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

Acute Intraoperative Conversion from Endovascular to Open vs Planned Open Operation for Abdominal Aortic Aneurysm: A Propensity-Score Matched Study from the American College of Surgeons NSQIP-Targeted Database

BACKGROUND

Evaluating outcomes for acute intraoperative conversion to open surgery during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was difficult due to low incidence. This study aimed to compare 30-day outcomes between patients with acute intraoperative conversion during EVAR and planned open surgery, and to identify risk factors associated with acute conversion.

STUDY DESIGN

Patients who underwent EVAR or planned open AAA repair were identified in American College of Surgeons NSQIP-targeted databases from 2012 to 2021. Patients with acute intraoperative conversion during EVAR were selected. A 1:3 propensity-score matching was used to match demographics, baseline characteristics, surgical indications, aneurysm size and extent, and emergency cases between the conversion open and planned open groups. Thirty-day postoperative outcomes were assessed.

RESULTS

Of 20,566 EVAR cases, 177 (0.86%) had acute intraoperative conversion to open surgery. The conversion open group was matched to 504 of 5,249 planned open patients. Conversion open and planned open groups had comparable 30-day mortality (23.43% vs 17.46%, p = 0.09) and organ system complications, including major adverse cardiovascular event (14.86% vs 10.71%, p = 0.17), pulmonary complications (17.71% vs 24.01%, p = 0.09), and renal complications (8.57% vs 11.11%, p = 0.39). The conversion open group had lower bleeding requiring transfusion (48.57% vs 75.60%, p < 0.01), shorter operation time (p < 0.01), and shorter length of stay (p < 0.01). Other postoperative outcomes did not differ. Risk factors associated with acute intraoperative conversion included ruptured aneurysm with or without hypotension. Protective factors included hypertension and aortic distal aneurysm extent.

CONCLUSIONS

Although this study does not endorse a universal "EVAR first" strategy for all patients with AAA, EVAR can be attempted first in eligible patients with AAA. Even when EVAR is unsuccessful, intraoperative conversion to open surgery still appears to be safe compared with planned open repair.

"Redo" 2D-3D Fusion Technique during Endovascular Redo Aortic Repair

PURPOSE

The present study aims to describe a new 2D-3D fusion registration method in the case of endovascular redo aortic repair and compare the accuracy of the registration using the previously implanted devices vs. bones as landmarks.

MATERIALS AND METHODS

This single-center study prospectively analyzed all the patients that underwent elective endovascular re-interventions using the Redo Fusion technique between January 2016 and December 2021 at the Vascular Surgery Unit of the Fondazione Policlinico Universitario A. Gemelli (FPUG)-IRCCS in Rome, Italy. The fusion overlay was performed twice, first using bone landmarks (bone fusion) and the second using radiopaque markers of a previous endovascular device (redo fusion). The pre-operative 3D model was fused with live fluoroscopy to create a roadmap. Longitudinal distances between the inferior margin of the target vessel in live fluoroscopy and the inferior margin of the target vessel in bone fusion and redo fusion were measured.

RESULTS

This single-center study prospectively analyzed 20 patients. There were 15 men and five women, with a median age of 69.7 (IQR 42) years. The median distance between the inferior margin of the target vessel ostium in digital subtraction angiography and the inferior margin of the target vessel ostium in bone fusion and redo fusion was 5.35 mm and 1.35 mm, respectively (p ≤ 0.0001).

CONCLUSIONS

The redo fusion technique is accurate and allows the optimization of X-ray working views, supporting the endovascular navigation and vessel catheterization in case of endovascular redo aortic repair.

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.

Perioperative and long-term outcomes after open conversion of endovascular aneurysm repair versus primary open aortic repair

BACKGROUND

The use of endovascular abdominal aortic aneurysm repair (EVAR) has superseded that of open aneurysm repair (OAR) as the procedure of choice for abdominal aortic aneurysm repair. However, significant rates of late reintervention and aneurysm rupture have been reported after EVAR, resulting in the need for conversion to OAR (C-OAR). To assess the relative effects of C-OAR on patients, we compared the outcomes of these patients to those of patients who had undergone P-OAR.

