Delayed Open Conversion after Endovascular Abdominal Aortic Aneurysm: Device-specific Surgical Approach

McNally

Feezor

et al. 2014

Objectives Type 1a endoleak after endovascular aortic repair (EVAR) can be a challenging complication to manage, and due to concerns regarding morbidity and mortality of open surgical conversion (OSC), reports of complex endoluminal salvage techniques are increasing. Despite development of these endovascular remedial strategies, many patients ultimately require OSC. The purpose of this analysis was to determine outcomes of elective open conversion for type 1a endoleak and compare them to elective primary open juxtarenal aortic repair (OJAR) to determine if these concerns are warranted. Methods From 2000–12, 54 patients underwent EVAR conversion at median time of 27 months [interquartile range (IQR): 9, 55]. Indications included: endograft thrombosis (N=2, 4%), intraoperative EVAR failure (N=3, 6%), rupture (N=5, 9%), graft infection (N=6, 11%), and endoleak (All: N=38, 70%; type 1a: N=25). Because many open conversions are performed for emergent indications without endovascular options, we chose elective type 1a endoleak patients as our study group. These 25 patients were compared to an elective open juxtarenal aneurysm repair cohort matched by anatomy and comorbidities. Primary end-points were 30-day and 1-year mortality. Secondary end-points included early complications, cross-clamp time, procedure time, blood loss, and length of stay (LOS). Results Demographic and comorbidity data in the OSC and OJAR groups did not differ with the exception that OJAR patients presented with smaller aneurysm diameter and a higher rate of chronic obstructive pulmonary disease (P = .03). OSC patients more frequently underwent a non-tube graft repair [OSC, N=6 (24%) vs. OJAR, N=20 (80%); P=.0002], required longer procedure times (P=.03), and received more plasma transfusion (P=.03). The 30-day mortality was 4% in both groups (observed difference in rates = 0%, 95% CI for difference in mortality rates = [−14.0%, 14.0%], P=1). A similar rate of major complications occurred [OSC (N = 9) 36% vs. OJAR (N = 8) 32%; P = 1]. One-year survival was 83% in OSC and 91% in OJAR (observed difference = 7%, 95% CI [−15%, 29%], P=.65). Conclusions Despite many advances in EVAR technology, the need for OSC persists, and will likely become more common as older generation devices fail or providers attempt EVAR in more anatomically complex patients. Elective OSC for type 1a endoleak can be technically challenging, but is not associated with increased morbidity or mortality when compared to OJAR in appropriately selected patients. These results should be considered before pursuing complex endovascular remediation of EVAR failures.

Section: Discussionmentioning

confidence: 67%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Elective endovascular aortic repair conversion for type Ia endoleak is not associated with increased morbidity or mortality compared with primary juxtarenal aneurysm repair

McNally

Feezor

et al. 2014

“…al. 6 documented a 1.9% 30-day mortality and 31% composite morbidity rate for 54 patients who underwent EVAR-c. A device-specific surgical approach was advocated with a preference for placing an infrarenal cross-clamp, if anatomically feasible to safely complete the repair. Similarly, Nabi and colleagues 8 argue for partial endograft removal when possible to minimize aortic dissection, operative time, risk of aortic/iliac vessel injury and need for visceral/renal ischemia.…”

Section: Discussionmentioning

confidence: 99%

Defining risk and identifying predictors of mortality for open conversion after endovascular aortic aneurysm repair

Beck

Chang

et al. 2016

Objective Risk of open conversion after endovascular aortic aneurysm repair(EVAR-c) is poorly defined. The purpose of this analysis was to determine outcomes of elective EVAR-c compared to elective primary open abdominal aortic aneurysm repair(PAR) in the Vascular Quality Initiative(VQI). Methods VQI patients undergoing elective EVAR-c and PAR(2002–2014) were reviewed. Candidate predictors of major adverse cardiac events(MACE) and/or 30-day mortality were entered into a multivariable model, and stepwise elimination was used to reduce the number of covariates to a best subset of predictors. To estimate the additive risk of EVAR-c for MACE or 30-day mortality over PAR, this variable was added along with the best subset of predictors into generalized estimating equations logistic regression models. Results 159 EVAR-c and 3,741 PAR patients were identified. EVAR-c patients were older (73.5±8.1 vs. 69.5±8.4 years;P<.0001), more likely to have diabetes(21% vs. 15%;P=.03) and prior history of lower extremity bypass(9% vs. 4%;P=.0006). EVAR-c was associated with a higher incidence of retroperitoneal aortic exposure(41%;N=64 vs. PAR, 26%, N=976;P<.0001), use of a bifurcated graft(65%;N=101 vs. PAR, 52%;N=1923;P=.001), greater blood loss (median, IQR: 2000mL[1010,3500] vs. PAR, 1200mL[750,2000];P<.0001) and longer procedure times (EVAR-c, 275±122min vs. PAR, 232±9min;P<.0001). However, PAR more frequently was completed with a suprarenal/mesenteric cross-clamp(74%, N=2749 vs. EVAR-c, 53%, N=83;P<.0001) and had a higher incidence of concomitant procedures(26%;N=972 vs. EVAR-c, 18%, N=28;P=.03). Non-risk adjusted 30-day mortality was higher after EVAR-c: EVAR-c, 8%(N=10) vs. PAR, 3%(N=105);P=.009. There was no difference in complication rates: EVAR-c, 33%(N=52) vs. PAR, 28%(N=1056);P=.3. Preoperative 30-day mortality predictors included age(OR 1.06/year, 95% C.I: 1.04–1.1;P<.0001), COPD (OR 2.4, 1.6–3.5;P<.0001), history of prior leg bypass (OR 2.3, 1.2–4.4;P=.01), suprarenal cross-clamp (OR 2.2, 1.2–4.1;P=.01), prior carotid revascularization (OR 2.2, 1.3–3.8;P=.0004), congestive heart failure (OR 1.8, .9–3.5;P=.08) and female gender (OR 1.6, 1.1–2.3;P=.02) (AUC=.75). When controlling for covariates, EVAR-c was not significantly associated with MACE (OR 1.2 95% CI 0.7–2.0;P=.4) or 30-day mortality (OR 2.0, .9–4.2;P=.08). Conclusions EVAR-c patients are typically older, have more comorbidities and experience greater blood loss and longer procedure times compared to PAR patients. However, postoperative morbidity and mortality are primarily driven by patient covariates and intraoperative factors, rather than the need for endograft explantation. Several preoperative variables were identified as predictors of 30-day mortality after elective EVAR-c and should be considered during the decision making process for remedial treatment of failed EVAR.

