Delayed open conversion following endovascular aortoiliac aneurysm repair: partial (or complete) endograft preservation as a useful adjunct

[Late Open Semi-conversion with Endograft Preservation for (Type II) Endoleaks with Late Aneurysm Sac Enlargement after EVAR - Indications, Method and Results in Our Own Patient Collective]

EVAR (endovascular aortic repair) is the most common method for treating an abdominal aortic aneurysm, but according to the latest findings it carries the risk of subsequent complications. These can be caused by (late) aneurysm sac growth. If conservative and surgical therapies fail to treat the aneurysm sac growth, open conversion is necessary to prevent aneurysm rupture. There are several options for open conversion, in which the EVAR prosthesis can be completely preserved or is (partially) removed. Late open semi-conversion with complete in-situ preservation of the EVAR-prosthesis and gathering of the aneurysm sac are a less invasive method than complete conversion and may be performed instead for selected patients. The aim of the present work is to present the surgical method, including indications and technical information, as well as the presentation of the results in our recent patient collective.All patients semi-converted in our department of vascular surgery and phlebology due to (type II) endoleak were included. All data are presented as n (%) or median (range).Between 6/2019 and 3/2023, 13 patients underwent semi-conversion 6 (2-12) years (median, range) after the initial EVAR. The aneurysm sac diameter at the time of semi-conversion was 69 mm (58-95 mm), the operating time was 114 min (97-147 min), the blood loss was 100 ml (100-1500 ml). Five (38%) patients received blood transfusion intraoperatively and 2 (15%) postoperatively. The stay in the intensive care unit lasted 1 (1-5) days, the hospitalisation time was 8 (6-11) days. Postoperative complications were intestinal atony (3 [23%], 1 [8%] with nausea/emesis and gastric tube insertion), anaemia (2 [15%]), hyponatraemia (2 [15%]), delirium (1 [8%]), COVID-19 infection (1 [8%]) and 1 [8%] intra-abdominal postoperative bleeding with the indication for surgical revision and the transfusion of 8 erythrocyte concentrates.Semi-conversion is a safe and practicable surgical method with few severe complications for a selected group of patients, which should be considered as an alternative to more invasive methods with (partial) removal of the EVAR-prosthesis. Further long-term studies comparing semi-conversion to full conversion are needed to demonstrate its benefits.

Clinical presentation, operative management, and long-term outcomes of rupture after previous abdominal aortic aneurysm repair

OBJECTIVE

The aim of the present study was to evaluate the presentation trends, intervention, and survival of patients who had been treated for late abdominal aortic aneurysm rupture (LAR) after open repair (OR) or endovascular aortic aneurysm repair (EVAR).

METHODS

We reviewed the clinical data from a single-center, retrospective database for patients treated for LAR from 2000 to 2020. The end points were the 30-day mortality, major postoperative complication, and survival. The outcomes between LAR managed with EVAR (group I) vs OR were compared (group II).

RESULTS

Of 390 patients with infrarenal aortic rupture, 40 (10%) had experienced aortic rupture after prior aortic repair and comprised the LAR cohort (34 men; age 78 ± 8 years). LAR had occurred before EVAR in 30 and before OR in 10 patients. LAR was more common in the second half of the study with 32 patients after 2010. LAR after prior OR was secondary to ruptured para-anastomotic pseudoaneurysms. After initial EVAR, LAR had occurred despite reintervention in 17 patients (42%). The time to LAR was shorter after prior EVAR than after OR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment for LAR was EVAR for 25 patients (63%; group I) and OR for 15 (37%, group II). LAR after initial OR was managed with endovascular salvage for 8 of 10 patients. Endovascular management was more frequent in the latter half of the study period. In group I, fenestrated repair had been used for seven patients (28%). Salvage for the remaining cases was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality (8% vs 13%; P = .3), complications (32% vs 60%; P = .1), and disposition were similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and less need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 21 months (interquartile range, 6-45 months). The overall 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between groups (28 vs 22 months; P = .48). Late mortality was not related to the aorta.

CONCLUSIONS

LAR after abdominal aortic aneurysm repair has been encountered more frequently in clinical practice, likely driven by the frequency of EVAR. However, most LARs, including those after previous OR, can now be salvaged with endovascular techniques with lower morbidity and mortality.

Partial and complete explantation of aortic endografts in the modern era

OBJECTIVE

Despite the progressive advancement of devices for endovascular aortic repair (EVAR), endografts continue to fail, requiring explant. We present a single-institutional experience of EVAR explants, characterizing modern failure modes, presentation, and outcomes for partial and complete EVAR explantation.

METHODS

A retrospective analysis was performed of all EVARs explanted at an urban quaternary center from 2001 to 2020, with one infected endograft excluded. Patient and graft characteristics, indications, and perioperative and long-term outcomes were analyzed. Partial versus complete explants were performed per surgeon discretion without a predefined protocol. This process was informed by patient risk factors; asymptomatic, symptomatic, or ruptured aneurysm presentation; and anatomical or intraoperative factors, including endoleak type.