METHODS

The data from all patients who had undergone C-OAR and P-OAR in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database from 2003 to 2018 were queried. Multivariable logistic regression and Kaplan-Meier survival and Cox proportional hazard regression analyses were used to assess the perioperative long-term outcomes.

RESULTS

A total of 4763 patients were included (91.4%, P-OAR; 8.6%, C-OAR). C-OAR was associated with a significant increase in the odds of perioperative mortality (odds ratio, 1.7; 95% confidence interval [CI], 1.1-2.7; P = .027) and renal complications (odds ratio, 1.5; 95% CI, 1.1-2; P = .004) vs P-OAR. At 5 years, conversion was associated with a higher risk of mortality (hazard ratio [HR], 1.5; 95% CI, 1.3-1.9; P < .001), aneurysmal rupture (HR, 1.9; 95% CI, 1.2-3.1; P = .007), and reintervention (HR, 1.4; 95% CI, 1.05-1.97; P = .022) compared with P-OAR. These results also persisted at 10 years, with conversion associated with a higher risk of mortality (HR, 1.5; 95% CI, 1.2-1.8; P < .001), rupture (HR, 1.8; 95% CI, 1.1-2.8; P = .018), and reintervention (HR, 1.5; 95% CI, 1.1-2.1; P = .010).

CONCLUSIONS

The results from the present study have demonstrated that C-OAR is associated with a significantly higher risk of perioperative morbidity and mortality compared with P-OAR. We found a significant increase in mortality, aneurysm rupture, and reintervention at 5 and 10 years of follow-up.

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.

Simultaneous Laparoscopic Cholecystectomy and Endovascular Infrarenal Aortic Aneurysm Repair

Background/Aim: With the increasing use of endovascular aneurysm repair (EVAR) and the availability of laparoscopic cholecystectomy (LC) for treating abdominal aortic aneurysms (AAA) and cholelithiasis, respectively, the association between these elective treatments is not yet well-defined. Thus, this study aimed to evaluate the results of elective and simultaneous EVAR and LC.

Methods: Thirteen patients (mean age, 72 years) with concomitant large and asymptomatic AAA and asymptomatic cholelithiasis underwent simultaneous EVAR and LC.

Results: Post-operative mortality was absent, and the morbidity rate was 7%. The mean total duration of the procedure was 142 min. The mean duration of fluoroscopy was 19 min, and the mean radiation dose was 65 mGy. The mean amount of iodinated contrast injected was 49 mL. The timing of oral fluid intake was 28 h (range, 24–48 h) and that of the oral low-fat diet was 53 h (range, 48–72 h). No patient presented with an aortic graft infection during the entire follow-up period (mean duration, 41 months). The mean length of post-operative hospital stay was 6 days (range, 5–8 days). Late survival was 85%, and the exclusion of AAA was 100%.

Conclusion: Simultaneous EVAR and LC can be performed safely, allowing effective and durable treatment under both AAA and cholelithiasis conditions.

Comparison of Outcomes Following EVAR Based on Aneurysm Diameter and Volume and Their Postoperative Variations

PURPOSE

to evaluate the impact of bi- and 3-dimensional preoperative aortic morphological features and their immediate postoperative variations on the outcome of abdominal aortic aneurysms (AAA) treated by endovascular exclusion with standard devices (EVAR).

MATERIALS AND METHODS

Double centre retrospective analysis of prospectively collected registry data of EVAR patients. For all patients, preoperative and 30-day computed tomographic angiography images (CTA) were reviewed. Preoperative maximum AAA diameter >59 mm and volume >159 cm³, and any 30-day postoperative increasing at CTA, were considered as potentially influencing the outcome. The outcome measures were: primary technical success; 30-day, 1-year, and mean follow-up reintervention, all-cause and AAA-related mortality rates, and also endoleak-related reinterventions.

