Late conversion of endovascular to open repair of abdominal aortic aneurysms

Clinical presentation, operative management, and long-term outcomes of rupture after previous abdominal aortic aneurysm repair

OBJECTIVE

The aim of the present study was to evaluate the presentation trends, intervention, and survival of patients who had been treated for late abdominal aortic aneurysm rupture (LAR) after open repair (OR) or endovascular aortic aneurysm repair (EVAR).

METHODS

We reviewed the clinical data from a single-center, retrospective database for patients treated for LAR from 2000 to 2020. The end points were the 30-day mortality, major postoperative complication, and survival. The outcomes between LAR managed with EVAR (group I) vs OR were compared (group II).

RESULTS

Of 390 patients with infrarenal aortic rupture, 40 (10%) had experienced aortic rupture after prior aortic repair and comprised the LAR cohort (34 men; age 78 ± 8 years). LAR had occurred before EVAR in 30 and before OR in 10 patients. LAR was more common in the second half of the study with 32 patients after 2010. LAR after prior OR was secondary to ruptured para-anastomotic pseudoaneurysms. After initial EVAR, LAR had occurred despite reintervention in 17 patients (42%). The time to LAR was shorter after prior EVAR than after OR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment for LAR was EVAR for 25 patients (63%; group I) and OR for 15 (37%, group II). LAR after initial OR was managed with endovascular salvage for 8 of 10 patients. Endovascular management was more frequent in the latter half of the study period. In group I, fenestrated repair had been used for seven patients (28%). Salvage for the remaining cases was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality (8% vs 13%; P = .3), complications (32% vs 60%; P = .1), and disposition were similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and less need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 21 months (interquartile range, 6-45 months). The overall 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between groups (28 vs 22 months; P = .48). Late mortality was not related to the aorta.

CONCLUSIONS

LAR after abdominal aortic aneurysm repair has been encountered more frequently in clinical practice, likely driven by the frequency of EVAR. However, most LARs, including those after previous OR, can now be salvaged with endovascular techniques with lower morbidity and mortality.

The failing endograft-A systematic review of aortic graft explants and associated outcomes

OBJECTIVE

The prominent use of endovascular stent grafts in the management of abdominal aortic aneurysms is associated with increased descriptions of late complications such as graft infection and endoleaks, which can confer significant morbidity and mortality. Failed endovascular management of late complications often requires open conversion and graft explantation. This systematic review sought to highlight the peri- and post-operative course of patients undergoing aortic graft explants to inform readers of the associated morbidity and mortality of patients undergoing this procedure.

METHODS

The review was conducted in accordance with PRISMA guidelines. A search of the PubMed, Google Scholar and Ovid MEDLINE databases from January 1995 to April 2021 was performed with a combination of MeSH terms pertaining to endovascular aneurysm repair and open conversion. Articles were screened and included based on pre-determined selection criteria.

RESULTS

A total of 818 studies were identified, with 41 meeting inclusion criteria. These studies examined a total of 1324 patients, 84.3% of whom were male with a mean age of 74 years at explantation. Mean time to graft explantation was 36 months, with a mean aneurysm size of 66 mm. The majority of aortic explants were performed for persistent endoleaks (68%), and 10% for infection. There was high morbidity with the procedure, with high rates of post-operative complications (mean, 37%) and 30-day mortality (11%). The most common complications included renal (15%), respiratory (12%) and cardiac (9%). Most explanted grafts were first-generation endografts. Morbidity and mortality rates were reduced in patients undergoing elective explants compared to emergent procedures (3.3% compared to 43.4%).

CONCLUSION

Aortic graft explant remains a highly co-morbid procedure, with high rates of peri- and post-operative complications and mortality. The number of explant procedures reported over the past 25 years has increased, reflecting the prominent use of EVAR in the management of AAAs. Whilst remaining a highly co-morbid procedure, patients undergoing elective explants had markedly reduced rates of mortality and morbidity compared to emergent explants. Thus, clinical focus should be on identifying patients who require graft explantation early to perform these procedures in an elective setting.

Impact of Instructions for Use and Endoleaks On Long-Term Mortality After Treatment for Abdominal Aortic Aneurysm

OBJECTIVES

We reported the clinical outcomes after open repair and endovascular aortic repair for abdominal aortic aneurysm and analyzed the risk factors for all-cause mortality and endoleak after endovascular aortic repair.

METHODS

Patients who underwent elective treatment for abdominal aortic aneurysm from January 2009 to March 2020 were included in this study. The treatment was according to a procedure selection algorithm based on the Society for Vascular Surgery comorbidity scores and instructions for use. All patients were divided into open repair and endovascular aortic repair groups, and the clinical results were compared between the groups.

