Gozzo et al. Insights into Imaging (2022) 13:5 https://doi.org/10.1186/s13244-021-01112-4 Insights into Imaging EDUCATIONAL REVIEW Open Access CT angiography for the assessment of EVAR complications: a pictorial review Cecilia Gozzo1, Giovanni Caruana2, Roberto Cannella3,4, Arduino Farina5, Dario Giambelluca6, Ettore Dinoto7, Federica Vernuccio3* , Antonio Basile1 and Massimo Midiri3 Abstract Endovascular aneurysm repair (EVAR) is a minimally invasive treatment proposed as an alternative to open repair in patients with abdominal aortic aneurysms. EVAR consists in a stent-graft placement within the aorta in order to exclude the aneurysm from arterial circulation and reduce the risk of rupture. Knowledge of the various types of devices is mandatory because some stents/grafts are more frequently associated with complications. CT angiography is the gold standard diagnostic technique for preprocedural planning and postprocedural surveillance. EVAR needs long-term follow-up due to the high rate of complications. Complications can be divided in endograft device-related and systemic complications. The purpose of this article is to review the CT imaging findings of EVAR complications and the key features for the diagnosis. Keywords: Aortic aneurysm, Abdominal, Computed tomography angiography, Endovascular procedures, Blood vessel prosthesis implantation, Stents Key points Introduction Endovascular aneurysm repair (EVAR) is a minimally • The rate of complications after endovascular aneu- invasive procedure introduced as an alternative to open rysm repair (EVAR) is 16–30%. repair (OR) in patients with abdominal aortic aneurysms • CT angiography is the reference standard for post- (AAAs) [1]. EVAR consists of placing a stent-graft within procedural surveillance of EVAR. the aorta to exclude the aneurysm from arterial circula- • Knowledge of implanted device allows adequate tion and reduce the risk of rupture [2]. Compared to interpretation of post-EVAR CT angiography. OR, EVAR has a lower operative mortality and a shorter • Complications after EVAR can be divided in endo- hospital stay [1]. Conversely, OR is known to be more graft device-related and systemic. durable and the repair is likely to last for the rest of the • The most common endograft device-related compli- patient’s lifetime [1]. Since EVAR has an early survival cations are endoleak and device migration. benefit but an inferior prolonged survival benefit com- pared to OR, it needs long-term post-repair surveillance and possible reintervention to correct graft-related com- plications [1]. CT angiography (CTA) plays a crucial role for both preprocedural planning and postprocedural surveillance [2, 3]. The rate of complication after EVAR is high, ranging between 16 and 30% [4]. Complications can be divided in endograft device-related and systemic *Correspondence: federicavernuccio@gmail.com complications [3], as summarized in Table 1. Concern- 3 Section of Radiology ‑ BiND, University Hospital “Paolo Giaccone”, ing the degree of severity, a non-standardized classifica- University of Palermo, Via del Vespro 129, 90127 Palermo, Italy Full list of author information is available at the end of the article tion of complication in “minor,” “moderate” and “severe” © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. Gozzo et al. Insights into Imaging (2022) 13:5 Page 2 of 18 Table 1 EVAR complication and related CT findings Complications Type of complication CT findings Incidence Endograft device-related Major suture breaks and metal-ring fractures Discontinuity of suture points and/or metallic frame 5.5% Endoleak Contrast extravasation in the aneurysm sac 15–30% Type I (attachment site leak) Centrally located, close to an attachment site of the endo- graft Type II (retrograde blood flow from aortic branches) Peripherally located, close to the origin of the involved ves- sels Type III (device failure) Centrally located, not immediately close to the attachment sites of the endograft Type IV (graft porosity) Hazy opacification around the stent-graft, without detectable sources of endoleak Type V (endotension) Expansion of the aneurysm sac without signs contrast extravasation Device migration Device movement: > 10 mm on the centerline or > 15 mm on 1–10% either the anterior or posterior aortic margin Device kinking Device angulation more frequently localized at stent-graft 2–4% limb Graft thrombosis and occlusion Non-enhancing concentric or eccentric thrombus along the 0.5–11% internal wall of the endograft Infection Mesenteric fat stranding adjacent to the stent-graft, perigraft 0.4–3% fluid collections, abnormal enhancement, air bubbles and erosion into adjacent structures Access site complication Pseudoaneurysm: tear of the arterial wall with a blood col- 3–5% lection, contained by the adventitia or by the surrounding perivascular soft