RESULTS

From 2001 to 2020, 52 explants met the inclusion and exclusion criteria. More than one-half (57.7%) were explants of EVAR devices placed at outside institutions, designated nonindex explants. Most patients were male (86.5%), the median age was 74 years (interquartile range, 70-78 years). More than one-half (61.5%) were performed in the second decade of the study period. The most commonly explanted grafts were Gore Excluder (n = 9 grafts), Cook Zenith (n = 8), Endologix AFX (n = 7), Medtronic Endurant (n = 5), and Medtronic Talent (n = 5). Most grafts (78.8%) were explanted for neck degeneration or sac expansion. Five were explanted for initial seal failure, five for symptomatic expansion, and seven for rupture. The median implant duration was 4.2 years, although ranging widely (interquartile range, 2.6-5.1 years), but similar between index and nonindex explants (4.2 years vs 4.1 years). Partial explantation was performed in 61.5%, with implant duration slightly lower, 3.2 years versus 4.4 years for complete explants. Partial explantation was more frequent in index explants (68.2% vs 56.7%). The median length of stay was 8 days. The median intensive care unit length of stay was 3 days, without significant differences in nonindex explants (4 days vs 3 days) and partial explants (4 days vs 3 days). Thirty-day mortality occurred in two nonindex explants (one partial and one complete explant). Thirty-day readmission was similar between partial and complete explants (9.7% vs 5.0%), without accounting for nonindex readmissions. Long-term survival was comparable between partial and complete explants in Cox regression (hazard ratio, 2.45; 95% confidence interval, 0.79-7.56; P = .12).

CONCLUSIONS

Explants of EVAR devices have increased over time at our institution. Partial explant was performed in more than one-half of cases, per operating surgeon discretion, demonstrating higher blood loss, more frequent acute kidney injury, and longer intensive care unit stays, however with comparable short-term mortality and long-term survival.

Technique of partial open surgical stent graft explantation with preservation of fenestrated stent graft component to treat recalcitrant type II endoleak

Fenestrated and branched stent grafts have been used with increasing frequency for endovascular repair of complex aortic aneurysms. Endoleaks are frequently encountered after endovascular aortic aneurysm repair, with treatment indicated when associated with an enlarging aneurysm sac. When endovascular treatment fails, complex open surgical explantation will become necessary. We have reported the technique of partial graft explantation in a patient with a recalcitrant type II endoleak. Both the proximal fenestrated segment and the distal iliac limbs were preserved, and aortic control was obtained by clamping the infrarenal stent graft. This method allowed for more distal aortic cross-clamping and negated the need for visceral branch reimplantation.

Aortoenteric fistula following endovascular abdominal aortic aneurysm repair

Aortoenteric fistula is a rare complication after endovascular stent grafting. In the present report, we have described the case of a 69-year-old man 3 years after endovascular repair of an abdominal aortic aneurysm who had presented with worsening back pain and fever. Computed tomography had demonstrated dilated bowel and a thickened aortic wall, with air foci within the native aneurysm sac. He underwent emergent right axillary–bifemoral bypass with explantation of the aortic endograft and primary repair of the duodenal fistula. Tissue cultures grew Streptococcus anginosus, Prevotella denticola, and Parvimonas micra, and he was discharged home with 6 weeks of intravenous ceftriaxone and oral metronidazole after an 18-day hospital admission.

The failing endograft-A systematic review of aortic graft explants and associated outcomes

OBJECTIVE

The prominent use of endovascular stent grafts in the management of abdominal aortic aneurysms is associated with increased descriptions of late complications such as graft infection and endoleaks, which can confer significant morbidity and mortality. Failed endovascular management of late complications often requires open conversion and graft explantation. This systematic review sought to highlight the peri- and post-operative course of patients undergoing aortic graft explants to inform readers of the associated morbidity and mortality of patients undergoing this procedure.

METHODS

The review was conducted in accordance with PRISMA guidelines. A search of the PubMed, Google Scholar and Ovid MEDLINE databases from January 1995 to April 2021 was performed with a combination of MeSH terms pertaining to endovascular aneurysm repair and open conversion. Articles were screened and included based on pre-determined selection criteria.

RESULTS

A total of 818 studies were identified, with 41 meeting inclusion criteria. These studies examined a total of 1324 patients, 84.3% of whom were male with a mean age of 74 years at explantation. Mean time to graft explantation was 36 months, with a mean aneurysm size of 66 mm. The majority of aortic explants were performed for persistent endoleaks (68%), and 10% for infection. There was high morbidity with the procedure, with high rates of post-operative complications (mean, 37%) and 30-day mortality (11%). The most common complications included renal (15%), respiratory (12%) and cardiac (9%). Most explanted grafts were first-generation endografts. Morbidity and mortality rates were reduced in patients undergoing elective explants compared to emergent procedures (3.3% compared to 43.4%).

CONCLUSION

Aortic graft explant remains a highly co-morbid procedure, with high rates of peri- and post-operative complications and mortality. The number of explant procedures reported over the past 25 years has increased, reflecting the prominent use of EVAR in the management of AAAs. Whilst remaining a highly co-morbid procedure, patients undergoing elective explants had markedly reduced rates of mortality and morbidity compared to emergent explants. Thus, clinical focus should be on identifying patients who require graft explantation early to perform these procedures in an elective setting.

Hybrid Approach with Angiography and Limited Open Exposure to Treat Type Ia Endoleaks after Endovascular Aortic Aneurysm Repair

BACKGROUND

Type Ia endoleaks after endovascular aortic repair (EVAR) almost always mandate secondary percutaneous reinterventions. Several patients, however, will require conversion to open surgical repair with complete graft explant, which is associated with significant morbidity and mortality. We herein present 3 cases of hybrid surgical repair for type Ia endoleaks, using a limited open exposure for proximal stent graft edge revision to achieve graft preservation and effective aneurysm sac exclusion.

METHODS

Angiography was used to confirm type Ia endoleak in 3 patients (2 males) who had previous EVAR between October 2017 and October 2019. Time to the endoleak after the index EVAR was immediate in 1 patient during repair of a ruptured aneurysm, 2 months in 1 patient and 2 years in 1 patient. The aorta was exposed through a limited transabdominal (n = 1) or retroperitoneal (n = 2) approach and circumferential aortic control was achieved below the renal arteries. A row of interrupted horizontal mattress sutures of 3-0 polypropylene reinforced with Teflon pledgets was placed along the aortic neck circumference. Multi-planar angiography was then repeated to verify the absence of sac filling and successful type Ia endoleak exclusion. Follow-up abdominal duplex was obtained for all 3 patients after discharge to monitor the stent graft and confirm endoleak resolution. Furthermore, there were no instances of acute renal failure.