RESULTS

Of the 278 patients, 116 patients (41.9%) underwent open repair, and 161 patients (58.1%) underwent endovascular aortic repair. The cumulative survival rate with endovascular aortic repair was 78.6%. In the Cox proportional hazard analysis, hemodialysis (hazard ratio = 4.56; 95% confidence interval = 1.5-14.0) and the presence of type I or III endoleak (hazard ratio = 5.7; 95% confidence interval = 1.50-14.5) were independent risk factors for all-cause mortality. The Society for Vascular Surgery comorbidity score was not an independent risk factor (hazard ratio = 1.11; 95% confidence interval = 1.0-1.2). In the multivariate logistic regression analysis to identify the risk factors for type I or III endoleak after endovascular aortic repair, anticoagulation drug therapy (odds ratio = 3.99; 95% confidence interval = 1.8-8.9), untreated thoracic aortic aneurysm (odds ratio = 4.8; 95% confidence interval = 1.8-17.3), and outside instruction for use for the proximal neck (odds ratio = 5.8; 95% confidence interval = 2.3-9.8) were independent risk factors.

CONCLUSIONS

We analyzed the risk factors for all-cause mortality after treatment and endoleak after endovascular aortic repair. The results indicated that the instructions for use should be respected to reduce the frequency of endoleaks and that open repair should be chosen more often to improve late survival.

Abdominal Aortic Neck Wrap for Refractory Type 1a Endoleak: A Case Series and a Novel Intraoperative Assessment Technique

Objective: Refractory type 1a endoleak after endovascular aneurysm repair (EVAR) can pose a significant challenge to surgeons and interventional radiologists. Continuous sac expansion results in aneurysm rupture and mortality. In such circumstances, an external infrarenal aortic wrap could serve as an essential and alternative solution. Methods: We assessed the application of an infrarenal aortic neck wrap for the treatment of refractory type 1a endoleak in n=6 consecutive patients along with the introduction of a novel assessment technique in order to assure their intraoperative success with no radiation exposure and contrast use. Results: The median sac expansion was 8.5 mm (interquartile range [IQR], 5-20 mm). The median neck diameter and length of the aortic neck were 23 mm (IQR, 18-25 mm) and 21 mm (IQR, 18-25 mm), respectively. The median length of follow-up post wrap is 24 months (IQR, 14-34 months). There was no associated mortality or morbidity and requirement for any further interventions. Conclusion: The study demonstrates that aortic wrapping for the treatment of refractory type 1a endoleak for any given neck diameter and length is safe, effective, and long lasting. The suggested novel intraoperative assessment technique contributes to the safety of the procedure by diminishing the need for intraoperative radiation exposure, contrast, and shorter operative time.

Lessons Learned from Open Surgical Conversion after Failed Previous EVAR

BACKGROUND

Delayed open conversion (OpC) after endovascular aortic aneurysm repair (EVAR) is becoming increasingly common worldwide. We reviewed our experience to characterize the perioperative spectrum of OpC repairs.

MATERIALS AND METHODS

A retrospective analysis of a prospectively maintained institutional database to identify patients who underwent late OpC after failed EVAR was performed. Patient and aneurysm baseline characteristics, mechanism of failure, perioperative details, including type of repair/complications/survival, and late outcomes were examined.

RESULTS

From January 2003 to January 2020, 38 male patients (mean age, 75 ± 7 years; range, 60-90) required late OpC. Interval time from initial EVAR to OpC was 63.6 ± 33.8 months (range, 17-120). Mean diameter of the aneurysms was 82.2 ± 22.1 mm before OpC compared with 62.9 ± 13 mm before endograft implantation. Mechanisms of failure were type Ia, Ib, II, and III endoleaks in 14 (36.8%), 9 (23.7%), 4 (10.5%), and 1 (2.6%) patient(s), respectively; infection in 3 (7.9%), leg ischemia in 2 (5.3%), and multiple causes in 5 (13.2%) patients. We observed 4 (10.5%) asymptomatic, 16 (42.1%) symptomatic, and 18 (47.3%) ruptured aneurysms. Four patients (10.5%) had stable contained ruptures, whereas the remaining 13 (34.2%) and 1 additional patient (2.6%) with aortoenteric fistula presented with hemorrhagic shock (class ≥II). Total endograft explantation, endograft preservation, or proximal/distal partial graft removal was performed in 16 (42.1%), 10 (26.3%), and 2 (5.2%)/9 (23.7%) of patients, respectively. Technical success was 100%, excluding an early postaortic clamping death. Overall, 30-day mortality was 21.1% (8 of 38) and significantly higher in patients with hemorrhagic shock or hemodynamic instability at presentation (P = 0.04 and P = 0.009, respectively) and in patients who had endografts with hooks/barbs or experiencing higher postoperative complication rate (P = 0.02 and P = 0.006, respectively). By definition, procedure success was 81.1%. Mean follow-up was 37.6 ± 39.8 months. By the end of the study, we recorded 11 deaths (2 were aneurysm related).

