemia (CLTI) define the diagnosis as the combination of ischemic rest pain or tissue loss with confirmed peripheral artery disease, introduce the WIfI (Wound, Ischemia, foot Infection) limb staging system, and use the GLASS (Global Limb Anatomic Staging System) framework to standardise infrainguinal anatomic complexity and the evidence-based revascularization plan
    Limitation
    GLASS does not replace individualized assessment of conduit availability, comorbidity burden, and patient preference.
    Citation
  • Population
    Patients with acute lower extremity bypass graft occlusion.
    Intervention
    Use catheter-directed thrombolysis for acute bypass graft occlusion when limb threat is not immediately severe enough to require urgent surgery; plan to correct the unmasked causative lesion after successful lysis.
    Key result
    Catheter-directed thrombolysis for acute lower extremity bypass graft occlusion achieves approximately 89% amputation-free survival at one month and 75% at twelve months; technical failure and advanced age are associated with worse amputation outcomes; an important role of thrombolysis is to unmask the underlying causative lesion (conduit stenosis, anastomotic defect, inflow or outflow problem) that must be corrected to prevent rethrombosis
    Limitation
    Contraindicated in stroke within 2 months, active bleeding, intracranial tumor, or systemic coagulopathy; bleeding risk must be weighed against limb threat severity.
    Citation

The clinical posture differs after open bypass, common femoral endarterectomy, EVAR, and large-bore percutaneous access. After infrainguinal bypass, the key failure modes are stenosis, anastomotic defect, inflow disease, outflow deterioration, and thrombosis. After EVAR, the surgeon must classify endoleak type, look for sac expansion, migration, limb kinking, junctional separation, and limb-graft occlusion. After femoral or supra-aortic access, the immediate questions are whether there is bleeding, pseudoaneurysm, arteriovenous fistula, device failure, access thrombosis, or an injury requiring surgical control.

Groin complications deserve particular respect because they can convert a technically adequate reconstruction into a prolonged morbidity episode. Contemporary summaries of arterial groin surgical-site infection show heterogeneous definitions and follow-up, making quoted rates difficult to compare across series, but the clinical message is consistent: groin wound risk should be anticipated at the time of exposure, closure, dressing choice, and follow-up. Evidence comparing transverse and vertical groin incisions suggests that incision orientation may influence wound outcomes in selected settings, and closed-incision negative pressure therapy has shown pooled reduction in infection compared with standard dressings, with greater apparent value in higher-risk patients.

Guideline comparison

Cochrane systematic review: transverse versus vertical groin incisions for femoral artery exposure (2020)

What guidance applies?

  1. A 2020 Cochrane systematic review of randomized trials comparing transverse versus vertical groin incisions for femoral artery exposure synthesized incision-orientation effects on wound complication rates including SSI and lymphocele and reported low-to-moderate certainty effect estimates favoring transverse incisions in selected outcomes.
    Applies to
    Patients undergoing femoral artery exposure through groin incisions, assessed for SSI and lymphocele.
    Boundary
    Estimates are of low-to-moderate certainty and favor transverse incisions only in selected outcomes.
  2. Meta-Analysis Cinpt Versus Standard Groin Dressings And Surgical Site Infection · 2023
    A 2023 meta-analysis of randomized and observational trials of closed-incision negative pressure wound therapy applied to groin incisions in arterial surgery reported a pooled reduction in surgical site infection compared with standard dressings, with subgroup signals favoring use in higher-risk patients.
    Applies to
    Patients undergoing arterial surgery with groin incisions, including higher-risk subgroups.
    Boundary
    Pooled estimate combines randomized and observational data; subgroup signals favouring higher-risk patients are exploratory.
  3. Systematic Review Groin Wound Surgical Site Infection After Arterial Intervention · 2023
    A 2023 systematic review of groin wound surgical site infection incidence after arterial intervention pooled rates across open and percutaneous arterial-access cohorts and characterized the heterogeneity in SSI definitions and follow-up duration that limits cross-study comparability of groin-SSI burden.
    Applies to
    Patients undergoing open or percutaneous arterial-access procedures, assessed for groin SSI.
    Boundary
    Pooled rates are limited by heterogeneous SSI definitions and follow-up duration, constraining cross-study comparability.
Source · ·

Anastomotic aneurysm and pseudoaneurysm are structural failures, not simply imaging findings. Long-term experience after open aortic bypass established paraanastomotic aneurysm as a late complication with important presentation and rupture implications, so surveillance must extend beyond the early postoperative window. In the groin, anastomotic femoral pseudoaneurysm after aortofemoral or femoropopliteal bypass may be repaired openly or excluded endovascularly; covered stent-grafts are attractive for hostile groins, prior infection fields, or high operative risk, but the short-term feasibility evidence does not remove concern about durability and infection in the flexion zone.