RESULTS

In the period of review, 77 patients underwent EVAR. In the 3 patients described, we were able to achieve complete aneurysm sac exclusion and stent graft preservation in all cases. Follow-up imaging was available on 2 patients at 4-6 weeks after surgery demonstrating sustained exclusion of the endoleak. Two patients died during follow-up: one from a myocardial infarction 7 weeks after surgery and one from metastatic lung cancer at 8 months after surgery. Follow up duplex imaging at one year on the single survivor demonstrated sac shrinkage and absence of endoleak.

CONCLUSIONS

Type Ia endoleaks represent a significant source of morbidity and mortality after EVAR and typically require repair to avoid aneurysm rupture. Our use of limited proximal revision without explant provides an alternative approach to resolve the endoleaks while reducing the magnitude of physiological stress when compared to an open explant. It represents a feasible option for high-risk patients.

Open repair of type III endoleak with preservation of the endograft for a ruptured abdominal aortic aneurysm after endovascular aneurysm repair

Abdominal aortic aneurysm rupture after endovascular aneurysm repair (EVAR) is rare, but remains a significant limitation of endovascular technology. Preservation of the endograft during open conversion of a post-EVAR rupture has been shown to be associated with improved perioperative outcomes. An interposition Dacron graft with felt pledgets is a novel bail-out option for the open reconstruction of a type III endoleak with total endograft preservation. This technique is useful in high-risk patients presenting with ruptured abdominal aortic aneurysm after EVAR and no clear source of endoleak.

Lessons Learned from Open Surgical Conversion after Failed Previous EVAR

BACKGROUND

Delayed open conversion (OpC) after endovascular aortic aneurysm repair (EVAR) is becoming increasingly common worldwide. We reviewed our experience to characterize the perioperative spectrum of OpC repairs.

MATERIALS AND METHODS

A retrospective analysis of a prospectively maintained institutional database to identify patients who underwent late OpC after failed EVAR was performed. Patient and aneurysm baseline characteristics, mechanism of failure, perioperative details, including type of repair/complications/survival, and late outcomes were examined.

RESULTS

From January 2003 to January 2020, 38 male patients (mean age, 75 ± 7 years; range, 60-90) required late OpC. Interval time from initial EVAR to OpC was 63.6 ± 33.8 months (range, 17-120). Mean diameter of the aneurysms was 82.2 ± 22.1 mm before OpC compared with 62.9 ± 13 mm before endograft implantation. Mechanisms of failure were type Ia, Ib, II, and III endoleaks in 14 (36.8%), 9 (23.7%), 4 (10.5%), and 1 (2.6%) patient(s), respectively; infection in 3 (7.9%), leg ischemia in 2 (5.3%), and multiple causes in 5 (13.2%) patients. We observed 4 (10.5%) asymptomatic, 16 (42.1%) symptomatic, and 18 (47.3%) ruptured aneurysms. Four patients (10.5%) had stable contained ruptures, whereas the remaining 13 (34.2%) and 1 additional patient (2.6%) with aortoenteric fistula presented with hemorrhagic shock (class ≥II). Total endograft explantation, endograft preservation, or proximal/distal partial graft removal was performed in 16 (42.1%), 10 (26.3%), and 2 (5.2%)/9 (23.7%) of patients, respectively. Technical success was 100%, excluding an early postaortic clamping death. Overall, 30-day mortality was 21.1% (8 of 38) and significantly higher in patients with hemorrhagic shock or hemodynamic instability at presentation (P = 0.04 and P = 0.009, respectively) and in patients who had endografts with hooks/barbs or experiencing higher postoperative complication rate (P = 0.02 and P = 0.006, respectively). By definition, procedure success was 81.1%. Mean follow-up was 37.6 ± 39.8 months. By the end of the study, we recorded 11 deaths (2 were aneurysm related).

CONCLUSIONS

Despite high technical success, OpC has a significant mortality in patients presenting with hemorrhagic shock and had active fixation endografts or experiencing high complication rate. Many other confounding factors may play a role.

Surgical "New Aortic Carrefour Technique" for Late Open Conversion After Endovascular Aortic Repair

BACKGROUND

The aim of the study is to report the early and midterm outcomes of late open conversion (LOC) after endovascular aortic repair (EVAR) using the "new aortic carrefour technique" (NACT) for preservation of the stent-graft iliac limbs. Late conversions were defined as explants >6 months after previous EVAR.

METHODS

Patients treated for elective or urgent LOC after EVAR with the NACT at a single center (2009-2019), and with ≥6 months of follow-up, were included. Briefly, after completing the proximal aortic anastomosis, the endograft iliac limbs were truncated and sutured together to create a "new aortic carrefour" (Veraldi's technique). A Dacron-knitted straight graft was therefore sutured to the newly created aortic bifurcation. Outcomes of interest were as follows: immediate technical success, intraoperative characteristics, and reinterventions. Results are reported as the number (and percentages) or median (and interquartile range [IQR]).