tissues; thrombosis; dissection; hematoma; infection; lymphocele Systemic Ischemia Limb ischemia 9% Bowel ischemia Spinal cord ischemia one, can be replaced by a standardized and reproducible Preprocedural CT angiography allows to define aneu- CIRSE (Cardiovascular and Interventional Radiological rysm morphology and preprocedural planning. Society of Europe) complication classification system [5, The aneurysm anatomical characteristics suitable 6]. for EVAR include aneurysm sac diameter < 7 cm, iliac The purpose of this article is to review the CT imag- artery angulation > 90° (< 90° without diffuse calci- ing findings of EVAR complications and the key features fication) and external iliac artery diameter > 7 mm for the diagnosis. We firstly describe EVAR eligibility, CT and < 14 mm [9]. To emphasize the importance of prox- angiography technique and the different types of devices imal neck evaluation, an “aortic neck scoring system” used for EVAR and then discuss the various types of was introduced in order to stratify the risk of graft fail- endograft device-related and systemic complications. ure [10]. This score considers proximal neck length, diameter, Evar eligibility angulation and the amount of calcification and throm- The indication for AAA treatment (surgical or EVAR) bus, which must be, in an ideal situation, ≥ 15 mm of includes aneurysm diameter > 5.0–5.5 cm or sympto- lenght, < 30 mm in diameter, > 120° of angulation, and matic, and an increase in aneurysm size > 5 mm in a with wall calcification extending to less than half of its 6-month interval and > 10 mm per year [3, 7]. circumference without significant thrombus apposi- The choice of EVAR instead of OR depends on both tion, respectively [9, 10]. patient’s contraindication to surgery and aneurysm char- EVAR contraindications include, in addition to the acteristics [8]. lack of the above-mentioned criteria, aneurysm involv- Patients ≥ 80 years old, obese, diabetic, with cardiac, ing both iliac arteries, or a hypogastric artery in the pulmonary or renal disfunction, and American Society case of contralateral occlusion, Marfan syndrome or of Anesthesiologists (ASA) III/IV are considered at high acute inflammatory AAA [9]. risk for surgery and may be eligible for EVAR [8, 9]. Gozzo et al. Insights into Imaging (2022) 13:5 Page 3 of 18 Fig. 1 Drawings illustrating the various types of metal ring and stent-graft CT angiography technique reformation (CVR) and volume rendering (VR), that CTA is considered the reference standard for both pre- facilitate the detection of complications [11]. procedural planning and postprocedural surveillance Considering the requirement of a lifelong surveillance, [2, 3]. Preprocedural CTA imaging allows to define patients treated with EVAR may absorb a substantial aneurysm size and morphology, proximal and distal cumulative radiation dose [14]. Current guidelines rec- landing zones and access vessel assessment [7]. Post- ommend as time interval of follow-up, CTA at 1 month, procedural surveillance allows confident assessment of 6 months, and 12 months or whenever complications are endograft device-related and systemic complications suspected [3, 15, 16]. Therefore, for radioprotection pur- both early and late ones [7]. poses, the acquisition of non-enhanced CT scan (NECT) A triphasic CTA study is typically performed before is generally avoided after the first CT follow-up. New and after the intravenous injection of a 90–130 ml generation dual-energy CT (DECT) scanners can obtain bolus of iodinated high-concentration contrast medium unenhanced images by subtracting iodine density from through an automated injector (flow rate of 3–5 ml/s, contrast-enhanced acquisitions without the need of a and, sometimes, even higher) in an antecubital vein separate NECT scan [5, 17]. [11]. DECT angiography could be used as a single-phase The CTA protocol includes a non-contrast acquisition examination with lower radiation exposure to the to differentiate calcifications from contrast leakage, an patient compared to the standard triple-phase CTA [17]. early arterial phase (12 s after the bolus-tracking thresh- Although DECT has the advantage of a higher contrast- old) to detect most of endoleaks, and a delayed phase to-noise ratio of iodine in the blood which improves the (120–300 s) to detect low-flow endoleaks (usually type II detection of endoleaks, virtual non-contrast images may endoleaks) [3, 12, 13]. reduce the perceived visibility of calcifications [5, 17, 18]. CTA allows postprocessing reconstructions such Other diagnostic techniques include digital subtrac- as maximum intensity projection (MIP), curvilinear tion angiography (DSA), magnetic resonance angiogra- phy (MRA) and contrast-enhanced ultrasound (CEUS) Gozzo et al. Insights into Imaging (2022) 13:5 Page 4 of 18 [19]. DSA is an invasive procedure currently reserved for medium, with techniques