Conversion to Open Repair After Endografting for Abdominal Aortic Aneurysm: Causes, Incidence and Results (original) (raw)
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Journal of Endovascular Therapy, 2010
Objective. To evaluate frequency, causes and results of conversion to Open repair (OR) after endovascular repair (EVAR) in a single centre during an 8-year period. Design. Six hundred and forty-nine consecutive patients undergoing EVAR were followed up prospectively for endograftrelated complications. Outcomes. Early conversion was any OR during or within 30 days from the primary EVAR. Late conversion was any OR with removal of the endograft after 30 days since a completed EVAR procedure. Results. Median patient follow-up was 38 months (1-93 months). Conversion to OR was performed in 38 patients; nine early and 29 late. Most (7/9) early conversions were due to extensive vessel calcification. Peri-operative mortality was 22% (2/9). Late conversions occurred at a median of 33 months after primary EVAR: 29 were elective and 4 urgent. During the same interval, 79 secondary endovascular interventions were performed, 7 of which failed. The risk of conversion to OR was 9% at 6 years. At multivariate logistic regression analysis, no single factor (short, large or angulated neck, suprarenal fixation, large pre-operative diameter, iliac aneurysms, ASA score risk) was associated with the risk of late failure requiring conversion to OR. Conclusion. The risk of death after early conversion should be recognized, to avoid forcing morphological indications for primary EVAR. Occurrence of late conversion after EVAR is not negligible, affecting almost 1 out of 10 patients after 6 years. In the presence of an expanding aneurysm after EVAR, especially after a failed secondary endovascular correction, an aggressive attitude in fit patients allows outcomes at similar to those of primary OR.
Late open conversion after endovascular aneurysm repair
Interactive CardioVascular and Thoracic Surgery, 2014
OBJECTIVES: Endovascular treatment of the infrarenal abdominal aorta (endovascular repair, EVAR) has emerged as an alternative to open surgery. However, a small subset of patients exists who undergo conversion either in the first 30 postoperative days or later during the course of postoperative surveillance. In the present study, we review our experience with late conversion operations.
Editor's Choice – Late Open Surgical Conversion after Endovascular Abdominal Aortic Aneurysm Repair
European Journal of Vascular and Endovascular Surgery
WHAT THIS PAPER ADDS Late open surgical conversion following endovascular aneurysm repair is associated with significant morbidity and mortality. Although endograft preservation may be preferentially offered as a less invasive alternative to high risk patients requiring open surgical conversion, significant mortality was identified with this procedure. Adherence to device instructions for use (IFU) is markedly lower among EVARs requiring open surgical conversion than uncomplicated cases. There was a trend for decreasing interval to conversion; an association with liberalisation of EVAR outside of IFU is possible, but cannot be concluded from this study. Introduction: Late open surgical conversion following endovascular aneurysm repair (EVAR) may occur more frequently after performing EVAR in anatomy outside the instructions for use (IFU). This study reviews predictors and outcomes of late open surgical conversion for failed EVAR. Methods: This retrospective cohort study reviewed all EVARs performed at the Ottawa Hospital between January 1999 and May 2015. Open surgical conversions >1 month post EVAR were identified. Variables analysed included indication for conversion, pre-intervention AAA anatomy, endovascular device and configuration, operative technique, re-interventions, complications, and death. Results: Of 1060 consecutive EVARs performed, 16 required late open surgical conversion. Endografts implanted were Medtronic Talent (n ¼ 8, 50.0%), Medtronic Endurant (n ¼ 3, 18.8%), Cook Zenith (n ¼ 4, 25.0%), and Terumo Anaconda (n ¼ 1, 6.2%). Eleven grafts were bifurcated (68.8%), five were aorto-uni-iliac (31.2%). The median time to open surgical conversion was 3.1 (IQR 1.0e5.2) years. There was no significant difference in pre-EVAR rupture status (1.4% elective, 2.1% ruptured, p ¼ .54). Indications for conversion included: Type 1 endoleak with sac expansion (n ¼ 4, 25.0%), Type 2 endoleak with expansion (n ¼ 2, 12.5%), migration (n ¼ 3, 18.8%), sac expansion without endoleak (n ¼ 2, 12.5%), graft infection (n ¼ 3, 18.8%), rupture (n ¼ 2, 12.5%). Nine patients (56.2%) underwent stent graft explantation with in situ surgical graft reconstruction, seven had endograft preserving open surgical intervention. The 30 day mortality was 18.8% (n ¼ 3, all of whom having had endograft preservation). Ten patients (62.5%) suffered major in hospital complications. One patient (6.5%) required postconversion major surgical re-intervention. IFU adherence during initial EVAR was 43.8%, versus 79.0% (p < .01) among uncomplicated EVARs. Conclusions: Open surgical conversion following EVAR results in significant morbidity and mortality. IFU adherence of EVARs later requiring open surgical conversion is markedly low. More data are required to elucidate the impact of increasing liberalisation of EVAR outside of IFU.