RESULTS

During the study period, 433 patients underwent standard EVAR for abdominal aortic aneurysm and 20 underwent LOC. Of these, 9 consecutive patients were deemed suitable and treated with NACT. The indication for conversion was endoleak in 6 (type IA n = 1, type II n = 4, type III n = 1), complete graft thrombosis (n = 2), and one case of sac enlargement without any clear signs of endoleak at computed tomography angiography. Of these cases, six were treated electively, while three were treated in urgent setting including one case of rupture. The median procedure, aortic cross-clamping, and distal anastomosis times were 280 minutes (IQR: 225-290), 24 minutes (IQR: 22-29), and 15 minutes (IQR: 14-18), respectively. The median blood loss was 1,600 mL (IQR: 700-1,900), and the median hospital stay was 8 days (IQR 7-12). None of the patients died and neither required unplanned reintervention within 30 days. At a median imaging follow-up of 13 months (IQR 8-43), there were no reinterventions due to residual leaks or technical defects. One patient died during follow-up, and the recorded cause of death was heart failure.

CONCLUSIONS

The use of the NACT with preservation of the original endograft iliac limbs for LOC after EVAR is a safe and feasible technique, which results in a low perioperative morbidity and mortality rate in selected patients. The technique is effective during midterm follow-up and might represent a valuable tool to expand the armamentarium of vascular surgeons for surgical regrafting after EVAR.

Stent-Graft Relining by Combined Aortic Cuff with Double-D Technique for Type IIIb or V Endoleak after Endovascular Aneurysm Repair: A Case Report

We report the case of a 83-year-old man with aneurysmal sac enlargement after endovascular aneurysm repair for an abdominal aortic aneurysm, despite no overt endoleak (EL) detected on imaging. Occult type II EL was suspected, and treatment was performed. However, the aneurysm continued to enlarge. Thus, we diagnose with type V EL as exclusion diagnosis. We combined an aortic cuff and stent-graft leg to cover the initially inserted stent graft, as a diagnostic treatment for unrefined type IIIb EL. Subsequently, the aneurysm diameter decreased. This technique and concept may be effective for type V EL, which may include another type occult EL.

Minimally Invasive Open Conversion for Late EVAR Failure

OBJECTIVE

With the increasing use of endovascular aortic aneurysm repair (EVAR), open repair after aortic stent grafting is of growing interest. The surgical conversion treatment may be a very challenging process with high mortality and in-hospital complication rates. The aim of this article is to present our experience in patients with EVAR failure treated by minimally invasive open conversion (MOC) and its technical aspects.

METHODS

A retrospective study was conducted on a prospectively compiled computerized database of consecutive patients treated by MOC at our institution between May 2014 and June 2018. Indications for treatment were endoleaks with sac growth at least >5 mm in the last 6 months and failure of previous endovascular tentative for aneurysm sealing. Demographics of the patients, reason for conversion, previous endovascular procedures, surgical outcomes, and survival were reviewed. MOC was performed by a small abdominal incision, infrarenal clamping, and partial explantation of the endograft in all patients.

RESULTS

A total of 10 patients were treated during the study period. The mean interval to MOC after EVAR was 45.1 months (range, 14-128). Indications for MOC included type Ia endoleak in three patients (30%), persistent type II EL in four (40%), and type III EL in one patient (10%), indeterminate or type V EL in two (20%). At 30 days, no deaths or reinterventions were reported, and major complication rate was 10% (one postoperative pneumonia). At mean follow-up of 22.9 ± 15.9 months, no reinterventions were described. Death rate was (20%) with one aneurysm-related death (10%) for graft infection 32 months after MOC and one (10%) cardiac event at 18 months.

CONCLUSIONS

Despite the potential high risk of open conversion, MOC appears to be a safe surgical solution for EVAR failure. This potentially challenging operation may be improved with minimally invasive techniques that are presented.

Outcomes of Late Open Conversion after Endovascular Abdominal Aneurysm Repair

Objective: To review our experience with a late open conversion as a final option for an endograft infection and aneurysm expansion after endovascular aneurysm repair (EVAR), especially in endoleaks for which radiological intervention is impossible. Materials and Methods: In this retrospective study, 13 late open conversions out of 513 consecutive patients treated by EVAR were analyzed. Indications for an open conversion were aneurysm enlargement, including all endoleaks, endograft migration, and endograft infection. The patients' data on demographics, operative details, and outcomes were reviewed. Results: Indications for a late open conversion included endoleaks, infection, and migration in 61.5%, 30.8%, and 7.7% of patients, respectively. The median interval from the initial EVAR was 32.4 months. Complete endograft explantation was performed in four patients with an endograft infection. In endoleak cases, the endograft was partially preserved and a neo-neck was used. Sacotomy and branch ligation were performed in one case. One major operative complication was an aortic injury during infrarenal aortic cross-clamping in an endograft migration case. There was no operative mortality. Conclusion: A late open conversion after EVAR is valuable as a final option. The aortic cross-clamp site, especially in endograft migration cases, should be carefully considered. To avoid aneurysm-related events, graft replacement is recommended, if possible.

Novel open technique for repair of endograft migration

Widespread adoption of endovascular aneurysm repair has led to increased incidence of late complications, such as endograft migration. Treatment options have to be tailored to the patient's health, quality of proximal aorta, and extent of migration. Complete or partial endograft removal is associated with significant morbidity and mortality. We describe a case in which open repair with endograft preservation was employed, with the additional benefit of a sutured proximal anastomosis.

State of the art and meta-analysis of secondary open aortic procedure after abdominal endovascular aortic repair

BACKGROUND

Secondary open aortic procedures (SOAP) treat complications of endovascular aneurysm repair, when further endovascular options are exhausted. We aimed at depicting the state of the art of SOAP with high-level evidence.

METHODS

A systematic review of the SOAP literature, with a meta-analysis of its outcomes (primary outcome operative mortality; secondary outcome major morbidity) and metaregression of risk factors for mortality (PROSPERO 42017075631).