such as time-of-flight magnetic preprocedural planning or intraprocedural guidance [3]. resonance angiography (TOF-MRA) [3, 19]. Contrast-enhanced-MRA with gadolinium may be use- CEUS is a minimally invasive modality in detection of ful in patients with contraindications to iodinated con- complications, cost-effective, with lack of ionizing radia- trast administration (i.e., iodine allergy) [3]. MRA has the tion use, but difficult to reproduce [19]. advantage of the possibility to avoid the use of contrast Fig. 2 Drawings illustrating the physiopathology of type I endoleak. a A typical EVAR device consisting of a main body for the aorta and one “limb” for each common iliac artery; b type Ia endoleak; c type Ib endoleak; d EVAR with an aorto-uniliac device, a femoral-femoral bypass and an iliac occluder; e type Ic endoleak with failure of the iliac occluder, resulting in retrograde blood flow through the common iliac artery and the aneurysm sac Fig. 3 a Sagittal maximum intensity projection and (b, c) axial CT angiography images at different levels show type Ia endoleak in a 67-year-old man detected as contrast agent extravasation outside stent-graft within aneurysm sac (arrows), close to the proximal attachment site of the endograft; d intraoperative aortography performed by the pigtail catheter with tip positioned above the proximal endograft fixation shows a type Ia endoleak (arrowhead) in a 82-year-old man; e the same angiographic image shows a type Ia endoleak profile remarked with a black line Gozzo et al. Insights into Imaging (2022) 13:5 Page 5 of 18 Type of device The Endurant II (Medtronic, Santa Rosa, CA) is a modu- Figure 1 depicts the various types of metal ring and stent- lar bifurcated stent-graft composed of M-shaped nitinol grafts used for EVAR. In regard of the material, the device stents and polyester graft. It is approved for infrarenal is formed by a metal-structure (i.e., stainless steel nitinol necks of ≥ 10 mm length with angulation ≤ 60 degrees or or cobalt-chromium alloys), while the graft is composed of 15 mm and ≤ 75 degrees [25]. The Zenith low profile of polyester or polytetrafluoroethylene (ePTFE) fabric (Cook Medical, Bloomington, USA) is a modular bifur- [20, 21]. Based on the anatomical structure, stent-grafts cated system consisting of a nitinol Z-stents sutured to a can be divided in bifurcated (aorto-bi-iliac) or aorto- woven polyester graft material. The proximal stent con- uni-iliac [20]. Stent-grafts usually adopt a modular tains barbs for suprarenal fixation. It is approved for a design with at least two component grafts: in detail two minimum 15 mm infrarenal neck and an infrarenal angu- (bimodular) or three (trimodular) separate components, lation of ≤ 60 degrees [21]. including an aortic bifurcated main body and one or two The AFX stent-graft, as well as its predecessor Pow- iliac limbs [20, 22]. More rarely, some stent-graft can be erlink (Endologix, Inc. Irvine, Calif ), is a unibody stent- unibody (e.g., Powerlink) [20]. Depending on the level of graft consisting of an inner endoskeleton with multiple fixation relative to the renal arteries, they are also sub- metallic struts of cobalt–chromium alloy covered by a divided into suprarenal (proximal to renal arteries, e.g., thin-walled ePTFE-graft fabric outer cover; these two Zenith low profile, Endurant II, Aorfix) or infrarenal (dis- stent-graft layers are sutured only at the proximal and tal to renal arteries, e.g., Excluder) [20, 21]. distal ends [26, 27]. The Aorfix stent-graft (Lombard The most common and old type is the AneuRx Medical Technologies, Oxfordshire, UK) is composed of (Medtronic, Santa Rosa, Calif ) formed by nitinol stent saddle or fish mouth-shaped nitinol rings on a polyester rings and woven polyester graft material; each stent ring fabric. This shape allows the rings to be placed trans- is a series of diamond-shaped segments connected side renally with the fish mouth trough aligned with the renal to side [23]. The C3 Excluder (W. L. Gore & Associates, arteries juxta-renally and the fish mouth peak extending Flagstaff, Ariz) is a modular bifurcated system com- suprarenally. It is approved for a neck length of ≥ 20 mm, posed of PTFE approved for infrarenal necks measur- and it is the only available endograft that can be used in ing ≥ 15 mm in length and ≤ 60 degrees angulation [24]. infrarenal angulation up to 90° [25]. Fig. 4 Drawing illustrating the physiopathology of type II endoleak. a Schematic representation of an abdominal aortic aneurysm (AAA) with a normal bowel circulation, supplied by superior mesenteric artery (SMA) and inferior mesenteric artery (IMA); b blood circulation after a typical EVAR: normal flow in the SMA, that provides blood to the major part of the bowel through collateral circles shared with the territories irrigated by the IMA; no flow in the IMA, that originates