RESULTS

Three hundred and thrity-three patients were enrolled. Mean preoperative and 30-day AAA diameter and volume were 50.4 mm ± 11.8 vs. 49.1 mm ± 12.1, and 112.9 cm3 ± 79.5 vs. 112.1 cm3 ± 80.5, respectively. Primary technical success was achieved in all cases. At 34.9 months follow-up, cumulative reintervention rate was 12.0%, mortality rates 7.2%, without AAA-related deaths. Endoleak-related reintervention rate was 7.5%. At uni- and multi-variate analysis, preoperative AAA diameter >59 mm, and AAA volume >159 cm³ were significantly associated to reintervention (P = 0.012; P = 0.002), and reintervention and death (P = 0.002; P = 0.001) during follow-up. Additionally, any increase in postoperative AAA diameter or volume was significantly associated with reintervention (P = 0.001, P = 0.001) and reintervention and death (P = 0.006, P = 0.001). Endoleak-related reintervention were also significantly associated with all of the analysed morphological parameters (P = 0.019, P = 0.005, P = 0.005, and P = 0.002, respectively).

CONCLUSIONS

Patients with larger baseline AAA size and volume as well as unfavourable early remodelling of the sac are associated to worse long-term EVAR outcome.

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.

Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

Background

Endovascular rescue of failed infrarenal repair (EVAR) has emerged as an attractive option to stent graft explantation. The procedure, however, is underutilized due to limited devices accessibility and the challenges associated with their implantation in this patient population. The purpose of this study was to report our outcomes and discuss our approach to rescuing previously failed infrarenal endovascular aneurysm repairs (EVAR) with fenestrated/branched endografts (f/b-EVAR).

Methods

A retrospective analysis of prospectively collected data of consecutive patients with failed EVAR rescued with f/b-EVAR at our institution from November 2013 to March 2019 was conducted. The study primary end point was technical success; defined as the implantation of the device with no type I a/b or type III endoleak or conversion to open repair. Secondary endpoints included major adverse events (MAEs), graft patency and reintervention rates.

Results

During this time, 202 patients with complex aortic aneurysms were treated with f/b-EVAR. Of these, 19 patients (Male: 17, mean age 79 ± 7 years) underwent repair for failed EVAR. The median time from failed repair to f/b-EVAR was 48 (30, 60) months. Treatment failure was attributed to stent graft migration in 9 (47.4%) patients, disease progression in 5 (26.3%), short initial neck in 3 (15.8%) and unable to be determined in 2 (10.5%). Three patients were treated urgently with surgeon modified stent graft. Technical success was achieved in 18 patients (95%), including two who had undergone emergent repair for rupture. Seventy-two targeted vessels (97.3%) were successfully incorporated. Sixteen (84.2%) patients required a thoracoabdominal repair to achieve a durable seal. Major adverse events (MAEs) occurred in 3 patients (15.7%) including paralysis and death in one (5.3%), compartment syndrome and temporary dialysis in another and laparotomy with snorkeling of one renal and bypass of the other in the third patient. Median (IQR) hospital length of stay was 3 (2, 4) days. Late reintervention, primary target vessel patency and primary assisted patency rates were 5.3%, 98.6% and 100%, respectively.

Conclusion

Implantation of f/b-EVAR in patients with failed previous EVAR is a challenging undertaking that can be performed safely with a high technical success and low reintervention rates.

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.

Conversion from endovascular to open abdominal aortic aneurysm repair

BACKGROUND

Previous studies have found conflicting results regarding the operative risks associated with conversion to open abdominal aortic aneurysm (AAA) repair after failed endovascular treatment (endovascular aneurysm repair [EVAR]). The purpose of this study was to assess the outcome of patients undergoing a conversion, and compare outcomes with standard open AAA repair and EVAR. In addition, we sought out to identify factors associated with conversion.

METHODS

All patients undergoing a conversion to open repair, and those undergoing standard EVAR and open repair between 2005 and 2013 were included from the National Surgical Quality Improvement Program. Multivariable logistic regression analysis was used to identify factors associated with conversion, and to assess independent perioperative risks associated with conversion compared with standard AAA repair. Subanalysis for factors associated with conversion was performed among patients additionally included in the more detailed targeted vascular module of the National Surgical Quality Improvement Program.

