Strategies and outcomes for aortic endograft explantation

Arnaoutakis, Dean J.; Sharma, Gaurav; Blackwood, Stuart; Shah, Samir K.; Menard, Matthew T.; Ozaki, C. Keith; Belkin, Michael

doi:10.1016/j.jvs.2018.03.426

Cited by 23 publications

(15 citation statements)

References 17 publications

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“…Even with this complex reconstruction, most patients were discharged home within 3 days of their surgery. This, in our opinion, validates the advantage of endovascular intervention over open surgical repair in this patient population (Perini et al, 2019;Arnaoutakis et al, 2019;Klonaris et al, 2014;Nabi et al, 2009) . MAEs occurred in three patients (15.7%).…”

Section: Discussionsupporting

confidence: 78%

“…While some patients with this pathology can be treated with an infrarenal cuffs and endoanchors, others do not have a "neck" suitable for such interventions and require endografts explantation or extension of the repair above renal arteries. Stent graft explanation carries a mortality and morbidity rates as high as 24% and 65%, respectively (Perini et al, 2019;Arnaoutakis et al, 2019;Klonaris et al, 2014;Nabi et al, 2009;Pitoulias et al, 2009). Endovascular options for patients with failed EVAR include parallel grafts and fenestrated/branched endografts (f/b-EVAR).…”

Section: Introductionmentioning

confidence: 99%

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Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

et al. 2019

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Background: Endovascular rescue of failed infrarenal repair (EVAR) has emerged as an attractive option to stent graft explantation. The procedure, however, is underutilized due to limited devices accessibility and the challenges associated with their implantation in this patient population. The purpose of this study was to report our outcomes and discuss our approach to rescuing previously failed infrarenal endovascular aneurysm repairs (EVAR) with fenestrated/ branched endografts (f/b-EVAR). Methods: A retrospective analysis of prospectively collected data of consecutive patients with failed EVAR rescued with f/ b-EVAR at our institution from November 2013 to March 2019 was conducted. The study primary end point was technical success; defined as the implantation of the device with no type I a/b or type III endoleak or conversion to open repair. Secondary endpoints included major adverse events (MAEs), graft patency and reintervention rates. Results: During this time, 202 patients with complex aortic aneurysms were treated with f/b-EVAR. Of these, 19 patients (Male: 17, mean age 79 ± 7 years) underwent repair for failed EVAR. The median time from failed repair to f/b-EVAR was 48 (30, 60) months. Treatment failure was attributed to stent graft migration in 9 (47.4%) patients, disease progression in 5 (26.3%), short initial neck in 3 (15.8%) and unable to be determined in 2 (10.5%). Three patients were treated urgently with surgeon modified stent graft. Technical success was achieved in 18 patients (95%), including two who had undergone emergent repair for rupture. Seventy-two targeted vessels (97.3%) were successfully incorporated. Sixteen (84.2%) patients required a thoracoabdominal repair to achieve a durable seal. Major adverse events (MAEs) occurred in 3 patients (15.7%) including paralysis and death in one (5.3%), compartment syndrome and temporary dialysis in another and laparotomy with snorkeling of one renal and bypass of the other in the third patient. Median (IQR) hospital length of stay was 3 (2, 4) days. Late reintervention, primary target vessel patency and primary assisted patency rates were 5.3%, 98.6% and 100%, respectively. Conclusion: Implantation of f/b-EVAR in patients with failed previous EVAR is a challenging undertaking that can be performed safely with a high technical success and low reintervention rates.