from the excluded aneurysm sac; c type II endoleak: collateral vessels provide retrograde blood flow to the IMA, bringing blood inside the aneurysm sac Gozzo et al. Insights into Imaging (2022) 13:5 Page 6 of 18 Fig. 5 86-year-old man with type IIa endoleak. a Axial and (b, c) sagittal maximum intensity projection CT angiography images show type II endoleak (arrows) due to retrograde perfusion of a lumbar artery (arrowheads) Although EVAR was initially limited to aneurysms consisting in a grading scale from one to six where grade with a neck long enough to accommodate the stent-graft, “one” is assigned to a complication that may be solved for AAAs with a short or absent neck involving visceral within the procedure operative session without addi- arteries (superior mesenteric artery, right renal artery or tional therapy, sequelae or deviation from the normal left renal artery), a fenestrated and branched stent-grafts post-therapeutic course, and “six” is assigned in case of (f/b EVAR) are proposed [28]. death [6]. Evar complication classification Endograft device‑related complications EVAR complications can be classified by time of onset, Endograft device-related complications occur in 16–30% cause and severity. of patients after EVAR; the most common types include Based on the time of appearance, they can be divided endoleak (occurring in 15–30%) followed by device into immediate (days 0–1), early (days 2–30) and late migration (1–10%), graft limb thrombosis (0.5–11%), and complications (days 31 +) [29]. structural endograft failure (5.5%) [3, 4, 30, 31]. Regarding the cause, complications can be divided in endograft device-related and systemic complications [3], as summarized in Table 1. Endoleak Concerning the degree of severity, a non-standardized Endoleak (EL) is considered the most frequent complica- classification divides complications in “minor,” “moder- tion after EVAR, occurring in 15–30% of patients within ate” and “severe” ones [5]. In 2017, CIRSE Standards of the first 30 postoperative days [3]. EL is defined as the Practice committee introduced a standardized and repro- persistent perigraft blood flow within the aneurysm sac ducible system for the classification of complications with contrast opacification changing in degree and shape Gozzo et al. Insights into Imaging (2022) 13:5 Page 7 of 18 attachment site, Fig. 3), Ib (involving the distal attach- ment site) and Ic (involving the iliac occluder) [32]. Type Ic EL refers to the failure of occlusion of the contralat- eral common iliac artery in patients with aorto-uniliac endograft placed in conjunction with a femoral-femoral bypass. Type I EL is more frequent in patients with com- plex arterial anatomy: short, angulated, or tapered proxi- mal necks leading to an imperfect seal between the stent-graft and the aortic walls, resulting in type Ia EL [32]. In the same way, dilated, irregular and tortuous iliac arteries increase the risk of type Ib EL [27, 35]. CT scan may show the presence of contrast agent extravasation more pronounced in the central part of the aneurysm sac, close to an attachment site of the endograft. Due to the direct communication with the aortic blood flow, Type I ELs tend to evolve and usually need to be treated [32]. Endovascular repair for Type I EL is successful in acute and asymptomatic presentation, but surgical conversion must always be considered if endovascular approach is Fig. 6 Drawing illustrating the physiopathology of type III endoleak. unsuccessful [36]. From left to right: type IIIa endoleak and type IIIb endoleak are Type II EL is the most common type of endoleak with characterized, respectively, by disconnection between modular a reported prevalence between 8 and 44% [36]. In type II components (IIIa) and structural stent-graft failure (IIIb) EL, the persistent perfusion of the aneurysm sac is caused by retrograde blood flow via collateral vessels (most com- monly the inferior mesenteric artery and lumbar arteries) between the arterial and delayed phases [32, 33]. ELs are [38]. Based on the number of patent branches involved, classified in five types (Table 1) according to the origin of type II EL (Fig. 4) can be classified into type IIa (only one the blood flow [34]. collateral artery, Fig. 5) and type IIb (two or more arter- Type I EL is considered a leakage from the attachment ies) [31]. Up to 40% of type II EL spontaneously resolve sites of the stent-graft and native artery [33]. Type I EL with collateral thrombosis [30]. Therefore, the “wait (Fig. 2) can be divided into type Ia (involving the proximal and see” approach is accepted for stable aneurysms at Fig. 7 82-year-old man with type IIIa endoleak. a Axial and (b) sagittal CT angiography images show contrast agent outside stent-graft (arrows) close to the junction of the main body with the iliac limb Gozzo et al. Insights into Imaging (2022) 13:5 