“…Indeed, Marone at al 4 demonstrated 30-day mortality rates of 1.9% and morbidity of 31% in appropriately selected patients (n = 54) with device-specific technical considerations, but only 13% were for nonelective indications. Truly determining how much the existing EVAR device itself contributes to the complexity or the increased mortality is not possible with the available VQI data.…”

Section: Discussionmentioning

confidence: 99%

Outcomes after endovascular aneurysm repair conversion and primary aortic repair for urgent and emergency indications in the Society for Vascular Surgery Vascular Quality Initiative

Runge

Feezor

et al. 2016

Objective Open conversion after endovascular aortic aneurysm repair (EVAR-c) is performed nonelectively in up to 60% of cases. EVAR-c has been reported to have significantly greater risk of postoperative morbidity and mortality than primary aortic repair, but few data exist on outcomes for symptomatic or ruptured presentations. This study determined outcomes and identified predictors of postoperative major adverse cardiac events (MACEs) and mortality for patients undergoing nonelective EVAR-c compared with nonelective primary aortic repair (PAR) in the Vascular Quality Initiative (VQI). Methods All VQI patients undergoing urgent/emergency EVAR-c or urgent/emergency PAR from 2002 to 2014 were reviewed. Urgent presentation was defined by repair ≤24 hours of a nonelective admission, and emergency operations had clinical or radiographic evidence, or both, of rupture. End points included in-hospital MACE (myocardial infarction, dysrhythmia, congestive heart failure) and 30-day mortality. Possible covariates identified on univariate analysis (P < .2) were entered into a multivariable model, and stepwise elimination identified the best subset of predictors. Generalized estimating equations logistic regression analysis was used to determine the relative effect of EVAR-c compared with PAR on outcomes. Results During the study interval, we identified 277 EVAR-c, and 118 (43%) underwent urgent/emergency repair. nonelective PAR was performed in 1388 of 6152 total (23%). EVAR-c patients were older (75 ± 9 vs 71 ± 10 years; P < .0001), more likely to be male (84% vs 74%; P =.02), and had a higher prevalence of hypertension (88% vs 79%; P =.02) and coronary artery disease (38% vs 27%; P = .01). No differences in MACE (EVAR-c, 31% [n = 34] vs PAR, 30% [n =398]) or any major postoperative complication (EVAR-c, 57% [n =63] vs PAR, 55% [n =740]; P =.8) were found; however, 30-day mortality was significantly greater in EVAR-c (37% [n = 41]) than in (PAR, 24% [n = 291]; P = .003), with an odds ratio (OR) of 2.2 (95% confidence interval [CI], 1.04–4.77; P = .04) for EVAR-c. Predictors of any MACE included age (OR, ×1.03 for each additional year; 95% CI, 1.01–1.03; P =.0002), male gender (OR, 1.3; 95% CI, 1.03–1.67; P =.03), body mass index ≤20 kg/m2 (OR, 1.8; 95% CI, 1.13–2.87; P =.01), chronic obstructive pulmonary disease (OR, 1.2; 95% CI, 0.86–1.80; P = .25), congestive heart failure (OR, 1.5; 95% CI, 0.98–2.34; P = .06), preoperative chronic β-blocker use (OR, 1.3; 95% CI, 0.97–1.63; P =.09), and emergency presentation (OR, 2.3; 95% CI, 1.8–3.01; area under the curve, 0.70; P < .0001). Significant predictors for 30-day mortality were age (OR × 1.07 for each additional year; 95% CI, 1.05–1.09; P < .0001), female gender (OR, 1.6; 95% CI, 1.01–2.46; P =.04), preoperative creatinine >1.8 mg/dL (OR, 1.6; 95% CI, 1.04–2.35; P = .03), an emergency presentation (OR, 4.8; 95% CI, 2.93–7.93; P < .0001), and renal/visceral ischemia (OR, × 1.1 for each unit increase log (time-minutes); 95% CI, 1.02–1.22; area under the curve, 0.84; P = ...