RESULTS

A total of 32,164 patients were included, with 300 conversions, 7188 standard open repairs, and 24,676 EVARs. Conversion to open repair was associated with a significantly higher 30-day mortality than standard open repair (10.0% vs 4.2%; odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), and EVAR (10.0% vs 1.7%; OR, 7.2; 95% CI, 4.8-10.9; P < .001). Conversion surgery was additionally followed by an increased occurrence of any complication (OR, 1.5; 95% CI, 1.2-1.9 [open]; OR, 7.8; 95% CI, 6.1-9.9 [EVAR]). Factors associated with conversion were young age (OR, 1.2 per 10 years decrease; 95% CI, 1.1-1.4), female gender (OR, 1.5; 95% CI, 1.2-2.0), and nonwhite race (OR, 1.8; 95% CI, 1.3-2.6). Conversely, body mass index >30 was negatively associated with (OR, 0.7; 95% CI, 0.5-0.9). Among anatomic characteristics captured in the targeted vascular data set (n = 4555), large aneurysm diameter demonstrated to be strongly associated with conversion (OR, 1.1 per 1 cm increase; 95% CI, 1.03-1.1).

CONCLUSIONS

Conversion to open repair after failed EVAR is associated with substantially increased perioperative morbidity and mortality compared with standard AAA repair. Factors associated with conversion are large diameter of the aneurysm, young age, female gender, and nonwhite race, whereas obesity is inversely related to conversion surgery.

Management of Immediate Post-Endovascular Aortic Aneurysm Repair Type Ia Endoleaks and Late Outcomes

BACKGROUND

Post-endovascular aortic aneurysm repair (EVAR) endoleaks and the need for reintervention are challenging. Additional endovascular treatment is advised for type Ia endoleaks detected on post-EVAR completion angiogram. This study analyzed management and late outcomes of these endoleaks.

STUDY DESIGN

This was a retrospective review of prospectively collected data from EVAR patients during a 10-year period. All post-EVAR type Ia endoleaks on completion angiogram were identified (group A) and their early (30-day) and late outcomes were compared with outcomes of patients without endoleaks (group B). Kaplan-Meier analysis was used for survival analysis, sac expansion, late type Ia endoleak, and reintervention.

RESULTS

Seventy-one of 565 (12.6%) patients had immediate post-EVAR type Ia endoleak. Early intervention (proximal aortic cuffs and/or stenting) was used in 56 of 71 (79%) in group A vs 31 of 494 (6%) in group B (p < 0.0001). Late type Ia endoleak was noted in 9 patients (13%) in group A at a mean follow-up of 28 months vs 10 patients (2%) in group B at a mean follow-up of 32 months (p < 0.0001). Late sac expansion and reintervention rates were 9% and 10% for group A vs 5% and 3% for group B (p = 0.2698 and p = 0.0198), respectively. Freedom rates from late type Ia endoleaks at 1, 3, and 5 years for group A were 88%, 85%, and 80% vs 98%, 98%, and 96% for group B (p < 0.001); and for late intervention, were 94%, 92%, and 77% for group A, and 99%, 97%, and 95% for group B (p = 0.007), respectively. Survival rates were similar.

CONCLUSIONS

Immediate post-EVAR type Ia endoleaks are associated with higher rates of early interventions, late endoleaks and reintervention, which will necessitate strict post-EVAR surveillance.

Delayed complication of abdominal aortic stent: a rare complication

We hereby present a case of recurrent abdominal aortic aneurysm due to endoleak to outline complications and secondary intervention strategies post endovascular aneurysm repair.

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.

Infective Etiology Affects Outcomes of Late Open Conversion After Failed Endovascular Aneurysm Repair