Page 8 of 18 Fig. 8 67-year-old woman with type IIIb endoleak: Axial CT images on (a) pre-contrast, (b) arterial and (c) delayed phases and (d) coronal arterial phase show a type IIIb endoleak (arrows); intraoperative aortography in (e) anteroposterior and (f) caudo-cranial projections performed in the same patient confirmed endoleak (arrowheads) with profile remarked through a black line Fig. 10 Drawing illustrating the physiopathology of type V endoleak. Fig. 9 Drawing illustrating the physiopathology of type IV endoleak Expansion of the aneurysm sac observed in follow-up examination, without signs of other types of contrast extravasation Gozzo et al. Insights into Imaging (2022) 13:5 Page 9 of 18 Fig. 11 65-year-old man with aneurismatic sac rupture: Axial CT images on (a) pre-contrast, (b) arterial phases and (c) coronal and (d) sagittal arterial phase show left antero-lateral rupture of the aneurysm sac with periaortic hematoma (*) and blood effusion close to the left psoas muscle Fig. 12 85-year-old man with a probable rupture of PTFE (polytetrafluoroethylene) graft material and type IIIa endoleak. a Coronal, (b) sagittal, and (c) axial maximum intensity projection CT angiography images show contrast agent outside stent-graft (arrows) consisting in type III endoleak caused by probable PTFE fabric erosion (arrowheads) follow-up [32, 38]. Type II EL treatment is advisable for embolization is a safe and effective treatment for type II cases persistent over 6 months and with more than 5 mm EL, with low complication and reintervention rate [38]. of sac expansion compared to preprocedural CT meas- Type III EL is a rare complication (incidence of 4% urements [39]. CT scan shows the presence of contrast beyond 1 year) attributed to structural stent-graft failure agent in the peripheral part of the aneurysm sac, close to or disconnection between modular components (Fig. 6) the origin of the involved vessels (anterior wall of the sac [32]. Type III EL can be divided into IIIa (junctional sepa- for inferior mesenteric artery, posterior wall of the sac for ration of modular components of the device) (Fig. 7) and lumbar arteries). Minimally invasive treatment includes IIIb (stent-graft fabric disruption, Fig. 8) [32, 40]. CT embolization through transarterial, transcaval, translum- scan shows the presence of contrast extravasation at the bar and transabdominal approaches. The translumbar central of the aneurysm sac, adjacent to the endograft Gozzo et al. Insights into Imaging (2022) 13:5 Page 10 of 18 but not immediately close to its attachment sites (may covered stent across the gap between the original stent- be close to the junction of modular components in case graft components or across the fabric disruption [40]. of type IIIa endoleak). As type I EL, type III ELs are con- Type IV EL is a complication caused by porosity of the sidered high-pressure, high-risk leaks and always war- endograft fabric, which can be angiographically seen rant urgent management [32]. Treatment of type III EL during the placement of the device or immediately after includes endovascular approach with placement of a (Fig. 9) [34]. Type IV EL is related to the anticoagulant Fig. 13 78-year-old man with stents migration. a Volume rendering reconstruction and b sagittal oblique CT images show a thoracoabdominal aneurysm treated with a f/b EVAR and three stent-grafts placement in aortic branches: celiac artery (CA), superior mesenteric artery (SMA) and right renal artery (RRA); the last one appears occluded. c Volume rendering and (d) sagittal oblique CT images after 3 years show distal migration of all three stent-grafts. In both examinations, there is contrast agent inside the aneurismal sac (*), likely a type IIIb endoleak due to imperfect junction of the branches with the main device body Gozzo et al. Insights into Imaging (2022) 13:5 Page 11 of 18 Fig. 14 87-year-old man with left stent-graft-limb kinking. a, b Coronal CT images and (c) volume rendering reconstruction CT angiography image show left limb kinking (arrows) with angulation of about 90°, which is associated with endograft thrombosis (*) treatment of the patient and it spontaneously resolves infection and seroma. No specific treatment is recom- within 30 days [32]. It is uncommon with new generation mended for type IV and type V ELs [3]. devices. Angiographic study shows hazy opacification The presence of EL (expecially type I) exposes to the around the stent-graft, without detectable sources of EL. risk of aneurysm sac rupture (Fig. 11) [41]. Type V EL, also named “endotension,” is referred to the In clinical practice, differential diagnosis can be dif- expansion of the aneurysm sac without signs of other ficult to establish in case of Endologix AFX/Powerlink types of EL (Fig. 10) [3]. Type V EL is a diagnosis of stent-graft placement, due to the presence of “billowing