RESULTS

Twenty-eight studies (1093 patients) were elected for analysis. SOAP was performed within the same hospitalization of or 30 days from domestic endovascular aneurysm repair (early SOAP) in 0.2% of the patients (85/40,256), and in a nonelective setting in 24.3% (95% confidence interval, 21.8-26.9). Most frequent indications were endoleak (44.4%; 95% confidence interval, 41.4-47.3) and rupture (12.7%; 95% confidence interval, 10.4-15.1). The most common procedures were infrarenal aortic replacement (85.2%; 95% confidence interval, 82.6-87.7) with high use of supravisceral clamping (suprarenal, 25% [95% confidence interval, 21.9-28.1] and supraceliac, 20.7% [95% confidence interval, 17.8-23.6]), and axillobifemoral bypass with stent explant (6.9%; 95% confidence interval, 5.1-8.7). Operative mortality (in-hospital or 30-day) was 10.9% (95% confidence interval, 8.7-13.5). The most frequent morbidities were respiratory (11.4%; 95% confidence interval, 8.1-15.9) and renal (9.5%; 95% confidence interval, 8.1-15.9). Risk factors for mortality were supravisceral clamping (Z = 3.007; Q = 9.044; P = .003) and nonelective status (Z = 3.382; Q = 11.440; P = .001).

CONCLUSIONS

Endoleak is the main indication for SOAP, which mostly consists of infrarenal aortic replacement. Risk factors for operative mortality are nonelective status and supravisceral clamping.

Delayed open conversion after endovascular aortic repair

AIM

We present the clinical outcomes of patients who underwent delayed (>30 days) open surgical repair after endovascular aortic aneurysm repair.

METHODS

All patients receiving delayed open repair of infrarenal and juxtarenal aortic aneurysms after endovascular repair from July 2001 to December 2017 were retrospectively reviewed. Patients' baseline characteristics, indications for delayed open conversion, and time between endovascular repair and open conversion are described. Early outcomes included operative approach, morbidity, and mortality. Midterm outcomes included survival.

RESULTS

Twenty-two (3.3%) of 667 patients with prior infrarenal endovascular aortic aneurysm repair had delayed open conversion (20 elective and 2 emergency). The time from endovascular repair to open conversion was 60 ± 36 months. The indications were 6 (27%) type Ia endoleaks, 6 (27%) type II endoleaks with enlarging sac size, 2 (9%) endotensions, 7 (32%) unknown types of endoleak, and 1 (5%) graft infection. The 7 minutes unknown endoleaks were confirmed as lumbar leaks in 4 cases and fabric leaks in 3. Operative time was 222 ± 48 min with blood loss of 2211 ± 2057 mL. Hospital stay after conversion was 12 ± 8 days. There was no 30-day mortality. Estimated survival rates were 96%, 91%, 86%, 79% and 57% at 1, 2, 3, 4, and 5 years postoperatively.

CONCLUSION

Delayed conversion to open surgery after endovascular aortic aneurysm repair by endograft explantation appears to be safe with good short- and mid-term outcomes. With careful preoperative assessment, open conversion remained a realistic and viable option in patients with failed endovascular treatment.

Endovascular and open surgical treatment of complications after endovascular aortic aneurysm repair: A single-center experience

While endovascular aortic aneurysm repair (EVAR) has proven to be a safer alternative to open surgical repair for infrarenal abdominal aortic aneurysms (AAA) repair, the development of stent-graft complications mandates follow-up computed tomography imaging to minimize AAA-related mortality. In this single-institution report, adverse EVAR events identified in 150 consecutive patients are detailed. Early morbidity was low (<3%), with only 1 patient death on post-procedure day 2. After discharge (mean follow-up of 24 months), 2 patients died from cancer and one AAA-related mortality occurred after open conversion for stent-graft migration. Although computed tomography imaging detected no EVAR endoleak at 30 days, 19 patients developed an endoleak, including three Type I and four Type III leaks. Our institutional series review confirmed that EVAR of infrarenal AAA is a safe and valid alternative to open surgical repair, but sac embolization at the primary procedure in patients judged to be at high risk for Type II endoleak should be considered.

Fenestrated and Branched Stent Grafting in Complex Aneurysmatic Aortic Disease: A Single-Center Early Experience

BACKGROUND

The aim of this study is to present our early experience and highlight the technical difficulties associated with the use of fenestrated and branched stent grafts to treat patients with juxtarenal abdominal aortic aneurysm (AAA), pararenal AAA, and thoracoabdominal aortic aneurysms (TAAAs).

METHODS

A prospectively held database maintained at our department was queried for patients who have undergone branched and fenestrated stent grafting for AAA or TAAA treatment. Indication for repair, comorbidity precluding open repair, technical challenges associated with the repair, as well as operative mortality, morbidity, and reintervention rate were evaluated.

RESULTS

A total of 8 patients underwent repair with a fenestrated or branched stent graft. All patients had aneurysmal degeneration of the juxtarenal aorta, pararenal aorta, and thoracoabdominal aorta not suitable to standard endovascular techniques. Two patients had a prior aortic repair, a failed migrated stent graft, and an old surgical tube graft after an open repair. One patient had a type III TAAA and 1 patient had a postdissection TAAA type I. For all patients, target vessel success rate was 96.4% (27/28) and mean hospital stay was 6.0 days (range 3-21). Thirty-day and 1-year mortality were 0%. Mean follow-up was 23 months (range 7-45). Two endoleaks occurred, 1 type III and 1 type II, which were treated endovascularly. No death or major complication occurred during follow-up.

CONCLUSIONS

Fenestrated and branched endovascular stent grafts can be used to repair juxtarenal AAA, pararenal AAA, and TAAA in patients with significant comorbidities. However, several technical challenges have to be overcome due to the unique complex aortic pathology of each patient.

Editor's Choice - Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis

OBJECTIVES

To compare management strategies for secondary abdominal arterio-enteric fistulas (AEFs).