Purpose: To retrospectively review all patients undergoing late open conversion (LOC) after endovascular aneurysm repair (EVAR) in order to identify any clinical or technical predictors of poor outcome. Methods: Twenty-six consecutive patients (24 men; mean age 74.7±8.3 years) underwent LOC between June 2006 and April 2013 at our institution. The mean interval from index EVAR to LOC was 40.4±29.2 months (range 5–93 months). The indication for LOC was endoleak in 14 (54%) patients and infection in 12 (46%): 2 (8%) patients with endoleak had a ruptured aneurysm and 6 (23%) patients with infection had a recurrent secondary aortoesophageal fistula (sAEF). Results: In all 12 cases of infection and in 12 of 14 endoleaks, the entire endograft was explanted. A rifampin-soaked Dacron silver graft was implanted in all patients with infection. Patients with any infection and with recurrent AEF required more blood units than patients with endoleak (6.40 vs. 1.86, p=0.045; 6.76 vs. 1.86, p=0.0036, respectively). Compared with endoleak, the duration of conversions in the setting of infection (274 vs. 316 minutes, p=0.42) and recurrent sAEF (274 vs. 396 minutes, p=0.021) was longer. All patients with recurrent sAEF died at a mean 3.0±2.5 days after LOC from proximal anastomosis disruption and hemorrhagic shock (n=2), myocardial infarction (n=2), acute stroke (n=1), or persistent sepsis (n=1). Perioperative mortality was significantly higher in patients with endograft infection (6/12, p=0.002) and in cases of supraceliac cross-clamping (4/6, p=0.003). The association of infection with supraceliac cross-clamping was a strong predictor for perioperative mortality (p<0.001). Conclusion: In our experience, endograft infection led to greater perioperative mortality after LOC. Recurrent aortoenteric fistula in association with supraceliac cross-clamping is a strong predictor of poor outcome. Patients surviving the perioperative period may have good chances of long-term survival.

Abdominal aortic aneurysm repair: long-term follow-up of endovascular versus open repair

INTRODUCTION

To compare early and long-term outcomes of endovascular abdominal aortic aneurysm repair (EVAR) versus open repair (OPEN).

DESIGN

Prospective observational, per protocol, non-randomized, with retrospective analyses.

MATERIAL AND METHODS

Between 2000 and 2005, a total of 311 patients having EVAR or OPEN repair of infrarenal abdominal aortic aneurysms were identified and included in this prospective single-center observational study. A propensity score-based optimal-matching algorithm was employed, and 138 patients undergoing EVAR procedures were matched (1: 1) to OPEN repair.

RESULTS

Open repair showed higher hospital mortality (17% vs. 6%, p = 0.004), respiratory failure (p < 0.026), transfusion requirement (p < 0.001), and intensive care unit admission (27% vs. 7%, p < 0.001), and longer hospitalization (p < 0.001). Median follow-up was 70 months (25(th) to 75(th) percentile, 24 to 101). Actuarial survival estimates at 1, 5 and 10 years were 93%, 74%, 49% for the OPEN group compared to 89%, 69%, 59% for the EVAR group (p = 0.465). A significant difference between groups was observed in younger patients (< 75 years) only (p < 0.044). Late complication and re-intervention rates were significantly higher in EVAR patients (p < 0.001 and p = 0.002, respectively). Freedom from late complications at 1, 5 and 10 years was 96%, 92%, 86%, and 84%, 70%, 64% for OPEN and EVAR procedures, respectively.

CONCLUSIONS

Our experience confirms the excellent results of the EVAR procedures, offering excellent early and long-term results in terms of safety and reduction of mortality. Patients < 75 years seem to benefit from EVAR not only in the immediate postoperative period but even in a long-term perspective.

Clinical significance of type I endoleak on completion angiography

Purpose

Type I endoleak is known to be associated with sac enlargement and occasional rupture, therefore, the treatment of type I endoleak is recommended at the time of diagnosis. The aim of this study was to identify the significance of early type I endoleak found on completion angiography.

Methods

Between January 2000 and December 2012, a total of 86 patients underwent endovascular abdominal aortic aneurysm repair (EVAR) and 10 patients (11.6%) were diagnosed with type Ia endoleak on completion angiography. Clinical and radiologic data were reviewed retrospectively.

Results

Of the 10 patients, two underwent EVAR with custom-made stent-grafts in the initial stage and both of them needed immediate treatment: one case involved open repair while the other involved insertion of an additional stent-graft. In 8 patients, the amount of leakage decreased after repeated balloon molding. They were managed conservatively and followed up with computed tomography angiography within 2 weeks after EVAR. In 7 of the 8 cases, type Ia endoleaks disappeared. In one patient with a persistent endoleak and a folded posterior wall of the stent-graft, coil embolization was performed 1 week after EVAR. With a median follow-up of 12 months (range, 1-61 months), no patients showed recurrence of type I endoleak or sac expansion.