exclusion, thus an occult endoleak has to be investigated phenomenon,” which may mimic an EL [28]. On CT scan, using other techniques (MRA, CEUS). Other causes of the billowing phenomenon appears as a slightly hyper- endotension include ultrafiltration of blood through the dense rim of density beyond the endoskeleton within stent-graft fabric, transmission of the blood pressure to the outer fabric material, with typical cauliflower-like the aortic wall through the thrombus around the device, shape [42]. On CT angiography, contrary to endoleak, in Endologix stent-graft, the intravenous contrast agent Fig. 15 81-year-old man with stent-graft thrombosis. a Axial and b sagittal CT angiography images show non-enhancing concentric thrombus (arrowheads) inside the lumen of the endograft Gozzo et al. Insights into Imaging (2022) 13:5 Page 12 of 18 stays confined inside the curvilinear thin hyperdense line type I and III endoleaks and with stent-graft migration of the graft cover, without any connection to the excluded after EVAR [24]. aneurysm sacs, and maintains the same curvilinear con- Both suture breaks and metal-frame fractures can figuration as before the contrast [43]. Although billowing involve one of the seven segments of the endograft: (a) was firstly considered a benign condition, the progression the main body, (b) the junction between the main body of this phenomenon may cause a continued pressuriza- and the limbs of the bifurcated graft, (c) the long limb of tion of the AAA sac with risk of rupture [42]. the bifurcated graft, (d) the extender cuff attached to the long limb, (e) the short limb of the bifurcated graft, (f ) Suture breaks and metal‑ring fractures secondary limb attached to the short limb in the aorta The structure of AneuRx stent-graft predisposes the (excluding overlap with short limb), and (g) the extender device to two kinds of mechanical damage: metal-ring cuff attached to the secondary limb [24]. fracture and suture break [24]. At CT scan, metal-ring In other stent-graft without any suture point, e.g., the fracture appears as a discontinuity of a metallic frame Excluder type (W. L Gore and Associates, Flagstaff, Ariz), [24]. Suture break is defined as breakage of the polyes- a rupture of PTFE graft material as a fabric disruption ter sutures that connect adjacent rings leading to their could be detected and be the underlying cause of IIIa separation and discontinuity of consecutive suture points endoleaks [44] (Fig. 12). [24]. Based on the proportion of the circumference of two adjacent metallic ring of stent involved, suture breaks Device migration can be classified as minor (< 180° of the circumference) Device migration is defined as device movement of more or major (> 180° of the circumference) [24]. Particularly, than 10 mm on the centerline or movement of more than major suture breaks and metallic stent-ring fractures 15 mm on either the anterior or posterior aortic margin demonstrated at CT scan are associated with delayed [3, 24]. Some authors considered device migration as a change of > 10 mm in the distance between the reference Fig. 16 81-year-old man with aorto-enteric fistula. Axial CT images on (a) pre-contrast, (b) arterial, (c) portal and (d) delayed phases show small air bubbles around the graft (arrow) and communication between the second portion of duodenum and the aneurysm sac as an aortoduodenal fistula Gozzo et al. Insights into Imaging (2022) 13:5 Page 13 of 18 Fig. 17 75-year-old man who underwent EVAR with right superficial femoral artery access. a Axial, (b) sagittal, and (c, d) volume rendering reconstruction CT angiography images show an access site complication: a pseudoaneurysm (*) of the right superficial femoral artery (arrows). It is also possible to see a contrast jet originating from the artery (arrowheads) vessel (celiac axis or superior mesenteric artery) and the potentially influencing limb migration include a large first visible portion of the stent-graft on a sagittal multi- aneurysm (> 6 cm), dilated or aneurysmal common iliac planar CT reconstruction [45]. artery (> 18 mm), short length of fixation (< 70%), and Device migration can affect both the proximal and lower degree of iliac limb oversizing (< 10–20%) [46]. distal fixation of stent-graft [46]. Changes of width and In case of f/b EVAR with placement of visceral arter- length of the aneurysm sac, hemodynamic forces and ies stents (superior mesenteric artery, right renal artery inadequate overlap between the device and the aneurysm or left renal artery), these latter could migrate (Fig. 13). neck can lead to device migration [47]. Stent-graft migra- tion can be the underlying cause of type I EL (since the Device kinking attachment sites of the endograft can be moved to a sec- Device kinking may occur in 2–4% of patients, due to size tion of the vessel that do not correspond to the size