Bypass thrombosis and access-site rescue

A thrombosed bypass is rarely “just a clot.” The rescue operation should be planned around the age of occlusion, limb threat, bleeding risk, conduit type, inflow, outflow, anastomotic integrity, and the likelihood that the underlying lesion can be corrected. Catheter-directed thrombolysis for acute lower-extremity bypass occlusion can preserve the limb in many patients, with reported amputation-free survival of approximately 89% at one month and 75% at twelve months, but its greatest value is often diagnostic: once thrombus clears, the stenosis, anastomotic problem, inflow lesion, or outflow failure that caused thrombosis becomes visible and must be treated.

Guideline note

Patients with iatrogenic femoral pseudoaneurysm after arterial access

  1. Supporting Study
    Ultrasound-guided thrombin injection is highly effective for femoral access-site pseudoaneurysm and is the preferred minimally invasive treatment for lesions greater than approximately 2 cm with a narrow neck; wide-neck or complex pseudoaneurysms carry higher risk of arterial occlusion from thrombin injection, and surgical repair should be considered for those cases.
    Applies to
    Patients with iatrogenic femoral pseudoaneurysm after arterial access.
    Boundary
    Embolization carries a small risk of distal embolization or arterial occlusion from thrombin; procedure should be performed under real-time ultrasound guidance.
Source

The first triage decision is whether the patient can safely undergo thrombolysis. Stroke within two months, active bleeding, intracranial tumor, and systemic coagulopathy are contraindications, and the bleeding risk must be weighed against limb-threat severity. When thrombolysis is inappropriate or time-to-rescue is unfavourable, open thrombectomy and operative revision remain central options. Contemporary synthesis of acute infrainguinal graft occlusion management emphasises diagnostic workup, selection between catheter-directed thrombolysis and open thrombectomy, adjunctive outflow correction, and the importance of time from occlusion in limb-salvage outcomes.

TreatmentPatients with acute lower extremity bypass graft occlusion
  • Action
    Use catheter-directed thrombolysis for acute bypass graft occlusion when limb threat is not immediately severe enough to require urgent surgery; plan to correct the unmasked causative lesion after successful lysis.
    Clinical point
    Catheter-directed thrombolysis for acute lower extremity bypass graft occlusion achieves approximately 89% amputation-free survival at one month and 75% at twelve months; technical failure and advanced age are associated with worse amputation outcomes; an important role of thrombolysis is to unmask the underlying causative lesion (conduit stenosis, anastomotic defect, inflow or outflow problem) that must be corrected to prevent rethrombosis.
    Caveat
    Contraindicated in stroke within 2 months, active bleeding, intracranial tumor, or systemic coagulopathy; bleeding risk must be weighed against limb threat severity.
    Citation
  • Patients with acute lower-extremity bypass graft occlusion being considered for thrombolysis, thrombectomy, or adjunctive endovascular outflow correction.
    Action
    Use limb-threat severity, time from occlusion, bleeding contraindications, conduit/anastomotic findings, and inflow/outflow lesions to choose thrombolysis, surgical thrombectomy, adjunctive endovascular correction, or urgent open revision.
    Clinical point
    A 2025 contemporary review of acute infrainguinal graft occlusion management synthesizes the diagnostic workup, indications for catheter-directed thrombolysis versus open surgical thrombectomy, and adjunctive endovascular techniques for outflow correction, with emphasis on time-from-occlusion thresholds influencing limb-salvage outcomes after failed bypass.
    Caveat
    Evidence is synthesis-level; individualize rescue by limb-threat severity, time from occlusion, conduit type, inflow and outflow lesions, and thrombolysis contraindications.
    Citation

The best rescue is prevention through surveillance of the failing graft. Duplex-based follow-up after lower-extremity revascularization is recommended to detect hemodynamically significant stenosis before thrombosis, with systematic clinical and duplex surveillance described at one, three, and six months in the first year and annually thereafter in European guidance; the same principle is carried forward in more recent lower-extremity PAD guidance, which also calls for prompt evaluation of symptomatic graft occlusion. The literature is not one-sided: surveillance-positive trial evidence supports pre-emptive rescue of failing vein and PTFE grafts, whereas a counterweight vein-graft surveillance trial tested whether routine duplex improved limb-salvage and cost-effectiveness outcomes, reminding the surgeon that surveillance programs must be linked to actionable thresholds and timely revision.