METHODS

This study is a review and pooled data analysis. Medline and Scopus databases were searched for studies published between 1999 and 2015. Particular emphasis was given to short- and long-term outcomes in relation to AEF repair type.

RESULTS

Two hundred and sixteen publications were retrieved, reporting on 823 patients. In-hospital mortality was 30.7%. Open surgery had higher in-hospital mortality (246/725, 33.9%), than endovascular methods (7/98, 7.1%, p < .001, OR 6.7, 95% CI 3-14.7, including staged endovascular to open surgery, 0/13, 0%). In-hospital mortality after graft removal/extra-anatomical bypass grafting was 31.2% (66/226), graft removal/in situ repair 34% (137/403), primary closure of the arterial defect 62.5% (10/16), and for miscellaneous open procedures 41.3% (33/80), p = .019. Among the subgroups of in situ repair, homografts were associated with a higher mortality than impregnated prosthetic grafts (p = .047). There was no difference in recurrent AEF-free rates between open and endovascular procedures. Extra-anatomical bypass/graft removal and in situ repair had a lower AEF recurrence rate than primary closure and homografts. Late sepsis occurred more often after endovascular surgery (2-year rates 42% vs. 19% for open, p = .001). The early survival benefit of endovascular surgery was blunted during follow-up, although it remained significant (p < .001). Within the in situ repair group, impregnated prosthetic grafts were associated with the worst overall and AEF related mortality free rates and vein grafts with the best. No recurrence, sepsis, or mortality was reported following staged endograft placement to open repair after a mean follow-up of 16.8 months (p = .18, p = .22, and p = .006, respectively, compared with patients in other groups).

CONCLUSIONS

Endovascular surgery, where appropriate, is associated with better early survival than open surgery for secondary AEFs. Most of this benefit is lost during long-term follow-up, implying that a staged approach with early conversion to in situ vein grafting may achieve the best results in selected patients.

Clinical Outcome and Technical Considerations of Late Removal of Abdominal Aortic Endografts: 8-Year Single-Center Experience

During an 8-year period, 355 patients underwent endovascular repair of mainly true (97%) infrarenal aneurysms. After a mean follow-up of 48 months, 11 (3.1%) patients required conversion to open repair and 10 were eligible for open surgical intervention. Via a midline incision, explantation of the endograft was performed by using an infrarenal aortotomy. Explantation was done for rupture in four patients (40%), with a marked difference in mortality rates between acute (50%) and elective (0%) explantations.

The main reason for explantation was proximal type I endoleak caused by (1) malposition of the device, (2) proximal migration of the endograft, and (3) dislodgment of a tube endograft that followed former central reconstruction. Proximal migration is most worrisome and demands preventive endovascular reintervention.

The mortality and morbidity rates of elective explantation are acceptable. When delayed conversion is indicated, priority has to be given to operate on these patients.

Aortoduodenal Fistula after Abdominal Aortic Stent Graft Presenting with Extremity Abscesses

Aortoenteric fistula (AEF) has been described after endovascular stent graft repair of abdominal aortic aneurysms (EVAR). AEF after EVAR has been associated with aneurysm growth, endoleak, migration, and aortic inflammation. We report a patient with an AEF presenting 2 years after EVAR with two abscesses in the right leg. A computed tomographic scan showed a gas-filled thrombus lining the right limb of his graft. At conversion, no endoleak, device migration, or residual aneurysm sac was found. AEF can occur after endoluminal stent graft (ELG) in the absence of aneurysm growth, endoleak, migration, or inflammation. AEF can cause ELG infection and extremity infection.

Early Elective Conversion for Failing Evar

Background:

The aim of the study was to assess the long term results of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms at the Helsinki University Central Hospital 1996–2004 with a special emphasis on elective conversion procedures and their outcome.

Methods:

Treatment results and follow-up data of all 110 elective EVAR procedures performed in our institution were gathered prospectively and evaluated.

Results:

Conversion to open surgery was performed in 23 (21%) of 110 EVAR patients. 30-day mortality after elective stent-graft deployment was 0% as it was also on elective conversions (n = 20). Secondary elective conversions were performed due to infection in two and after failing stent-graft treatment in 12 patients. Six of the conversions were performed primarily. Three urgent conversions (3% overall) were performed: two of these patients died, corresponding to an overall mortality of 9% (2/23) in all conversions. Five-year aneurysm-related mortality after EVAR among patients with elective conversion was 0% and 19% in patients with secondary procedures other than elective conversions.

Conclusions:

As conversions seem to be hazardous only when performed in urgent situations, elective conversion could be an alternative treatment method in complex failing first-generation stent-grafts as it may reduce mortality associated with urgent conversions or repeated attempts to maintain graft integrity with endovascular procedures.

Surgical infrarenal "neo-neck" technique during elective conversion after EVAR with suprarenal fixation

OBJECTIVES

Conversion of a previous endovascular aneurysm repair (EVAR) with suprarenal fixation is a challenging situation even in the elective setting. The outcomes of a technique based on preservation of the first proximal covered stent of the endograft, used as a "neo-neck" for proximal anastomosis, are presented.

METHODS

From 2001 to 2014, nine patients underwent elective conversion of a previous suprarenally fixed EVAR. After supraceliac clamping, the aneurysm sac was opened and the endograft identified; the fabric was cut beyond the first covered stent together with its native aortic wall in order to create a "neo-neck." An aortic balloon was inflated into the visceral aorta to avoid back bleeding. A Dacron bifurcated tube graft (Intergard, Maquet) was then sutured to the neo-neck mimicking endobanding, passing the stitches into the aortic wall and the first covered stent.