and reduction in the residual aneurysm sac over time, severe the shape of the device), type III EL (because of rupture proximal aortic neck angulation and a narrow diam- of the device or disjunction of modular components) and eter of the distal aortic neck [3, 49, 50]. Device kinking device kinking [46–48]. Migration of the iliac limb can (Fig. 14) can be localized at stent-graft limb and is defined lead to type Ib EL and type III EL [46]. The risk factors as a sharp localized angulation > 90° on radiological Gozzo et al. Insights into Imaging (2022) 13:5 Page 14 of 18 Fig. 18 87-year-old man with bilateral iliac stent occlusion. a, b Sagittal and (c, d) CT multiplanar reconstruction images show non-enhancing concentric thrombus inside the lumen of the endograft limbs, with subsequent endograft limb occlusion (arrows) Fig. 19 68-year-old man with segmental renal ischemia. a Sagittal CT angiography image shows left kidney normally perfused by the main left renal artery (not showed) and by an accessory renal artery (arrowheads); b sagittal CT image obtained from the same patient after EVAR shows occlusion of the accessory renal artery and lack of enhancement in the lower renal pole (*), which appears reduced in volume, due to chronic ischemia examination [50, 51]. Kinking can lead to device migra- shows a non-enhancing concentric or eccentric tissue tion, type I and type III EL, endograft thrombosis and along the internal wall of the endograft (Fig. 15). Treat- occlusion [49]. Limb kinking treatments include percu- ment options include thrombectomy and stent place- taneous angioplasty with or without placement of rein- ment of the thrombosed limb [2]. Sometimes, a surgical forcing stents or additional endograft limbs within the femoral-to-femoral artery bypass may be required [2]. original graft [49]. Infection Graft thrombosis and occlusion Endograft infection is an uncommon complication (< 1%) Graft thrombosis is reported in 4% of patients and often with a high mortality rate [3, 7]. It is usually caused by related to device kinking, migration and dislocation [2, 7, procedural contamination or eventually by device colo- 40]. Excessive oversizing can also result in folding of the nization from remote sites of infection [52]. Patients graft material, with twisting of the limbs and subsequent with endograft infection typically show fever, leucocy- endograft limb thrombosis [2, 40]. CT angiography scan tosis, and back pain [3, 53]. CT scan can demonstrate Gozzo et al. Insights into Imaging (2022) 13:5 Page 15 of 18 periaortic fat stranding adjacent to the stent-graft, per- case of a short aortic neck [3]. In addition to ischemia, igraft fluid collections, abnormal enhancement, air bub- kidney may be exposed to contrast nephropathy [61]. bles, and erosion into adjacent structures [52]. Cases of Bowel ischemia after EVAR most commonly involves aorto-enteric fistulas (Fig. 16) have been described in the the left colon. It results from embolus or endograft cov- literature with significant poor prognosis [52, 54]. erage of the inferior mesenteric artery origin. Albeit this Endograft infections may be managed conservatively latter occurs in all cases of EVAR, it becomes clinically with antibiotics and possible percutaneous drainage; relevant in case of insufficient mesenteric collateral cir- severe cases could require endograft removal [52, 53, 55, culation [62]. Small bowel or right colonic ischemia is 56]. less common [3]. Pelvic ischemia after EVAR is more frequent in case of Access site complications intentional embolization of the internal iliac arteries as The EVAR percutaneous procedure begins with the in the case of internal iliac artery aneurysms exclusion. puncture of the femoral artery as access site which can Clinical signs may include buttock claudication, rectal be associated with several local complications reported ischemia, erectile dysfunction and possible skin necrosis in 3–5% of patients [7]. These latter can be related to [3]. patients’ predisposition (i.e., obesity or severe femo- Spinal cord ischemia, although rare, is reported in the ral artery calcification) or access technique (i.e., lack of literature as EVAR-related complication [59, 63, 64]. It operator experience, repeated groin access, large sheath typically develops within 12 h following EVAR and may size) [57, 58]. Access site complications include arterial cause paraplegia [3, 64]. The underlying causes include thrombosis, pseudoaneurysm, dissection and other local intraoperative hypotension, embolism and interrup- wound complications (i.e., groin hematoma, lymphocele tion of the collateral circulation from the iliolumbar and and infection) [2, 58]. In order to avoid these complica- internal iliac arteries [64]. tions, some authors suggest preprocedural CT scans for common femoral artery calcium arcs and meticulous Conclusion