Medical therapy after revascularization is part of graft-complication prevention, but it must be individualised. The 2024 lower-extremity PAD guideline supports antiplatelet or anticoagulant strategies after infrainguinal revascularization to reduce graft thrombosis and major adverse limb events, while accounting for bleeding risk and conduit-specific factors. In VOYAGER PAD, rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily reduced the composite of acute limb ischemia, major amputation for vascular causes, myocardial infarction, ischemic stroke, and cardiovascular death compared with aspirin alone at three years, but increased ISTH major bleeding without increasing fatal bleeding.

Anticoagulation should not be treated as a universal patency solution. In a registry analysis of 7,612 infrainguinal bypass grafts, anticoagulation did not improve primary patency overall, although it was associated with better secondary patency in prosthetic conduits to below-knee targets; the same analysis found higher wound complication rates among anticoagulated patients. This is the practical trade-off at the bedside: a below-knee prosthetic graft with high thrombosis risk may justify more aggressive antithrombotic therapy, whereas a groin wound at risk of infection or dehiscence may make the same decision hazardous.

Guideline comparison

Adults with peripheral artery disease undergoing lower extremity revascularization

What guidance applies?

P03 1161 Cir
  1. The 2024 ACC/AHA Guideline for Management of Lower Extremity Peripheral Artery Disease provides Class I recommendations for dual antiplatelet or anticoagulant therapy after infrainguinal revascularization to reduce graft thrombosis and major adverse limb events, specifies duplex ultrasound surveillance at defined intervals after bypass to detect hemodynamically significant stenosis before graft failure, and recommends prompt evaluation and management of graft occlusion in patients with ischemic symptoms.
    Applies to
    Adults with peripheral artery disease undergoing lower extremity revascularization.
    Boundary
    Antithrombotic regimen should account for bleeding risk; guideline recommendations apply broadly but specific conduit and anatomic factors require individualized assessment.
    Strength
    Class I
Supporting Study2 positions
  1. In VOYAGER PAD (6564 patients after lower extremity revascularization), rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily reduced the composite of acute limb ischemia, major amputation for vascular causes, myocardial infarction, ischemic stroke, and cardiovascular death compared to aspirin alone (17.3% vs 19.9% at 3 years; HR 0.85, 95% CI 0.76–0.96, p=0.009), with increased ISTH major bleeding (HR 1.42, p=0.007) but no increase in fatal bleeding.
    Applies to
    Adults with PAD undergoing lower extremity revascularization (surgical or endovascular).
    Boundary
    ISTH major bleeding was significantly higher with the combination; absolute risk reduction for the primary endpoint was 2.6% at 3 years; benefit applies to both surgical and endovascular revascularization.
  2. In a registry-based comparative effectiveness analysis of 7,612 infrainguinal bypass grafts, anticoagulation did not significantly improve primary patency overall (HR 0.98, 95% CI 0.86–1.11), but was associated with modestly better secondary patency in prosthetic conduits reaching below-knee targets (HR 0.72, 95% CI 0.54–0.97); anticoagulated patients had significantly higher wound complication rates (OR 1.33, 95% CI 1.11–1.61), illustrating the trade-off between graft patency and local morbidity.
    Applies to
    Patients after infrainguinal bypass, registry-based US cohort (2003-2015).
    Boundary
    Retrospective observational design; anticoagulation type and dosing varied; selection bias for high-risk patients receiving anticoagulation cannot be excluded.
Source · ·

Access-site pseudoaneurysm management begins with anatomy. Ultrasound-guided thrombin injection is highly effective for iatrogenic femoral pseudoaneurysm and is preferred for lesions greater than approximately 2 cm when the neck is narrow, but wide-neck and complex pseudoaneurysms carry higher risk of arterial occlusion or distal embolisation and should push the surgeon toward operative repair or another controlled strategy. The broader pseudoaneurysm literature comparing compression, thrombin injection, and surgery supports this anatomy-based approach rather than a one-treatment-fits-all pathway.

