Aortic endograft infection can be eradicated by excision and in situ or extra-anatomic replacement but is often associated with early postoperative morbidity and mortality and occasionally with a need for late removal for reinfection. Prosthetic graft replacement after explanation is associated with higher reinfection and graft-related complications and decreased survival compared with autogenous reconstruction.

The rate of EVAR late explants has increased during the past decade at our institution. Survival is higher when the explant is done electively compared with emergent repair. Difficulty in obtaining a seal at the initial EVAR often leads to failure ≤1 year, whereas progression of aneurysmal disease is the primary reason for failure >5 years.

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Objective: The incidence of failed endovascular aneurysm repair (EVAR) is increasing, and understanding the different methods of management and repair is paramount. The objective of this study was to evaluate the clinical management and rescue of failed EVAR by either explantation or fenestrated-branched EVAR (F/B-EVAR).Methods: A retrospective analysis (1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016) of 247 patients who underwent either explantation (n ¼ 162) or F/B-EVAR (n ¼ 85) for failed EVAR was performed. F/B-EVAR was performed under a physician-sponsored investigational device exemption. Demographics of the patients, clinical presentation and failure etiology, perioperative management, rate of reinterventions, morbidity, and mortality were analyzed. Those undergoing surgical explantation were compared with those undergoing F/B-EVAR conversion. Statistical analysis included multivariable logistic regressions, Fisher exact test, and c 2 test. Results:The majority of patients were male (n ¼ 216 [87%]), with a mean age of 75 years (range, 50-93 years). The mean time from primary EVAR was higher in F/B-EVAR (46 6 7 months vs 69 6 41 months; P < .001). Graft manufacturer did not differ between those requiring explantation and those having endovascular rescue (P ¼ .170). All emergencies (n ¼ 24 [10%]) and infections (n ¼ 28 [11%]) were treated with open conversion. Endoleak was the most common reason for failure in both explantation and F/B-EVAR groups (75% vs 64%, respectively; P ¼ .052). Type I endoleak was the most common endoleak reported in both groups, occurring more frequently in F/B-EVAR (64% vs 40%; P < .001); type II endoleak was more common in those undergoing open repair (28% vs 2%; P < .001). Graft migration (12% vs 26%; P ¼ .005) and neck degeneration/disease progression (14% vs 59%; P < .001) were more prevalent in F/B-EVAR, but aneurysm enlargement was more common in explantation (68% vs 33%; P < .001). Thirty-day reintervention rates did not differ between F/B-EVAR and explantation (odds ratio, 0.6258; 95% confidence interval, 0.2-1.86; P ¼ .4115); however, 30-day mortality was lower in the F/B-EVAR group (5% vs 10%; P ¼ .0192). Similarly, aneurysm-related mortality was also lower in the F/B-EVAR group (hazard ratio, 0.0683; 95% confidence interval, 0.01-0.44; P ¼ .0048). A subset analysis excluding emergencies and infections did not alter the lack of difference in terms of freedom from reinterventions (P ¼ .1175), 30-day mortality (P ¼ .6329), or aneurysm-related mortality (P ¼ .7849).Conclusions: Explantation and F/B-EVAR are necessary options in treating patients with failed EVAR, and both techniques have competitive results. Different modes of failure may point to a preferred method of treatment; consequently, rescue of failed EVAR should be individualized according to each patient's presentation and resources available.

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Conclusions: Among Medicare beneficiaries undergoing AAA repair, 10% of alive patients are institutionalized at the 1-year time point. A significant proportion of frail AAA patients (21%-25%) are institutionalized at 1 year, irrespective of procedure type. Frailty is significantly associated with institutionalization in risk-adjusted models at 1 year, irrespective of procedure type. Further research is needed to identify the effects of the decline in living status on patients' quality of life and the inclusion of these outcomes in shared decision making.