ultrasound-guided arterial puncture [58, 59]. EVAR complications are common and can be life- CT scan can show pseudoaneurysm, thrombosis, threatening if not early identified by the radiologist on dissection and other local wound complications, i.e., CTA and promptly treated. They can usually be eligi- hematoma, infection and lymphocele. On CT scan, pseu- ble for an endovascular treatment. EVAR complications doaneurysm appears as a tear of the arterial wall with a can be classified by time of onset, cause and severity. hematic collection, contained by the adventitia or by the Careful detection and precise description of image surrounding perivascular soft tissues (Fig. 17). findings are essential prerequisites for treatment suc- cess. CTA is currently the gold standard diagnostic technique used for the assessment of EVAR. In future Systemic complication perspectives, further possible new technologies (post- Ischemia elaboration techniques with DECT acquisition, DSA, Ischemic complications are reported in approximately 9% MRI and CEUS) can help where critical issues still of patients causing by arterial thrombosis, embolism, dis- arise. section, or obstruction occurring as a result of endograft malposition [3]. It can involve the lower extremities and Abbreviations also the kidneys, bowel and pelvic organs. AAAs: Abdominal aortic aneurysms; CA: Celiac artery; CEUS: Contrast- Lower Limb ischemia is the most common type of enhanced ultrasound; CT: Computer tomography; CTA​: Computer tomogra- ischemia after EVAR, and it may be the result of endo- phy angiography; CVR: Curvilinear reformation; DECT: Dual-energy computer tomography; DSA: Digital subtraction angiography; EL: Endoleak; ePTFE: graft limb occlusion [59]. Patients may complain Polytetrafluoroethylene; EVAR: Endovascular aneurysm repair; f/b EVAR: Fenes- with pain, paresthesia, intermittent claudication and trated and branched endovascular aneurysm repair; MIP: Maximum intensity decreased femoral pulse [59]. CT angiography scan is projection; MRA: Magnetic resonance angiography; NECT: Non-enhanced computer tomography; OR: Open repair; RRA​: Right renal artery; SMA: Superior helpful to underlain the cause of the ischemia such as mesenteric artery; TOF-MRA: Time-of-flight magnetic resonance angiography; endograft thrombosis, occlusion (Fig. 18), and kinking. VR: Volume rendering. Renal ischemia could be secondary to arterial throm- Authors’ contributions bosis embolus, dissection, and inadvertent coverage of CG and GC contributed to collecting data, manuscript preparation/editing, the origin of the renal arteries in patients with multiple literature research; CG, GC, RC, AF, DG and ED contributed to study concept accessory arteries by the endograft or endograft migra- and design; RC and FV contributed to data analysis and interpretation, and for manuscript editing; AB and MM contributed to study design/planning and tion (Fig. 19) [3, 60]. The inadvertent coverage of the final approval. All authors read and approved the final manuscript. renal arteries by the endograft may be more frequent in Gozzo et al. Insights into Imaging (2022) 13:5 Page 16 of 18 Funding Interventional Radiological Society of Europe and the Canadian Interven- This study was not supported by any funding. tional Radiology Association. J Vasc Interv Radiol 21(11):1632–55. https://​ doi.​org/​10.​1016/j.​jvir.​2010.​07.​008. Availability of data and materials 9. Cotroneo AR, Iezzi R, Giancristofaro D et al (2006) Endovascular All data are included in this manuscript. abdominal aortic aneurysm repair: how many patients are eligible for endovascular repair? Radiol Med 111(4):597–606. https://​doi.​org/​10.​1007/​ s11547-​006-​0054-z Declarations 10. Chaikof EL, Fillinger MF, Matsumura JS et al (2002) Identifying and grading factors that modify the outcome of endovascular aortic aneurysm repair. Ethics approval and consent to participate J Vasc Surg 35(5):1061–1066. https://​doi.​org/​10.​1067/​mva.​2002.​123991 Not applicable. 11. Iezzi R, Santoro M, Dattesi R et al (2012) Multi-detector CT angiographic imaging in the follow-up of patients after endovascular abdominal aortic Consent for publication aneurysm repair (EVAR). Insights Imaging 3(4):313–321. https://​doi.​org/​ Not applicable. 10.​1007/​s13244-​012-​0173-0 12. Caruana G, Vernuccio F, Giambelluca D et al (2017) Evaluation of EVAR Competing interests complications: a practical radiological approach. ECR. https://​doi.​org/​10.​ All the authors have nothing to disclose for this paper. 1594/​ecr20​17/C-​2227 13. Lehmkuhl L, Andres C, Lücke C et al (2013) Dynamic CT angiography after Author details abdominal aortic endovascular aneurysm repair: influence of enhance- 1 Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgi- ment patterns and optimal bolus timing on endoleak detection. 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