Late conversion of endovascular to open repair of abdominal aortic aneurysms

Abstract

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 proced ures 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.

Late graft explants in endovascular aneurysm repair

“…2,[13][14][15] The increased use of EVAR for ruptured aneurysms, when durability of repair is often a secondary consideration, has also been a factor contributing to an increased need for late conversion in other series. 16,17 We have seen a reduction of conversions in our own patients. Although we are not sure of the reason, we have limited our use of commercial devices outside of the IFU.…”

Open Surgery for Abdominal Aortic Aneurysm in the Era of Endovascular Repair: Comparison with Long Term Results of Endovascular Repair Using Zenith Stentgraft

“…Moreover, late open conversion after EVAR is reported to be associated with significant morbidity and mortality if explant of the stentgraft is inevitable, 12) and under this circumstance, suprarenal, and even supraceliac aortic clamping is often required. 13) Gupta and colleagues reported similar perioperative mortality after open surgery and EVAR in patients which made the aortic bifurcation 58 mm wide. The other patient had the stentgraft legs positioned in the non-aneurysmal common iliac arteries in the initial EVAR, but he later developed a right internal iliac artery aneurysm, which seemed to have caused malapposition of the stentgraft leg.…”

Open Reintervention for Aneurysmal Sac Enlargement after EVAR

“…Therefore, direct clamping of these relatively stiff endoprostheses can lead to the risk of insufficient aortic control and damage to the aortic tissues if the supra-renal bare metal stent or fixation barbs tear the aorta. 5) Although "the clamp and pull" complete endograft extraction approach was suggested by several surgeons, 6,7) this is considered to be a very hazardous approach because of the existence of transrenal fixated endografts as the bare metal stent becomes incorporated into the juxtrenal aortic lining with a layer of neointima. 8) Therefore, endograft extraction using infection.…”

“…However, it is important to note that further close and regular surveillance is necessary to establish if the long-term results of this technique are superior to that of other reported surgical options. [5][6][7][8][9][10][11] …”