Access devices, imaging, and endoleak rescue

Percutaneous access complications are reduced most reliably before the sheath enters the artery. Ultrasound-guided femoral puncture lowers access-site complication rates compared with landmark-guided puncture and should be treated as routine practice for percutaneous femoral access, particularly in patients with obesity, scarring, or absent femoral pulse. Registry data from peripheral vascular interventions show that access-site complications occur in roughly 3–4% of procedures, with female sex, increasing sheath size, antithrombotic exposure, and non-routine closure-device use among independent predictors; these complications prolong admission and increase in-hospital morbidity.

Closure devices are not substitutes for arterial judgment. Older closure-device complication reviews remain relevant because device failure, bleeding, occlusion, pseudoaneurysm, and the need for rescue repair are recurring patterns across platforms. Contemporary large-bore access evidence comparing ProGlide and Prostar in transfemoral TAVI reports pooled vascular complication, bleeding, and device-failure outcomes, while axillary-access closure-device synthesis characterises major vascular complications, conversion to surgical repair, and access-site bleeding in percutaneous axillary series. The operative lesson is to select the access artery, puncture site, sheath profile, and closure method as a single plan, with surgical bailout already defined.

Endoleak rescue begins with classification and sac behavior. Type I and Type III endoleaks are high-pressure failure modes and usually require prompt endovascular correction once identified; Type II endoleak is different, because management is driven by sac enlargement and persistence rather than leak presence alone. Type II endoleaks have a heterogeneous natural history, with approximately one-third resolving spontaneously, but persistent Type II endoleak with sac growth carries late rupture risk and warrants intervention.

For Type II endoleak requiring intervention, transarterial coil embolisation is a common first-line approach when sac enlargement triggers treatment. Technical success is achievable in most cases, but recurrence and reintervention are frequent enough that the procedure should be explained as part of a surveillance-dependent pathway rather than a guaranteed definitive cure. CTA-defined inflow, outflow, and sac anatomy determine whether transarterial access is realistic; direct sac embolisation and transcaval embolisation remain alternatives when feeders are not accessible transarterially.

Device and anatomy influence endoleak surveillance. PTFE-based endografts have shown higher Type II endoleak prevalence within one year than polyester-based devices, with the difference emerging mainly after 30 days; this should not trigger automatic treatment without sac growth, but it should sharpen the post-EVAR imaging plan and the threshold for investigating a new or persistent leak. Secondary endoleak management syntheses reinforce the need for surveillance imaging capable of distinguishing Type I, Type II, and Type III mechanisms, because embolisation, graft extension, relining, and conversion address different failure modes.

TreatmentEndoleak classification and rescue table separating Type I, Type II, and Type III pathways
  • Classify endoleak type and pressure-risk, obtain CTA/adjunct imaging to map anatomy, repair Type I/III promptly, and reserve Type II intervention for persistent or sac-expanding leaks with anatomically planned embolization.
    Trigger
    Post-EVAR endoleak or suspected endograft failure on surveillance imaging.
    Branch / Endpoint
    Type I and III endoleaks are high-pressure seal failures; Type II intervention depends on persistence, sac growth, and CTA-defined embolization anatomy.
    Citation
  • Observe type II endoleak without sac enlargement; intervene when sac grows ≥5 mm on serial imaging; document sac diameter trend at every surveillance visit.
    Trigger
    Patients with type II endoleak after EVAR.
    Branch / Endpoint
    Spontaneous resolution is more common for early type II endoleaks; late persistent endoleak with sac growth carries the highest rupture risk.
    Citation
  • Perform transarterial coil embolization targeting the feeding vessel(s) when type II endoleak with sac growth requires intervention; plan surveillance imaging to confirm sac stability and detect recurrence.
    Trigger
    Patients with type II endoleak after EVAR with indication for intervention.
    Branch / Endpoint
    Reintervention rates are non-trivial; alternative approaches include direct sac embolization and transcaval embolization for feeders not accessible transarterially.
    Citation
  • A 2024 EJVES Vascular Forum literature synthesis of published Type III endoleak reports after endovascular aortic repair characterized device-era differences in junctional and fabric Type III endoleak incidence and summarized contemporary rescue strategies including bridging-stent relining, proximal cuff placement, and graft replacement for definitive seal restoration.
    Trigger
    Junctional or fabric Type III endoleak after endovascular aortic repair.
    Branch / Endpoint
    Applies to junctional and fabric Type III endoleak after endovascular aortic repair.
    Citation