Late open conversion after failed endovascular aortic aneurysm repair
2014
Objective: Endovascular aortic aneurysm repair (EVAR) is widely used for the treatment of abdominal aortic aneurysms. Complications secondary to EVAR are also treated with endovascular techniques. When this is not applicable, open surgical repair is mandatory. This study aims to present our experience in open surgical repair after failed EVAR. Methods: Within the period from 2004 through 2013, 18 patients (17 men; mean age, 73.9 years) were operated on because of EVAR failure due to persistent type II endoleak (n [ 10), type I or III endoleak (n [ 3), mixed-type endoleaks (n [ 2), stent graft thrombosis (n [ 2), and aortoenteric fistulae (n [ 1). Stent grafts used for EVAR were Zenith (n [ 8), Talent (n [ 4), Excluder (n [ 4), and Anaconda (n [ 2). Results: Mean time interval between EVAR and open conversion was 36 months (range, 2-120 months). Fifteen (83.3%) operations were elective, and three (16.7%) were urgent due to aneurysm rupture (n [ 2) and aortoenteric fistula (n [ 1). Six (33.3%) patients with type II endoleak were treated with simple ligation of the culprit vessels, without aortic clamping and stent graft explantation. In six (33.3%) patients, the stent graft was partially removed except from the segment attached to the proximal neck, while in five (27.8%) patients, complete removal of the stent graft was necessary. Finally, in one patient, with type III endoleak, a hybrid endovascular and open repair was performed. Clamping of the aorta was necessary in 12 (66.7%) patients (infrarenal, n [ 10 or suprarenal, n [ 2). Overall operative mortality was 5.6%. Postoperative complications included one abdominal wall defect requiring surgical revision and paroxysmal atrial fibrillation both in the same patient, and one case of pulmonary infection, requiring prolonged intubation and intensive care unit stay for 6 days.
Delayed open conversions after endovascular abdominal aortic aneurysm repair
Journal of Vascular Surgery, 2012
Objective: Secondary interventions after endovascular aneurysm repair (EVAR) remain a concern. Most are simple catheter-based procedures, but in some instances, open conversions (OCs) are required and carry a worse outcome. We reviewed our experience to characterize these OCs. Methods: A retrospective review was conducted of all patients who underwent an OC after a previous EVAR for an aneurysm-related indication from 2001 to 2010. Clinical outcomes are reported. Results: Data were reviewed for 44 patients (77% men) with a mean age of 74 years (range, 55-90 years). The average time from EVAR to the first OC was 45 months (range, 2-190 months). In six patients (14%), the initial EVAR was at another institution. The endografts used were Ancure in 16, Excluder in 13, AneuRx in eight, Zenith in three, Lifepath in one, Renu in one, and undetermined in two. Twenty-two patients had previously undergone a total of 32 endovascular reinterventions before their index OC. Indications for OC were aneurysm expansion in 28 (64%), rupture in 12 (27%), and infection in four (9%). The endograft was preserved in situ in 10 patients (23%). Explantation was partial in 18 (41%) or complete in 16 (36%). Endograft preservation was used for type II endoleak in all but one patient by selective ligation of the culprit arteries (lumbar in four, inferior mesenteric artery in five, and middle sacral in one). Proximal neck banding was performed in one type Ia endoleak. Overall morbidity was 55%, and mortality was 18%. No deaths occurred in a subgroup of patients who underwent endograft preservation with selective ligation of culprit vessels for type II endoleak. Intraoperative complications included bowel injury in two, bleeding in two, splenectomy in one, and ureteral injury in one. At a mean follow-up of 20 months, two patients underwent additional procedures after the index OC: one after endograft preservation and one after partial explantation. None of the patients who underwent elective OC with endograft preservation required subsequent endograft explantation. Conclusions: Most OCs after EVAR are associated with significant morbidity and mortality, except when electively treating an isolated type II endoleak with ligation of branches and preservation of the endograft.
