Incidence, Risk Factors, and Outcomes of Iliac Limb Occlusions After Endovascular Aneurysm Repair. A Scoping Review of Literature

Introduction: The objectives of this scoping review were threefold: (1) to assess the incidence and risk factors of iliac limb occlusion (ILO); (2) to evaluate the evidence linking ILO to short- and long-term outcomes in patients undergoing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA); and (3) to identify recurring themes and gaps in the literature to guide further research and suggest standardized reporting details for future studies. Methods: A scoping review methodology was employed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Specific Population, Intervention, Comparison, Outcome questions were developed prior to the literature search. Studies published in English between January 1, 2000, and December 31, 2024, were considered. Inclusion criteria were as follows: (1) studies reporting ILO following standard EVAR; (2) a minimum sample size of 50 patients; (3) at least 1 y of follow-up; and (4) reporting of relevant clinical outcome measures. Results: Fifty-two studies met inclusion criteria and were analyzed. These included one randomized controlled trial, five prospective registry studies, five prospective nonrandomized cohort studies, and 41 retrospective cohort studies. Collectively, these studies evaluated 17,716 patients (15,133 males) who underwent EVAR for AAA. Only half of the studies provided details on timing or clinical presentation of ILO. The diagnosis was primarily clinical, with symptoms reported in up to 93.6% of cases (289 symptomatic and 20 asymptomatic patients). When specified, most patients (64.4%, n = 154) presented with acute limb ischemia or rest pain, while one third (35.6%, n = 85) had claudication. The reported incidence of ILO varied significantly across studies, ranging from 0.86% to 11.20%, with approximately half reporting rates between 3 and 6%. Both patient- and procedure-related factors were associated with increased risk of ILO after EVAR. Several authors emphasized the importance of addressing intraoperative findings– such as iliac stenosis >50%, residual stenosis >50% or kinking of the iliac limb–to help mitigate ILO risk. A total of 385 secondary interventions for ILO correction were reported. Of these, 55.9% (n = 223) involved open surgical revascularization, 28.6% (n = 114) were hybrid procedures, and 15.5% (n = 62) were treated using only endovascular techniques. Notably, only nine studies reported treatment outcomes, including a total of 3713 patients. When provided, treatment results were favorable, with immediate technical success rates ranging from 80% to 100%. Conclusions: ILO is one of the most common failure modes of EVAR, with a reported incidence from 0 to 11% during follow-up. Several anatomical and procedural factors have been identified to increase risk of ILO, and increasing evidence supports the use of intraoperative strategies to mitigate risk of these complications. Although secondary interventions are often successfully managed using endovascular or hybrid approaches, further research is needed to refine prevention strategies and improve long-term EVAR durability.