Aortoiliac graft occlusion presenting as lumbar plexopathy: a report of reversible neurological deficit

• Ischemic lumbar plexopathy is a rare complication of aortic interventions. • This case involved lower limb weakness due to EVAR and bypass occlusion. • Early revascularization led to full neurologic recovery, which is rarely reported. • Imaging showed lumbar artery compromise and restored perfusion after surgery. • Diagnosis requires high clinical suspicion, especially with overlapping symptoms. Ischemic lumbar plexopathy is a rare and challenging neurological complication resulting from vascular insufficiency. Its clinical presentation varies, making diagnosis difficult and often leading to it being overlooked. Although it has been documented following aortic reconstruction procedures, complete neurologic recovery after revascularization has not previously been reported. We present the case of a 79-year-old male patient with a history of EVAR for the treatment of an infrarenal abdominal aortic aneurysm utilizing an aortouniiliac endograft and a left-to-right femoral-femoral bypass, who presented with acute left lower extremity pain and progressive weakness of bilateral lower extremities. Evaluation revealed acute occlusion of both the endograft and femoral-femoral bypass. He underwent left external iliac artery thrombectomy and a left axillary-to-femoral artery bypass, a redo left-to-right femoral-femoral bypass, and a left common femoral to above-knee popliteal artery bypass. This revascularization resulted in immediate sensory and motor function improvement. A review of fifteen published cases involving lumbar plexopathy after aortic interventions revealed typical presentation in the early postoperative period. Management was predominantly conservative, with nearly all patients receiving physical therapy, and one was treated with surgical revascularization via bypass. Despite these efforts, most patients experienced persistent motor deficits, with only one patient achieving full neurologic recovery through physical therapy alone. Ischemic lumbar plexopathy secondary to aortic graft occlusion is extremely rare. This case highlights the need to consider ischemic lumbar plexopathy in patients with complex vascular histories. Timely revascularization, even in a high-risk patient, led to meaningful neurological recovery.