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Section: Discussionsupporting

confidence: 78%

Section: Introductionmentioning

confidence: 99%

Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

et al. 2019

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“…However, in the case of a suprarenal fixation stent, supramesenteric or, in most cases, supraceliac aortic cross-clamping is required. [8][9][10] Otherwise, an aortic occlusion balloon is inserted through the axillary artery and inflated at the top of the endograft. In cases of suprarenal cross-clamping, adequate renal protection using cold crystalloid perfusions can be routinely applied to limit the injury caused by prolonged renal ischemia.…”

Section: Complete Endograft Removalmentioning

confidence: 99%

Surgical Treatment of Sac Enlargement Due to Type II Endoleaks Following Endovascular Aneurysm Repair

Onitsuka

Ito

2023

Annals of Vascular Diseases

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An aneurysm sac enlargement caused by type II endoleak (T2EL) following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms may cause serious complications such as rupture. Consequently, methods that preoperatively prevent or postoperatively treat T2EL have been employed. When significant aneurysm enlargement occurs due to persistent T2EL, embolization is first performed through several access points. However, although these endovascular reinterventions have a high technical success rate and are safe, their effectiveness remains questionable. When such endovascular procedures fail to stabilize sac enlargement, open surgical conversion (OSC) becomes the last-resort treatment option. We review several strategies of OSC for the repair of T2EL following EVAR. Among the three main OSC procedures, namely, complete endograft removal, partial endograft removal, and complete endograft preservation, partial endograft removal under infrarenal clamping was considered the most appropriate owing to its less invasiveness and durability.

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“…We adopted the PASHA technique over contrast-enhanced ultrasound imaging, which is operator-dependant, as PASHA is standardised, easily reproducible and can be read by everyone (7,44,45). We recommend lifelong follow-up every six months by DUS for both iliac arteries post explantation of aorto-bi-iliac endograft for fear of iliac degeneration and rupture, as reported by Arnaoutakis et al (46) Postoperative CTA provides better diagnostic utility for proximal and distal neck dilatation or disconnection of the stent-graft components, which DUS could miss on regular follow-ups.…”

Section: Current Guidelines Recommend Intervention In Patients Withmentioning

confidence: 99%

Two decades of experience in explantation and graft preserving strategies following primary endovascular aneurysm repair and lessons learned

et al. 2022

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ObjectivesWe aim to scrutinize our evolving re-intervention strategies following primary endovascular aortic aneurysm repair (EVAR) - EVAR GORE SalvAge Fabric Technique (ARAFAT), aortic sac double breasting with endograft preservation, and stent-graft explantation.MethodsWe performed 1,555 aortic interventions over the study period, including 910 EVARs. Factors associated with the need for reintervention and the likelihood of chronic fabric fatigue failure (CFFF) were investigated. Using conventional and innovative diagnostic modalities with Prone contrASt enHanced computed tomography Angiography (PASHA), 136 endoleaks (ELs) were identified (15 type I, 98 type II; 18 type III; 5 type IV).ResultsForty-four (4.84%) patients underwent re-intervention post-primary EVAR; 18 ARAFATs, 12 double breastings, and 14 explantations. Choice of re-intervention was based on patient fitness and mode of failure. Mean EL detection duration following primary EVAR was 53.3 ± 6.82 months, while mean time to re-intervention was 70.20 ± 6.98 months. The mean sac size before the primary EVAR and re-intervention was 6.00 ± 1.75 cm and 7.51 ± 1.94 cm, respectively. Polyester (61.40%) was the most commonly employed stent-graft material. Use of more than three modular stent-graft components (3.42 ± 1.31, p = 0.846); with the proximal stent-graft diameter of 31.6 ± 3.80 cm (p = 0.651) and the use of iliac limbs more than 17 mm (p = 0.364), all added together are contributing factors. We had one peri-operative mortality following explantation due to sepsis-induced multiorgan failure.ConclusionsOur re-intervention strategies matured from stent graft explantation to graft preservation with endovascular relining of the stent-graft. Graft preservation with aortic sacotomy and double breasting were used to manage concealed ELs due to aortic hygroma.

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Strategies and outcomes for aortic endograft explantation

Abstract: Both complete and partial endograft explantation, although morbid procedures, can be performed safely. Postoperative imaging surveillance is important, especially if the endograft has been removed from the iliac arteries, as degeneration can occur.

Cited by 23 publications

References 17 publications

Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

Surgical Treatment of Sac Enlargement Due to Type II Endoleaks Following Endovascular Aneurysm Repair

Two decades of experience in explantation and graft preserving strategies following primary endovascular aneurysm repair and lessons learned

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