Type I and Type III endoleaks are seal failures until proven otherwise. Type Ia management may require balloon angioplasty, proximal cuff placement, endostapling, chimney or fenestrated strategies, embolisation in selected anatomy, open conversion, or conservative management only when the clinical and anatomic context supports it. Type III endoleak rescue is directed at restoring device continuity and seal, using bridging-stent relining, proximal cuff placement, graft replacement, or selected endovascular aneurysm sealing platforms when anatomy permits. Late open conversion after EVAR is increasingly encountered, most often for endoleak progression and sac expansion, and carries perioperative outcomes that exceed those of primary open repair.

Guideline comparison

Vascular Quality Initiative registry analysis: access-site complications (2014)

  1. Supporting Study
    Ultrasound-guided percutaneous femoral artery access reduces access-site complication rates compared with anatomic landmark-guided puncture; systematic review evidence supports routine use of ultrasound guidance as the standard of care for percutaneous femoral access during endovascular procedures to reduce hematoma, pseudoaneurysm, and arteriovenous fistula formation.
    Applies to
    Patients undergoing percutaneous femoral artery access for endovascular procedures.
    Boundary
    Evidence quality varies across included studies; the benefit is most pronounced in patients with obesity, scarring, or absent femoral pulse.
  2. In a multicentre Vascular Quality Initiative registry analysis of peripheral vascular interventions, access-site complications occurred in roughly 3-4% of procedures, with female sex, increasing sheath size, antithrombotic exposure, and non-routine vascular closure-device use among the independent predictors, and complications were associated with prolonged length of stay and excess in-hospital morbidity.
    Applies to
    Access-site complications after peripheral vascular interventions: incidence and predictors, including female sex, larger sheath size, antithrombotic exposure, and vascular closure-device use.
    Boundary
    Registry analysis; the identified predictors are associations and do not establish causation, and apply to peripheral vascular interventions.
  3. Systematic Review And Meta-Analysis Proglide Versus Prostar Vascular Closure Devices In Transfemoral TAVI · 2023
    A 2023 systematic review and meta-analysis comparing ProGlide and Prostar suture-mediated vascular closure devices in transfemoral transcatheter aortic valve implantation reported pooled major and minor vascular complication rates, access-site bleeding, and device-failure incidence across the two platforms, with subgroup analyses by sheath profile and operator volume.
    Applies to
    Suture-mediated vascular closure devices (ProGlide vs. Prostar) for large-bore transfemoral access in transcatheter aortic valve implantation; vascular and access-site complications by sheath profile and operator volume.
    Boundary
    Findings apply to ProGlide versus Prostar closure in transfemoral TAVI; subgroup analyses by sheath profile and operator volume are exploratory.
Source · ·

Clinical integration, follow-up, and evidence boundaries

The reintervention decision after local complication or graft failure should integrate limb stage, anatomy, physiology, and expected durability. In CLTI requiring infrapopliteal revascularization, BASIL-2 found better amputation-free survival with a best endovascular treatment first strategy than with a vein bypass first strategy, largely driven by fewer deaths in the endovascular group; cardiovascular and respiratory comorbidities were the dominant causes of death in both arms. BASIL-1 remains the foundational earlier trial context for bypass-first versus angioplasty-first strategies in severe limb ischemia, so the practical conclusion is not that one strategy always wins, but that failed reconstruction should be rescued in the context of the patient’s survival risk, conduit, anatomy, and limb threat.

Follow-up must be specific to the reconstruction. After lower-extremity bypass, the program should look for stenosis before thrombosis and act on hemodynamic deterioration or anatomically significant stenosis; after EVAR, it should look for sac growth, endoleak class, migration, kinking, fatigue, limb occlusion, and need for relining or conversion. Limb-graft occlusion after EVAR occurs in a small minority but is strongly associated with hostile iliac anatomy, limb oversizing, and distal landing in a caliber-mismatched external iliac artery; many occlusions can be managed with endovascular thrombolysis followed by adjunctive bare-metal stenting when the anatomy supports it.