Conclusion

Type I endoleaks diagnosed on completion angiography sealed spontaneously in 7 of 10 patients (70.0%). In cases of decreased amounts of leakage after balloon molding, simple observation may be an alternative to repetitive procedures. The long-term follow-up of patients with self-sealed type I endoleaks is mandatory.

Ten-year results of endovascular abdominal aortic aneurysm repair from a large multicenter registry

OBJECTIVE

To assess outcomes after endovascular abdominal aortic aneurysm repair (EVAR) in an integrated health care system.

METHODS

Between 2000 and 2010, 1736 patients underwent EVAR at 17 centers. Demographic data, comorbidities, and outcomes of interest were collected. EVAR in patients presenting with ruptured or symptomatic aneurysms was categorized as urgent; otherwise, it was considered elective. Primary outcomes were mortality and aneurysm-related mortality (ARM). Secondary outcomes were change in aneurysm sac size, endoleak status, major adverse events, and reintervention.

RESULTS

Overall, the median age was 76 years (interquartile range, 70-81 years), 86% were male, and 82% were Caucasian. Most cases (93.8%) were elective, but urgent use of EVAR increased from 4% in the first 5 years to 7.3% in the last 5 years of the study period. Mean aneurysm size was 5.8 cm. Patients were followed for an average of 3 years (range, 1-11 years); 8% were lost to follow-up. Intraoperatively, 4.5% of patients required adjunctive maneuvers for endoleak, fixation, or flow-limiting issues. The 30-day mortality rate was 1.2%, and the perioperative morbidity rate was 6.6%. Intraoperative type I and II endoleaks were uncommon (2.3% and 9.3%, respectively). Life-table analysis at 5 years demonstrated excellent overall survival (66%) and freedom from ARM (97%). Postoperative endoleak was seen in 30% of patients and was associated with an increase in sac size over time. Finally, the total reintervention rate was 15%, including 91 instances (5%) of revisional EVAR. The overall major adverse event rate was 7.9% and decreased significantly from 12.3% in the first 5 years to 5.6% in the second 5 years of the study period (P < .001). Overall ARM was worse in patients with postoperative endoleak (4.1% vs 1.8%; P < .01) or in those who underwent reintervention (7.6% vs 1.6%; P < .001).

CONCLUSIONS

Results from a contemporary EVAR registry in an integrated health care system demonstrate favorable perioperative outcomes and excellent clinical efficacy. However, postoperative endoleak and the need for reintervention continue to be challenging problems for patients after EVAR.

Chronic contained abdominal aortic aneurysm rupture after suprarenal fixation fatigue fracture

Chronic contained rupture (CCR) of an abdominal aortic aneurysm is a rare condition, and differential diagnosis might be difficult. We present a clinical case of a hemodynamically stable octogenarian who presented with intermittent pain in the left lower abdomen. The patient had a history of diverticulitis, and 6 years ago, he had undergone endovascular abdominal aortic aneurysm repair (EVAR) with a Talent bifurcated prosthesis. Additionally, 20 days before his admission to our hospital, he had undergone a secondary iliac limb extension for treatment of post-EVAR rupture. On admission, abdominal plain radiography identified suprarenal fixation fracture as a possible reason for CCR, but computed tomographic angiography failed to confirm any endoleak or "active" bleeding and rupture. The patient received medication treatment for possible diverticulitis and was kept under close monitoring for suspected failure of recently performed secondary endovascular procedure and CCR. A day later, the abdominal pain symptoms worsened, and a new computed tomographic angiography confirmed the suspected CCR. The patient was treated successfully by "open" repair using a Y prosthesis. To our knowledge, this is the first reported case of post-EVAR CCR due to suprarenal fixation fatigue fracture. Lifelong post-EVAR follow-up with high level of both clinical and imaging diagnostic accuracy is essential for the early recognition and proper treatment of EVAR pitfalls.