RESULTS

The mean age was 68 years (range, 52-84 years). The stent grafts removed were four Zenith (Cook Medical), three Endurant (Medtronic), and two E-vita (Jotec). The indication for conversion was type 1A (n = 2), type 2 (n = 2), and type 3 (n = 1) endoleak, complete endograft thrombosis (n = 2), and abdominal pain with sac enlargement with no radiological sign of endoleak (n = 2). Blood loss was 1,428 mL (range 500-3,000 mL); the visceral ischemic time to perform the proximal anastomosis was 23.5 min ± 2.3 min). The post-operative complication rate was 11% (n = 1/9) related to a case of sac wall bleeding requiring re-intervention; mortality at 30 days was 0%. At 22 months (range, 8-41) the computed tomography angiogram demonstrated no signs of leaks or anastomotic pseudoaneurysm.

CONCLUSION

Preservation of the proximal covered stent of an endograft with suprarenal fixation used as an infrarenal "neo-neck" with incorporation of the aorta to the suture line during elective surgical explantation simplifies the procedure, and can be achieved with very low early morbidity and mortality; furthermore, it seems to be durable over mid-term follow up.

Late open conversion after endovascular abdominal aortic aneurysm repair

OBJECTIVE

This study determined the incidence, the surgical details, and the outcome of late open conversion after failed endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm.

METHODS

A review of English-language medical literature from 1991 to 2014 was conducted using the PubMed and EMBASE databases to find all studies involving late conversion after EVAR for abdominal aortic aneurysm. The search identified 26 articles encompassing 641 patients (84% men; median age, 73.5 years).

RESULTS

Mean interval from the initial implantation was 38.5 ± 10.7 months. The cumulative single-center open conversion rate was 3.7%. The indications for late open conversion included endoleak in 62.4%, infection in 9.5%, migration in 5.5%, and thrombosis in 6.7%. Operations were urgent in 22.5% of the patients. The 30-day mortality was 9.1%. Mortality rates were different between elective (3.2%) and nonelective patients (29.2%). Five aneurysm-related deaths (1.5%) and two graft infections (0.6%) occurred during a median follow-up of 26.4 months (range, 5-50.2 months).

CONCLUSIONS

The number of patients with failed EVAR and without further options for endovascular salvage is growing. Endoleak remains the most important weakness of EVAR as the leading cause of late open conversion. Such procedures, although technically demanding, are associated with relatively low mortality rates when performed electively. Open repair still represents a valuable solution for many patients with failed EVAR.

Open Reintervention for Aneurysmal Sac Enlargement after EVAR

We performed a late open reintervention for aneurysmal sac enlargement due to persistent type 2 endoleak (PT2EL) after EVAR for 8 of 286 patients. Surgical techniques are as follows: (1) The entire aneurysmal body was exposed. (2) All the aortic branched vessels were ligated. (3) The aneurysmal sac was opened followed by the performance of complete hemostasis. (4) An equine pericardium was wrapped and sutured to the aneurysmal sac to for reinforcement. This method is considered to be one of the feasible options for the treatment of aneurysmal sac re-enlargement after EVAR.

Aortouni-iliac endografting as an alternative salvage procedure to open conversion in failed endovascular aneurysm repair

PURPOSE

To present a single-center experience with failed EVAR requiring conversions comparing open surgery to a minimally invasive procedure modifying the existing stent-graft into an aortouni-iliac (AUI) configuration.

METHODS

A prospectively maintained database at our tertiary care university hospital was interrogated to identify all patients with failed EVAR who had undergone either stent-graft modification into an AUI configuration or open conversion between March 1995 and January 2012. Patients with late aneurysm ruptures were excluded. The search found 30 patients (one had initial treatment elsewhere) who required conversion among the 688 patients who had undergone EVAR in that time period. Before conversion, 16 (53%) patients had prior endovascular corrections to maintain aneurysm exclusion.

RESULTS

An average time of 52.2 months (median 46.9, IQR 0.0-92.5) elapsed between initial EVAR and conversion. There were 11 early conversions (including 7 on-table), while 19 procedures were done >30 days post EVAR. Twenty-two (73%) patients underwent AUI endografting, while open conversions were carried out in 8 (27%). Mean hospital stay after conversion was 19.5 days (median 13.0, IQR 8.0-17.0). Overall mortality after conversion was 3.3% (1 patient after on-table open conversion), but since the introduction of AUI endografting as an alternative treatment approach, 30-day mortality following conversions fell to zero.

CONCLUSION

Modification of a failed stent-graft into an AUI configuration serves as a less invasive treatment option compared to open conversion and allows salvage of the failed device. With the implementation of this alternative approach, mortality after conversion parallels the mortality of elective abdominal aneurysm repair.

Open Conversion after Endovascular Aortic Aneurysm Repair with the Ovation Prime™ Endograft

Advances in abdominal aortic aneurysm (AAA) endograft device technology have contributed to improved outcomes and durability of endovascular aortic aneurysm repair (EVAR), even in complex infrarenal aortic anatomies. However, stent graft failure secondary to endoleaks, migration, endotension and sac enlargement are persistent problems that can result in aneurysm rupture following EVAR.

A symptomatic infrarenal AAA (4mm proximal neck) was treated initially with an Ovation Prime™ device (TriVascular, Inc., Santa Rosa, CA) in an off-label fashion, leading to type Ia endoleak moderately reduced by additional proximal neck ballooning. A failed Chimney technique to the single patent, but severely stenosed, right renal artery preceded the use of this device. A large type Ia endoleak was evident at 6-month follow-up, but following a failed supplementary endovascular intervention with coils to seal the endoleak, the patient presented with hemorrhagic shock from AAA rupture, requiring urgent open conversion. Intraoperatively it was impossible to explant this new type of endograft. Circumferential tying of the infrarenal aorta with a Teflon band was unable to stop the bleeding. However, after dividing the body of the stent-graft below the two proximal polymer rings, the endoleak was successfully treated by suturing the graft with the proximal aortic neck. The procedure was completed with extension of the stump to the common femoral arteries using a bifurcated Dacron prosthesis.

