Surgery 2011 Oct;150(4):788-95
Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
Background: Despite advances in endoluminal salvage for failed endografts, certain circumstances necessitate open endovascular abdominal aneurysm repair (EVAR) conversion. We review the indications for and outcomes after late EVAR explants.
Methods: Retrospective review of EVAR patients requiring delayed (>30 days) conversion from 1999 to 2009. Demographics, index endovascular procedure, conversion indication/technique, and outcomes were analyzed.
Results: Among 16 patients who required late conversion, the mean age was 73 years (range, 41-84 years) and 94% were men. Indications included 9 device failures, 6 endograft infections, and a single type II endoleak with sac enlargement. Explanted prostheses included the following: 7 Cook Zenith(®) endoprosthesis, 3 Gore Excluder(®) grafts, 3 Medtronic AneuRx(®) endograft devices, 2 Endologix Powerlink(®) endografts, and 1 Guidant Ancure(®) graft. Before conversion, 7 patients underwent unsuccessful secondary salvage procedures. Transperitoneal (81%) and left retroperitoneal approaches (19%) were used, with 75% requiring supraceliac control. Reconstructions depended on clinical manifestations and included 10 in situ prosthetic repairs, 4 extra-anatomic bypasses, and 2 in situ cryopreserved human allograft repairs. Two patients died during their hospitalization, resulting in a 13% mortality rate. Mean hospitalization for survivors was 18 days (range, 6-78 days), and 7 (50%) of the patients were discharged directly home.
Conclusion: Most delayed EVAR conversions are because of device failure or infection and can be successfully converted to open surgical reconstruction. Supraceliac control is often required, and the perioperative complications are greater than primary elective open or endovascular repair. This study addresses how best to manage failed abdominal aortic endografts and what can be done to improve patient outcomes with this difficult clinical problem.