Quality improvement guidelines for imaging detection and treatment of endoleaks following endovascular aneurysm repair (EVAR)

Major concerns after aortic aneurysm repair are caused by the presence of endoleaks, which are defined as persistent perigraft flow within the aortic aneurysm sac. Diagnosis of endoleaks can be performed with various imaging modalities, and indications for treatment are based on further subclassifications. Early detection and correct classification of endoleaks are crucial for planning patient management. The vast majority of endoleaks can be treated successfully by interventional means. Guidelines for Imaging Detection and Treatment of endoleaks are described in this article.

Two-dimensional versus three-dimensional CT angiography in analysis of anatomical suitability for stentgraft repair of abdominal aortic aneurysms

BACKGROUND

The morphological analysis prior to endovascular abdominal aneurysm repair (EVAR) plays an important role in long-term outcomes. Post-imaging analysis of computed tomographic angiography (CTA) by three-dimensional reconstruction with central lumen line detection (CLL 3D-CTA) enables measurements to be made in orthogonal slices. This might be more precise than equal post-imaging analysis in axial slices by two-dimensional computed tomographic angiography (2D-CTA).

PURPOSE

To evaluate the intra- and interobserver variability of CLL 3D-CTA and 2D-CTA post-imaging analysis methods and the agreement between them in pre-EVAR suitability analysis of patients with abdominal aortic aneurysm (AAA).

MATERIAL AND METHODS

Anonymized CTA data-sets from 70 patients with AAA were analyzed retrospectively. Length measurements included proximal and distal aortic neck lengths and total distance from the lower renal artery to the higher iliac bifurcation. Width measurements included proximal and distal neck diameters, maximum AAA diameter and common iliac diameters just above the iliac bifurcations. The measurements were performed in random order by two vascular surgeons, twice per method with 1-month interval between readings. In the CLL 3D-CTA method we used semi-automated CLL detection by software and manual measurements on CTA slices perpendicular to CLL. The equal measurements in 2D-CTA were performed manually on axial CTA slices using a DICOM viewer workstation. The intra- and interobserver variability, as well as the agreement between the two methods were assessed by Bland-Altman test and bivariate correlation analysis.

RESULTS

The intraobserver variability was significantly higher in 2D-CTA measurements for both readers. The interobserver variability was significant in 2D-CTA measurements of proximal neck dimensions while the agreement in CLL 3D-CTA analysis between the two readers was excellent in all studied parameters. The agreement between the two suitability analysis techniques was poor for both readers, especially in measurements of proximal neck's dimensions and in total aortoiliac length (p = 0.001).

CONCLUSION

In pre-EVAR morphological evaluation of AAAs the CLL-3D CTA post-imaging analysis has better intra- and interobserver correlation than 2D-CTA and might represent a useful tool for the proper selection of endograft's type and size.

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.

Use of baseline factors to predict complications and reinterventions after endovascular repair of abdominal aortic aneurysm

BACKGROUND

It is uncertain which baseline factors are associated with graft-related complications and reinterventions after endovascular aneurysm repair (EVAR) in patients with a large abdominal aortic aneurysm.

METHODS

Patients randomized to elective EVAR in EVAR Trial 1 or 2 were followed for serious graft-related complications (type 2 endoleaks excluded) and reinterventions. Cox regression analysis was used to investigate whether any prespecified baseline factors were associated with time to first serious complication or reintervention.

RESULTS

A total of 756 patients who had elective EVAR were followed for a mean of 3.7 years, by which time there were 179 serious graft complications (rate 6.5 per 100 person years) and 114 reinterventions (rate 3.8 per 100 person years). The highest rate was during the first 6 months, with an apparent increase again after 2 years. Multivariable analysis indicated that graft-related complications increased significantly with larger initial aneurysm diameter (P < 0.001) and older age (P = 0.040). There was also evidence that patients with larger common iliac diameters experienced higher complication rates (P = 0.011).

CONCLUSION

Graft-related complication and reintervention rates were common after EVAR in patients with a large aneurysm. Younger patients and those with aneurysms closer to the 5.5-cm threshold for intervention experienced lower rates.