Late open conversion after endovascular abdominal aortic aneurysm repair
Journal of vascular surgery, 2015
This study determined the incidence, the surgical details, and the outcome of late open conversion after failed endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm. A review of English-language medical literature from 1991 to 2014 was conducted using the PubMed and EMBASE databases to find all studies involving late conversion after EVAR for abdominal aortic aneurysm. The search identified 26 articles encompassing 641 patients (84% men; median age, 73.5 years). Mean interval from the initial implantation was 38.5 ± 10.7 months. The cumulative single-center open conversion rate was 3.7%. The indications for late open conversion included endoleak in 62.4%, infection in 9.5%, migration in 5.5%, and thrombosis in 6.7%. Operations were urgent in 22.5% of the patients. The 30-day mortality was 9.1%. Mortality rates were different between elective (3.2%) and nonelective patients (29.2%). Five aneurysm-related deaths (1.5%) and two graft infections (0.6%) occurred during a med...
European Journal of Vascular and Endovascular Surgery, 2013
WHAT THIS PAPER ADDS Endovascular treatment of abdominal aortic aneurysms is nowadays performed in many centers at high and low volumes of activity. Often its failure can be treated only by surgical conversion. This work gives an overview of the causes and the possibility of surgical management of abdominal aortic aneurysms after endovascular treatment failure. Objectives: Despite several advances in endoluminal salvage for failed endovascular abdominal aortic repair (EVAR), in our experience an increasing number of cases necessitate delayed open conversion (dOC). Methods: EVAR patients requiring delayed (>30 days) conversion were prospectively collected in a computerized database including demographics, details of aortoiliac anatomy, procedural and clinical success, and postoperative complications. Results: Between 2005 and 2011, 54 patients were treated for aortic stent-graft explantation. Indications included 34 type I and III endoleaks, 13 type II endoleaks with aneurysm growth, 4 cases of material failures, and 3 stent-graft infections. All fit-for-surgery patients with type I/III endoleak underwent directly dOC. Different surgical approaches were used depending on the type of stent-graft. Overall 30-day mortality was 1.9%. Overall morbidity was 31% mainly due to acute renal failure (13 cases). Mean hospitalization was 6 days (range, 5e27 days). Overall survival at mean follow-up of 19 months was 78%. Conclusions: In recent years, the use of EVAR has increased dramatically, including in young patients regardless of their fitness for open repair. dOC after endovascular abdominal aortic aneurysm seems to be a lifesaving procedure with satisfactory initial and mid-term results.
