Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 86-89

Successful endovascular reconstruction of acute lower limb ischemia secondary to embolic aortoiliac occlusion using endologix AFX unibody stent graft

Department of Vascular Surgery, Royal North Shore Hospital, Sydney, Australia

Date of Submission07-Dec-2020
Date of Acceptance16-Feb-2021
Date of Web Publication30-Aug-2021

Correspondence Address:
Animesh Singla
Department of Vascular Surgery, Royal North Shore Hospital, Sydney
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_164_20

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Embolic aortoiliac occlusion presenting with acute lower limb ischemia is uncommon and represents a challenge for appropriate management. Several techniques for reconstruction are available, taking into account patient's demographics, surgical risk, and aortoiliac anatomy. Several endovascular and open surgical options exist. We present a novel management strategy, with the use of an endovascular aneurysm stent graft for the reconstruction of native aortoiliac system in a middle-aged female. This allowed for successful revascularization of her lower limb ischemia, while maintaining options for future intervention. Long-term data on this option for the management of acute aorto-iliac occlusion are limited.

Keywords: Aortic occlusion, AFX, endovascular

How to cite this article:
Wang Y, Singla A, Puttaswamy V. Successful endovascular reconstruction of acute lower limb ischemia secondary to embolic aortoiliac occlusion using endologix AFX unibody stent graft. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:86-9

How to cite this URL:
Wang Y, Singla A, Puttaswamy V. Successful endovascular reconstruction of acute lower limb ischemia secondary to embolic aortoiliac occlusion using endologix AFX unibody stent graft. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Aug 15];8, Suppl S1:86-9. Available from:

  Introduction Top

Embolic aortoiliac occlusion presenting with acute lower limb ischemia is uncommon and represents a challenge for appropriate management. Several techniques for reconstruction are available, considering patient's demographics, surgical risk, and aortoiliac anatomy. Several endovascular and open surgical options exist. We present a novel management strategy, with the use of an endovascular aneurysm stent graft (AFX) for reconstruction of the native aortoiliac system in a middle-aged female. This allowed for successful revascularization of her lower limb ischemia, whilst still maintaining contralateral access options for future intervention. This case discusses the considerations of management, including underlying etiology and treatment options.

  Case Report Top

A 54-year-old woman presented to the emergency department with acute left lower limb pain and difficulty weight bearing for 1 week duration. She also complained of recent onset of buttock claudication in the preceding few months. Her medical history was significant for obesity (body mass index 58, 140 kg), hypertension, and newly diagnosed type 2 diabetes mellitus. She had also suffered from a prior episode of superficial thrombophlebitis. There was no prior history of hematological investigations. She had significant family history of recurrent venous thromboembolism and chronic lymphocytic leukemia. On the clinical examination, the left lower limb had no palpable left-sided pulses with reduced sensation to the left foot (Rutherford 2A ischemia).

Computed tomography (CT) angiography was performed and revealed a 4 cm occlusive thrombus in the distal aorta with a 2.4 cm clot extension to the proximal left iliac artery [Figure 1]. There was also evidence of a left-sided popliteal occlusion with single vessel peroneal reconstitution supplying the left foot. She was transferred to our tertiary center for ongoing management and intervention.
Figure 1: Preoperative aortoiliac acute occlusion

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She was commenced on full anticoagulation with a heparin infusion. Further investigations for thrombophilia and thromboembolic sources were carried out during preoperative workup. Genetic testing and serum coagulation profiles returned normal. Her case was discussed at a multi-disciplinary meeting, and the decision was made to plan for endovascular reconstruction using AFX (Endologix, Irvine, CA, USA) aortic stent technology. Due to her extreme obesity, an endovascular option was deemed to be the optimal treatment.

The procedure was performed under general anesthesia in a hybrid operating suite with fixed C-arm capabilities. Arterial access was established through bilateral common femoral artery punctures using an ultrasound-guided retrograde approach. Proglide (Abbott Vascular, Abbott Park, IL, USA) sutures were placed in both common femoral arteries with a preclosed technique. She was systemically heparinized with 10,000 units to maintain an activated clotting time of >250 s.

A 22 mm × 60 mm AFX endograft (covered stent graft) was delivered using a dedicated 17-Fr introducer sheath on the right side and a 7-Fr introducer sheath on the contralateral side. A contralateral wire was snared in the mid-aorta to reduce manipulation within thrombus and both wires were passed into main AFX device. The AFX device was passed into the infrarenal aorta and brought down into position on the aortic bifurcation, taking care to minimize manipulation to reduce the chance of distal embolization. The AFX stent was deployed with the main body and ipsilateral limb, followed by the contralateral limb [Figure 2]. Gentle postdilatation was performed using bilateral 8 mm kissing balloon angioplasty.

