Management of failed endovascular aortic aneurysm repair with explantation or fenestrated-branched endovascular aortic aneurysm repair

Abstract

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.

Perioperative Outcome of Fenestrated and Branched Stent Grafting after Previous Open or Endovascular Abdominal Aortic Repair

“…Varying rates of technical success were reported. [4][5][6]10,22,[24][25][26][27] Wang et al recently reported a 100% technical success rate in six patients after fenestrated EVAR for previously failed EVAR and in six after previous open repair. 24 Similar to our experience, Wang et al did not find a difference between the technical success rates after post-open or post-endo fbEVAR, respectively.…”

Early and Mid-Term Outcomes of the Inverted Limb Configuration Below Fenestrated and Branched Endografts: Experience from Two European Centers

“…15 Fenestrated-branched endovascular aortic aneurysm repair is presently a first treatment option in high surgical risk patients and in those with failed EVAR or previous OSR. 1,2,23 Despite being technically demanding, the use of IL custom-manufactured device overcomes the anatomical limitations of short-body initial grafts and short distance between lowest TVV and bifurcation, leading the fixation inside the endograft. As reported in our series, a short-body graft does not ensure a stable overlap, 2 which normally requires 6 to 7 cm, and does not allow neither a tube graft below FB-EVAR nor a standard EVAR inside the preexisting devices.…”

Thoracoabdominal aortic aneurysm repair: A Single center experience

“…These methods were extremely used all over the world [10]. However, failure of these grafts occurred during follow-up [11]. Consequently, surgical conversion of these stents became an indication of aneurysm management or obligation for life-saving.…”