Increasing use of open conversion for late complications after endovascular aortic aneurysm repair

• Published in: Journal of vascular surgery Vol. 69; no. 6; pp. 1766 - 1775
• Main Authors: Mohapatra, Abhisekh, Robinson, Darve, Malak, Othman, Madigan, Michael C., Avgerinos, Efthimios D., Chaer, Rabih A., Singh, Michael J., Makaroun, Michel S.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-06-2019
• Subjects: Abdominal aortic aneurysm; Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal - diagnostic imaging; Aortic Aneurysm, Abdominal - mortality; Aortic Aneurysm, Abdominal - surgery; Aortic rupture; Conversion to Open Surgery - adverse effects; Conversion to Open Surgery - mortality; Device Removal - adverse effects; Device Removal - mortality; Endoleak; Endoleak - diagnostic imaging; Endoleak - etiology; Endoleak - mortality; Endoleak - surgery; Endovascular aneurysm repair; Endovascular Procedures - adverse effects; Endovascular Procedures - mortality; Female; Humans; Male; Open conversion; Reoperation; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Open conversion; Endovascular aneurysm repair; Aortic rupture; Endoleak; Abdominal aortic aneurysm
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2018.09.049

Open procedures are often required for late complications after endovascular aneurysm repair (EVAR). Our aim was to describe the indications for open interventions and their postoperative outcomes and to specifically examine our experience with limited conversions in which problem endoleaks are targeted without endograft explantation.
We reviewed patients from 2002 to 2017 who underwent any surgical abdominal aortic operation after a previous EVAR. Baseline characteristics, preoperative imaging, procedural details, and postoperative outcomes were reviewed. The primary end point was 30-day mortality.
There were 102 patients who underwent open conversion 3.8 ± 3.1 years after EVAR. The numbers increased significantly in recent years, with 18 cases performed in 2016; 48.5% of patients had undergone 1.9 ± 1.0 prior endovascular interventions. The indication for surgical conversion was an endoleak in 85 patients and infection in 15. One patient had a limb occlusion and another a proximal aneurysm. The 30-day mortality was 6.2% in 65 patients treated electively for endoleak but higher in 20 ruptures (40.0%) and 15 infections (40.0%). In a multivariate logistic regression model, independent predictors of 30-day mortality were rupture (odds ratio [OR], 6.70; 95% confidence interval [CI], 1.75-25.60; P = .005), endograft infection (OR, 8.48; 95% CI, 1.99-36.20; P = .004), and use of a supraceliac clamp (OR, 4.80; 95% CI, 1.47-15.66; P = .009). Transient acute kidney injury (12.8%) and prolonged intubation (11.8%) were the most common postoperative complications. In 65 patients treated for endoleak without rupture, 37 underwent endograft explantation, whereas 28 had a graft-preserving intervention (branch vessel ligation for type II endoleak in 26, external banding of the aneurysm neck for type IA endoleak in 8). Mortality was 8.1% when the endograft was explanted and 3.6% when it was not (P = .63). During 3.0 ± 3.5 years of follow-up, there was one reintervention after endograft explantation (for rupture secondary to type IB endoleak) and two reinterventions after graft preservation (for a new type IA endoleak and a new type II endoleak). Survival was 87.4% at 1 year and 70.9% at 5 years.
Open conversion is playing an increasing role in the management of late EVAR complications. Endoleaks treated electively by open conversion are reasonably safe and show good midterm durability, even with graft-preserving interventions that avoid endograft explantation.