European Journal of Vascular and Endovascular Surgery, 2020
WHAT THIS PAPER ADDS Late open conversions for endovascular aneurysm repair complications have increased in number over the last 20 years. They are technically challenging operations, with high post-operative mortality and morbidity rates, especially for infection and urgent operations. Morbidity rates are lower when the endograft is clamped infrarenally. Objective: The aim was to report indications, technical aspects, and outcomes of a multicentre experience of late open conversions (LOCs) after endovascular abdominal aneurysm repair (EVAR), in order to identify risk factors which may influence early morbidity and mortality rates, and long term survival. Methods: Ten vascular centres retrospectively reviewed all patients requiring LOC (!30 days from initial EVAR, undergoing total or partial endograft explantation) from 1996 to 2017. Baseline characteristics, endograft data, indications, procedural details, post-operative outcomes, and follow up data were reviewed and analysed. Results: Included patients totalled 232 (90.1% males, mean age 74.3 AE 7.9 years). The number of LOC per year significantly increased during the study period, reaching 22 in 2017 (correlation r ¼ 0.867, p < .0001). Reasons for LOC were 80.2% endoleak (186/232), 15.5% endograft infection (36/232), and 9.9% endograft thrombosis (23/232). Sixty-nine patients (29.7%) were operated on urgently; rupture was present in 18.5% (43/232). Eighty-nine patients (38.4%) underwent endovascular re-interventions prior to LOC. The proximal aortic cross clamp site was infrarenal in 40.5% (94/232), suprarenal in 25.4% (59/232), supracoeliac in 32.8% (76/232), and thoracic in 1.3% (3/232). Endograft explantation was total in 164/232 patients (70.7%), and partial in the remaining 68/232 (29.3%). The overall 30 day mortality was 11.2% (26/232). Early mortality was significantly higher for patients operated on urgently (26.1% vs. 4.9%, p < .001). Suprarenal clamping (odds ratio (OR) 2.34, 95% CI 1.12e4.88) and pre-existing renal insufficiency (OR 2.11, 95% CI 1.03e4.31) were independent risk factors for post-operative renal failure on multivariable analysis. Median follow up was 24.1 months (IQR 4.4e60.6). The estimated overall one and five year survival rates were 79.7% and 58.6%, respectively. Survival estimates were significantly lower for patients with endograft infection (83.8% vs. 59% at one year, 65.2% vs. 28.9% at five years; log rank p ¼ .005), as well as for urgent patients (87.2% vs. 62.1% at one year, 65.1% vs. 43.7% at five years; log rank p < .0001). Conclusion: The annual number of LOC increased over time. LOCs performed urgently or for endograft infection are associated with poor survival. Infrarenal aortic clamping has lower post-operative complication rates.
Outcomes of acute intraoperative surgical conversion during endovascular aortic aneurysm repair
Journal of Vascular …, 2011
Purpose-Outcomes and predictors of acute surgical conversion during endovascular aortic aneurysm repair (EVAR) were examined using the American College of Surgeons-National Safety and Quality Improvement Project (ACS-NSQIP) Database (2005 to 2008). Methods-Acute intraoperative surgical conversions occurring during elective EVAR were identified using Current Procedural Terminology codes. Nonemergent EVAR and primary open surgical repairs of infrarenal aneurysms were examined for comparison. Perioperative morbidity was categorized as wound, pulmonary, venous thromboembolic, genitourinary, cardiovascular, operative, and septic. Mortality, overall morbidity, and length of stay (LOS) were examined. Results-We identified 72 acute conversions, 2414 open repairs, and 6332 EVAR without acute conversion. Demographics and comorbidities were generally similar among operative groups. Mean operative time was 274 minutes for acute conversion vs 226 minutes for primary open repair
Open Conversion After Endovascular Abdominal Aneurysm Repair: An 8 year Single Centre Experience
European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2017
To report experience with open conversion (OC) after previous failed EVAR and to compare outcomes of patients undergoing elective OC with those operated on in an urgent setting. Patients undergoing OC after EVAR between August 2008 and September 2016 were included in this retrospective and observational single institution study. Indications, demographic, anatomical, intra-operative and post-operative data were collected prospectively. Primary endpoints were 30 day and in hospital mortality. Secondary endpoints included moderate to severe complications, secondary interventions, length of intensive care unit, and hospital stay. OC was performed in 31 patients over the study period: 19 elective and 12 emergency OC, including six ruptures. Median time from index EVAR to delayed OC was 35 months (0-228 months). The most common indications for OC were endoleaks (n = 24, 77%), followed by stent graft infection (n = 3, 10%), thrombosis (n = 3, 10%) and kinking (n = 1, 3%). Eight of the remo...