Aortoiliac and supra-aortic access complications require the same failure-mode discipline. Iliac branch devices can preserve hypogastric flow during aortoiliac aneurysm repair, with midterm reports describing technical success, branch patency, freedom from secondary intervention, and pelvic-ischemia outcomes; comparative evidence on internal iliac revascularization versus occlusion addresses buttock claudication, sexual-function endpoints, and reintervention but remains limited by evidence certainty. For zone-2 TEVAR, left subclavian revascularization options include surgical bypass or transposition and endovascular strategies, each with reported procedural success, stroke, spinal cord ischemia, and patency considerations.

TreatmentPatients after lower extremity arterial revascularization (bypass or endovascular)
  • Action
    Schedule duplex surveillance at 1, 3, 6 months post-revascularization, then annually; intervene for hemodynamic deterioration or >50% stenosis on surveillance to prevent graft thrombosis and limb loss.
    Clinical point
    The 2017 ESC guidelines on peripheral arterial diseases recommend systematic clinical and duplex ultrasound surveillance after lower extremity revascularization at one, three, and six months in the first year and annually thereafter to detect graft failure and restenosis before thrombosis; hemodynamic deterioration or anatomically significant stenosis (>50%) should trigger evaluation for reintervention to preserve secondary patency.
    Caveat
    The 2024 ACC/AHA guideline updates some of these intervals; evidence base for specific surveillance intervals is largely observational.
    Citation
  • Patients undergoing open common femoral endarterectomy followed for late restenosis and secondary intervention beyond 5 years.
    Action
    Interpret alongside anatomy, presentation, operative risk, and local practice before changing management.
    Clinical point
    A 2022 single-center long-term cohort of patients undergoing common femoral endarterectomy reported primary patency, freedom from reintervention, limb-salvage, and overall survival at follow-up beyond 5 years, characterizing the durability profile of open CFA reconstruction and the incidence of late restenosis or secondary intervention.
    Caveat
    Single-center cohort without a comparator; durability results may not generalise beyond the reported series.
    Citation
  • Endograft surveillance and rescue, consolidating multiple complication categories — migration, kink, endoleak surveillance, and late conversion.
    Action
    Interpret alongside anatomy, presentation, operative risk, and local practice before changing management.
    Clinical point
    A 2018 Cardiovascular Diagnosis and Therapy comprehensive review of endovascular aortic repair complications consolidates contemporary surveillance imaging schedules, evaluation pathways for stent-graft migration, kinking, and endograft fatigue, and procedural management options including relining, conversion, and explantation as definitive rescue paths.
    Caveat
    Comprehensive review consolidating management options; it does not provide comparative outcome data favouring any single rescue path.
    Citation
  • Iliac branch device implantation for aortoiliac aneurysm to preserve hypogastric flow, including technical success, branch-vessel patency, and pelvic-ischemia outcomes.
    Action
    Interpret alongside anatomy, presentation, operative risk, and local practice before changing management.
    Clinical point
    A single-center midterm cohort of iliac branch device implantation for aortoiliac aneurysm reported technical success, branch-vessel patency, freedom from secondary intervention, and pelvic-ischemia outcomes during initial program experience, characterizing the early procedural and follow-up profile of contemporary IBD use to preserve hypogastric flow.
    Caveat
    Single-center midterm cohort from initial program experience; early outcomes may not reflect later or wider practice.
    Citation

Open common femoral reconstruction remains a durable benchmark for local groin reintervention, particularly when endovascular repair would leave persistent flexion-zone, infection, or access concerns. Long-term common femoral endarterectomy cohorts report patency, freedom from reintervention, limb salvage, and survival beyond five years, helping frame late restenosis and secondary intervention as expected surveillance topics rather than surprises. When a groin anastomotic pseudoaneurysm is treated with a covered stent because open revision is high risk, follow-up must remain vigilant for patency loss, infection, and durability limits, because the supporting evidence is case-series level and open repair remains the reference standard.