The body of an Ovation Prime™ endograft may be impossible to explant in open conversion conditions. Large prospective studies with longer follow-up are required to adequately reflect the behavior of this particular device.

Late conversion of endovascular to open repair of abdominal aortic aneurysms

BACKGROUND

Failure of endovascular repair (EVAR) of an abdominal aortic aneurysm can result in significant risk of morbidity and mortality. We review our experience with late conversions to open repair.

METHODS

We conducted a retrospective database review to identify all EVAR procedures performed between 1997 and 2010 and the number converted to open repair at our university-affiliated medical centre. Late conversion was defined as those occurring at least 30 days after initial EVAR.

RESULTS

In all, 892 EVARs took place during the study period. Six patients (0.7%) required late conversion to open repair. Their mean age was 71 (range 58-83) years, and half were women. Half of the initial EVARs were for ruptured aneurysms. The median time to conversion was 15.6 (range 1.7-61.3) months. Indications for secondary conversion (50% urgent, 50% elective) included persistent type I endoleak (n = 3), combined type II and III endoleak (n = 1), graft thrombosis (n = 1) and aneurysm rupture (n = 1). Supraceliac clamping was required in most patients (67%), and the mean transfusion requirement was 2.6 units. Total endograft explantation occurred in 2 patients (33%), whereas partial or total endograft preservation occurred in 4 (67%). Median length of stay in hospital after conversion was 7 (range 6-73) days. There were no instances of early or in-hospital mortality following conversion.

CONCLUSION

Our EVAR experience includes a low rate of late conversion to open repair, with most conversions being a result of persistent aneurysm perfusion. Although technically challenging, late conversion can be safe. Our experience supports ongoing surveillance after EVAR.

Conversion to open repair after endografting for abdominal aortic aneurysm: a review of causes, incidence, results, and surgical techniques of reconstruction

PURPOSE

To review the incidence, causes, and mortality rates of early and late conversion to open surgery after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA).

METHODS

A systematic search of the English-language literature from 2002 to 2009 was performed by interrogation of the PubMed, MEDLINE, and EMBASE databases. Studies were included if they: (1) had >100 patients treated with EVAR and (2) provided adequate data to calculate incidence and associated mortality rates. The search yielded 13 articles with sufficient data to analyze early conversion (12,236 patients, 178 conversions) and 15 articles with available data for late conversion (14,298 patients, 279 conversions).

RESULTS

The rate of early conversion among the 13 articles reviewed ranged from 0.8% to 5.9%; more recent studies carried lower rates of early conversion. Mortality rates of early conversion varied between 0% and 28.5%. Overall, there were 178 (1.5%) early conversions among the 12,236 AAAs treated with EVAR, with an average mortality of 12.4%. The rates of late conversion ranged from 0.4% to 22%. Of the 14,289 AAA patients undergoing endovascular repair, 279 (1.9%) required late conversion; the mortality rate was 10%.

CONCLUSION

Though the incidence is gradually declining, secondary interventions persist as the Achilles' heel of EVAR. A lifelong follow-up strategy for AAA patients treated with EVAR is essential for early detection and treatment of complications of the procedure. Vascular surgeons should be familiar with the complex open conversion procedures.

Thoracoabdominal aneurysm repair after failed endovascular abdominal aneurysm repair without endograft removal

Open surgical repair after failed endovascular aneurysm repair usually involves complete aneurysm removal and replacement with a prosthetic surgical graft. We describe an alternative strategy of open surgical repair of a thoracoabdominal aneurysm repair after failed endovascular aneurysm repair that entails preserving the functioning portion of the endograft and sewing the thoracoabdominal graft on the existing abdominal endograft.

Secondary Endovascular and Conversion Procedures for Failed Endovascular Abdominal Aortic Aneurysm Repair: Can We Still Be Optimistic?

The purpose of this study was to evaluate the incidence, etiology, and outcome of secondary endovascular and “open” conversion procedures after failed endovascular abdominal aortic aneurysm repair (EVAR). From January 1997 until December 2005, 625 patients with an infrarenal abdominal aortic aneurysm were treated by elective EVAR, with 98.7% ( n = 617) primary EVAR success. The mean follow-up of the 617 patients was 46.7 ± 11.2 months. One hundred of these patients (16.2%) required secondary endovascular or peripheral procedures, and 39 (6.3%) patients underwent a secondary abdominal conversion. There were 5 acute conversions (0.8%) and 34 elective conversions (5.5%). The pre-EVAR anatomic suitability data, the main cause of the secondary procedure, and stent graft type were compared between patients with primary EVAR success, patients in need of a secondary endovascular or peripheral procedure, and patients with abdominal conversion. The overall main causes for reinterventions were proximal migration ( n = 60; 9.7%), progressive kinking of the stent graft ( n = 59; 9.6%), and late type III endoleak ( n = 12; 1.9%). Multivariate logistic regression analysis showed that factors significantly correlated with secondary procedures were the abdominal aortic aneurysm's maximum diameter, the proximal neck's width and length, and particularly the commercial withdrawal of the stent graft ( p < .001). The morbidity and mortality rates of secondary endovascular or peripheral interventions were 0%. The mortality rate of acute secondary conversions was 20% ( n = 1) and of elective secondary conversions was 8.8% ( n = 3). The morbidity rates for acute and elective conversions were 0% and 65%, respectively. The aneurysm-related mortality rate in our series was below 1%. Abdominal conversion surgery still carries a high mortality rate, but the overall EVAR-related mortality rate remains low. Early pitfall detection and proper reintervention are crucial to long-term EVAR success.