On repeat angiogram, excellent flow was noted through the aorta and both common iliac arteries. No residual clot was seen at the bifurcation [Figure 3]. There was thrombus in the left distal common iliac artery, which appeared to have migrated during the AFX deployment. A decision was made to proceed with a left femoral cut down and open embolectomy. The left common femoral artery was dissected and controlled. A transverse arteriotomy in the common femoral artery was performed, and embolectomy was performed using size 4 Fogarty catheters. The retrieved clot was highly organized and fibrotic.
Figure 2: 2021 endologix. (a) AFX deployment device (b) configuration of AFX stent graft with reconstruction of aortoiliac bifurcation

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Figure 3: Postaortoiliac reconstruction using AFX unibody stent graft

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Completion angiography confirmed no evidence of aortoiliac thrombus. The left femoral arteriotomy was closed with 6-0 Prolene sutures, and the wound was closed in layers over a suction drain. The right femoral puncture was sealed after the removal of the 17-Fr sheath using the previously positioned Proglide sutures. A decision was made not to treat the popliteal occlusion due to distal extent of disease and significant improvement in inflow.

She was transferred to the intensive care unit for postoperative monitoring. There was an improvement in her lower limb circulation; however, she continued to have left foot swelling as well as plantar foot neuropraxia. Postoperative CT angiography showed good flow through the AFX graft at the aortic bifurcation with no proximal embolus but ongoing occlusion of the popliteal artery. Over the next 2 weeks with anticoagulation, the left leg symptoms improved. She had some persistent sensory changes to her left foot but continued to mobilize. A decision was made not to treat the popliteal occlusion. She was discharged on long-term anticoagulation (warfarin) for ongoing rehabilitation.

  Discussion Top

Acute embolic aortoiliac occlusion can be a life-threatening condition associated with significant morbidity and mortality.[1],[2],[3] Patients can present with acute lower limb ischemia affecting one or both lower limbs. It can also lead to ischemic complications of abdominal and pelvic viscera due to inferior mesenteric artery and internal iliac artery involvement.[2]

In the acute setting, these patients are often in extremis and require swift revascularization. Underlying etiology is important to determine and can be suggested by history and imaging features. This lady had no prior history of cardiac or aortic disease that would account for an embolic source, although she did have several atherosclerotic risk factors, including diabetes, hypertension, and obesity. Acute occlusions can occur from both embolic and thrombotic causes, and imaging features of calcification can help differentiate the presence of prior plaque or stenosis. Rarely, other uncommon pathologies such as aortic sarcoma, atrial myxoma, or infective endocarditis can present with an acute aortic bifurcation occlusion.[4]

Open, endovascular, and hybrid options exist, highlighted below. The advantages of open reconstruction include durability (especially in younger patients) and allow for direct histo-pathological assessment of the specimen. However, there is morbidity related to laparotomy, aortic cross-clamping and aortoiliac reconstruction. In our patient, this approach had increased risk of significant morbidity due to her extreme obesity and general body habitus.[5] Other open surgical options include axillo-bifemoral reconstruction with a prosthetic extra-anatomical bypass. The reconstruction is likely to be successful however not ideal in a younger patient with 5-year patency rates of 75%–80%.[6] Furthermore, due to her body habitus, control of the axillary artery and bilateral femoral exposures would be technically challenging with increased overall morbidity resulting in long-term complications relating to limb occlusion, graft infection and wound breakdown in such a young patient. Another open reconstruction method involves bilateral femoral cutdowns and removal of the thrombus using bilateral Fogarty embolectomy techniques. This may be particularly difficult if there is a large thrombotic burden extending deep into the aorta as in this case.

Endovascular options include the use of clot lysis and mechanical thrombectomy using devices such as the AngioJet (Boston Scientific, Marlborough, MA, USA). This may be successful with recent emboli however may lead to distal embolization and inadequate clot clearance[7] necessitating stents to trap thrombus at the aortic bifurcation.

The covered endovascular reconstruction of aortoiliac bifurcation (CERAB) includes options with the use of separate balloon mounted covered stents. If a CERAB procedure was required, data are available to confirm relatively good long-term patency. Whilst COBEST and Dutch Iliac Trials have confirmed the use of common iliac stent for chronic disease, its role in acute iliac occlusions is less clear.[8],[9] However, this technique changes aortic bifurcation hemodynamics and the ability to gain contralateral access is lost. A variation of a CERAB procedure may need to be performed using stents in both the aorta and iliac arteries. Many different options for stenting and trapping the thrombus exist including the use of both covered and uncovered self-expanding and balloon-expandable stents.

Another option for treating aortic bifurcation disease is the use of the AFX stent graft system. This minimally invasive approach allows reopening of the aortic bifurcation region in addition to thrombus entrapment. The AFX unibody covered stent graft preserves normal geometry of the native aortoiliac bifurcation allowing to maximize patency, improving flow dynamics, and allowing contralateral access if required whilst maintaining options for future endovascular intervention using up and over approaches.[10] AFX has been described for the use of TASC C and D chronic aortoiliac occlusive disease. We report the first case in the literature of using the AFX for the treatment of acute embolic aortic bifurcation occlusion.[10]

The main disadvantage to this technique is requirement for familiarity with the endovascular stent technology. Whilst concern regarding added complexity in comparison to standard kissing iliac stents, the use of this technique in familiar hands can lead to excellent results with minimal morbidity.