Adults with PAD undergoing lower extremity revascularization (surgical or endovascular) vs Patients with CLTI requiring infrapopliteal revascularization with or without additional infrainguinal procedure vs Patients with anastomotic femoral pseudoaneurysm after aortofemoral or femoropopliteal bypass
  • Population
    Adults with PAD undergoing lower extremity revascularization (surgical or endovascular).
    Intervention
    After lower extremity revascularization, consider rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily to reduce major adverse limb and cardiovascular events; assess bleeding risk before prescribing and counsel patients on the trade-off between reduced ischemic events and increased non-fatal bleeding.
    Comparator
    19.9% at 3 years; HR 0.85, 95% CI 0.76–0.96, p=0.009), with increased ISTH major
    Key result
    In VOYAGER PAD (6564 patients after lower extremity revascularization), rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily reduced the composite of acute limb ischemia, major amputation for vascular causes, myocardial infarction, ischemic stroke, and cardiovascular death compared to aspirin alone (17.3% vs 19.9% at 3 years; HR 0.85, 95% CI 0.76–0.96, p=0.009), with increased ISTH major bleeding (HR 1.42, p=0.007) but no increase in fatal bleeding
    Limitation
    ISTH major bleeding was significantly higher with the combination; absolute risk reduction for the primary endpoint was 2.6% at 3 years; benefit applies to both surgical and endovascular revascularization.
    Citation
  • Population
    Patients with CLTI requiring infrapopliteal revascularization with or without additional infrainguinal procedure.
    Intervention
    When planning revascularization for infrapopliteal CLTI, the BASIL-2 data support considering an endovascular-first strategy; the superior outcomes were driven by mortality differences, so patient comorbidity burden should inform whether an open or endovascular approach is preferable.
    Comparator
    63%; adjusted HR 1.35, 95% CI 1.02–1.80, p=0.037), with the difference largely d
    Key result
    In the BASIL-2 trial (345 patients with CLTI requiring infrapopliteal revascularization), a best endovascular treatment first strategy was associated with significantly better amputation-free survival than a vein bypass first strategy (major amputation or death: 53% vs 63%; adjusted HR 1.35, 95% CI 1.02–1.80, p=0.037), with the difference largely driven by fewer deaths in the endovascular group; cardiovascular and respiratory comorbidities were the predominant causes of death in both arms
    Limitation
    The trial was open-label; baseline cardiovascular comorbidities influenced outcomes independent of revascularization strategy; vein bypass patients had higher perioperative mortality risk, which drove the primary endpoint difference.
    Citation
  • Population
    Patients with anastomotic femoral pseudoaneurysm after aortofemoral or femoropopliteal bypass.
    Intervention
    Consider covered stent-graft exclusion for anastomotic femoral pseudoaneurysm in patients with hostile groins or high operative risk; reserve open revision as the reference standard and preferred approach in anatomically favorable patients.
    Comparator
    Endovascular exclusion with covered stent-grafts is technically feasible for anastomotic femoral pseudoaneurysm repair and offers a less invasive alternative to open revision in patients with hostile groins, prior groin infections, or high operative risk; published case series report satisfactory short-term technical success, but longer-term durability data remain limited and open repair remains the reference standard.
    Key result
    Evidence is case series-level; long-term patency and infection risk with covered stents in the groin are uncertain; open repair remains the reference standard.
    Limitation

The evidence base in this chapter is heterogeneous, and that matters at the operating table. Some decisions are supported by large trials or major registries, such as antithrombotic therapy after lower-extremity revascularization, BASIL-2 strategy data, VOYAGER PAD, and bypass anticoagulation registry outcomes. Other decisions, especially covered stent-graft repair of anastomotic femoral pseudoaneurysm, Type III endoleak rescue platforms, axillary closure-device practice, and several endoleak rescue maneuvers, rest on observational series, systematic reviews of heterogeneous reports, or society standards. The surgeon should therefore present certainty honestly: high-pressure endoleak and symptomatic graft occlusion demand prompt action, whereas Type II endoleak without sac growth, marginal surveillance abnormalities, and high-risk groin relining require measured, anatomy-specific judgment.

References

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  2. 2.
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  4. 4.
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  5. 5.
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    Non-Surgical treatment Versus Surgery for Iatrogenic Femoral Artery Pseudoaneurysms: Systematic Review and Meta-Analysis. Front Surg. 2022. doi:10.3389/fsurg.2022.905701. PMID:36211300.

  6. 6.
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