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

Abstract

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.

Surgical Infrarenal “Neo-neck” Technique During Elective Conversion after EVAR with Suprarenal Fixation

“…Similarly, the literature shows that open conversion after EVAR has significantly longer operative times than primary AAA open repair (p ¼ .03). 14 On the other hand, the time needed to complete the proximal anastomosis was a mean of 23 minutes, and no complications related to visceral ischemia were observed within 30 days. Clamp time in this experience was lower than the 43 minutes reported by the large Cleveland Clinic 10 report, where interventions for conversion with suprarenal fixation required significantly longer mean visceral ischemia than those with infrarenal fixation (43 vs. 28 min; p ¼ .039).…”

“…Even if this type of intervention represents a challenging situation for the surgeon, the overall elective 30 day mortality is low in most of the reported series in the literature (0 to <10%). Recently, Scali et al 14 published their experience comparing open elective conversion for type 1A endoleak and primary open repair of juxtarenal aneurysm; in their conclusions there were no differences in the 30 day mortality rates between the two groups (4% for both; p ¼ 1). Mortality in this series at 30 days was 0% in line with that observed in the literature review, 12,15e25 where the overall 30 day mortality after explantation was very low (<2%), with no significant difference when comparing total versus partial explantation.…”

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

“…An important consequence of older generation devices accruing follow-up time and treatment of more difficult anatomies with modern devices may be higher rates of failure 33, 34 . Indeed, the rationale for pursuing this analysis is related to an increasing number of referrals to our own institution for failed EVAR 7 .…”

“…In an effort to understand the risk of EVAR conversion, we recently performed a study at the University of Florida where we demonstrated that in an anatomically and physiologically analogous group of elective EVAR-c and PAR patients, similar rates of postoperative morbidity and mortality can be anticipated 7 . While EVAR-c was associated with increased operative complexity, short-term outcomes did not significantly differ when compared to a similar risk group of elective open AAA patients which reflects the results of this analysis.…”

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

“…Using these methods, we have been able to obtain similar outcomes in elective EVAR-c compared with open repair. 27 Unfortunately, the VQI does not collect data that allow exact determination of the conduct of the EVAR-c, the type of device explanted, or whether any endograft was left in situ to corroborate these results.…”