There is a risk of distal thromboembolism at different stages of the procedure. For example, with the introduction of the 17-Fr sheath, snaring of a contralateral limb wire during stent graft deployment and angioplasty of the stent resulting in “toothpasting.” To minimize these risks, snaring of the contralateral limb wire well above the thrombus, light manipulation into position and gentle angioplasty should be performed to allow adequate opening of the graft. Cutdown and control of common iliac bifurcation can also be considered to reduce this risk. As in our case, following AFX deployment, left common femoral exposure and embolectomy allowed resolution of distal thromboembolism. After removal, it was clear that due to its highly organized nature, a simple embolectomy of the distal aorta would have been unlikely to be successful without other adjuvant treatments. Finally, appropriate access vessels may limit utility of this device, with minimum 7 mm iliac vessel required for delivery of the device.

With the AFX stent graft, we have been able to successfully trap most of the embolic burden at the aortic bifurcation, optimizing arterial inflow and avoiding a laparotomy due to maintenance of the native aortic bifurcation. In addition, we preserved access to her contralateral groin should further endovascular treatments be required for this patient's left popliteal disease which is comparatively less morbid than attempting an antegrade approach from the ipsilateral common femoral artery. The device was easy to deploy and should be considered in other similar cases of acute embolic aortic bifurcation occlusion.

  Conclusion Top

This case highlights elegant endovascular reconstruction of aortoiliac system for a patient presenting with acute lower limb ischemia. It allowed for a minimally invasive solution whilst preserving options for future endovascular intervention. While long-term durability in this patient age group is largely unknown, it has avoid significant major laparotomy associated morbidity whilst allowing for a successful revascularization.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Dossa CD, Shepard AD, Reddy DJ, Jones CM, Elliott JP, Smith RF, et al. Acute aortic occlusion. A 40-year experience. Arch Surg 1994;129:603-7.  Back to cited text no. 1
Yamamoto H, Yamamoto F, Tanaka F, Motokawa M, Shiroto K, Yamaura G, et al. Acute occlusion of the abdominal aorta with concomitant internal iliac artery occlusion. Ann Thorac Cardiovasc Surg 2011;17:422-7.  Back to cited text no. 2
Crawford JD, Perrone KH, Wong VW, Mitchell EL, Azarbal AF, Liem TK, et al. A modern series of acute aortic occlusion. J Vasc Surg 2014;59:1044-50.  Back to cited text no. 3
Lioudaki S, Kontopodis N, Palioudakis S, Koutsopoulos AV, Drositis I, Ioannou CV. Acute aortic occlusion due to tumor embolism in a patient with lung malignancy. SAGE Open Med Case Rep 2017;5:2050313X17720627. doi: 10.1177/2050313X17720627.  Back to cited text no. 4
Khorgami Z, Sclabas GM, Aminian A, Lau PJ, Chow GS, Malgor RD, et al. Mortality in open abdominal aortic surgery in patients with morbid obesity. Surg Obes Relat Dis 2019;15:958-63.  Back to cited text no. 5
Passman MA, Taylor LM, Moneta GL, Edwards JM, Yeager RA, McConnell DB, et al. Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease. J Vasc Surg 1996;23:263-9.  Back to cited text no. 6
Spiliopoulos S, Katsanos K, Fragkos G, Karnabatidis D, Siablis D. Treatment of infrainguinal thromboembolic complications during peripheral endovascular procedures with AngioJet rheolytic thrombectomy, intraoperative thrombolysis, and selective stenting. J Vasc Surg 2012;56:1308-16.  Back to cited text no. 7
Mwipatayi BP, Sharma S, Daneshmand A, Thomas SD, Vijayan V, Altaf N, et al. Durability of the balloon-expandable covered versus bare-metal stents in the Covered versus Balloon Expandable Stent Trial (COBEST) for the treatment of aortoiliac occlusive disease. J Vasc Surg 2016;64:83-940.  Back to cited text no. 8
Maldonado TS, Westin GG, Jazaeri O, Mewissen M, Reijnen MM, Dwivedi AJ, et al. Treatment of aortoiliac occlusive disease with the endologix AFX unibody endograft. Eur J Vasc Endovasc Surg 2016;52:64-74.  Back to cited text no. 9
Bekken JA, Vos JA, Aarts RA, de Vries JP, Fioole B. DISCOVER: Dutch Iliac Stent trial: COVERed balloon-expandable versus uncovered balloon-expandable stents in the common iliac artery: Study protocol for a randomized controlled trial. Trials 2012;13:215.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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