CONCLUSIONS

Despite high technical success, OpC has a significant mortality in patients presenting with hemorrhagic shock and had active fixation endografts or experiencing high complication rate. Many other confounding factors may play a role.

Techniques and future perspectives for the prevention and treatment of endoleaks after endovascular repair of abdominal aortic aneurysms

The presence of endoleaks remains one of the main drawbacks of endovascular repair of abdominal aortic aneurysms leading to the increase of the size of the aneurysmal sac and in most of the cases to repeated interventions. A variety of devices and percutaneous techniques have been developed so far to prevent and treat this phenomenon, including sealing of the aneurysmal sac, endovascular embolisation, and direct sac puncture. The aim of this review is to analyse the indications, the effectiveness, and the future perspectives for the prevention and treatment of endoleaks after endovascular repair of abdominal aortic aneurysms.

Five-year results of endovascular abdominal aortic aneurysm repair with the Ovation abdominal stent graft

OBJECTIVE

Endovascular abdominal aortic aneurysm repair (EVAR) has been rigorously compared with open repair for the treatment of abdominal aortic aneurysms in randomized trials and observational studies, but a comparison of individual devices is lacking, and single-device registries and trials are limited by small sample size. Here we report a descriptive analysis of the Effectiveness of Custom Seal with Ovation: Review of the Evidence (ENCORE) database, pooled results of multiple studies evaluating the midterm results of EVAR with the Ovation Abdominal Stent Graft Platform.

METHODS

This is a retrospective analysis of the ENCORE database, a cohort of patients undergoing EVAR with the Ovation platform composed of pooled, prospectively collected data from 1296 patients from five clinical trials and the prospectively maintained European Union Post-Market Registry. The primary outcomes were 5-year rates of type IA and type I or III endoleak. Secondary outcomes included were 30-day mortality, 30-day major adverse event, technical success (successful deployment of the aortic body and iliac limbs), as well as 5-year survival, and freedom from aneurysm-related mortality, type II endoleak, device-related intervention, aneurysm rupture, sac expansion, and conversion to open repair.

RESULTS

A total of 1296 patients were included in the analysis. The average age was 73 ± 8 years and 81% of patients were male. Fifty percent of patients had complex aortic anatomy, (neck length <10 mm, neck diameter >28 mm, neck angle >60°, reverse neck taper >10%, distal common iliac artery diameter <10 mm, or external iliac artery diameter <6 mm). Technical success was 99.7%. Thirty-day mortality was 0.3%, 30-day rate of major adverse event was 1.6%, and polymer leak rate was 0.2%. Freedom from type IA endoleak at 1, 3, and 5 years was 97.6%, 97.1%, and 95.8%, respectively; type I or III endoleak at 1, 3, and 5 years was 96.9%, 95.7%, and 94.0%, respectively. Freedom from device-related reintervention at 1, 3, and 5 years was 96.2%, 94.4%, and 92.4% and primary freedom from sac expansion was 97.0% at 1 year, 90.3% at 3 years, and 84.9% at 5 years. Freedom from all-cause mortality and aneurysm-related mortality at 5 years were 78.9% and 99.3%, respectively.

CONCLUSIONS

This analysis of the ENCORE database demonstrates that EVAR with the Ovation platform has favorable midterm durability evidenced by successful aneurysm exclusion and 5-year freedom from aneurysm-related mortality.

State of the art and meta-analysis of secondary open aortic procedure after abdominal endovascular aortic repair

BACKGROUND

Secondary open aortic procedures (SOAP) treat complications of endovascular aneurysm repair, when further endovascular options are exhausted. We aimed at depicting the state of the art of SOAP with high-level evidence.

METHODS

A systematic review of the SOAP literature, with a meta-analysis of its outcomes (primary outcome operative mortality; secondary outcome major morbidity) and metaregression of risk factors for mortality (PROSPERO 42017075631).

RESULTS

Twenty-eight studies (1093 patients) were elected for analysis. SOAP was performed within the same hospitalization of or 30 days from domestic endovascular aneurysm repair (early SOAP) in 0.2% of the patients (85/40,256), and in a nonelective setting in 24.3% (95% confidence interval, 21.8-26.9). Most frequent indications were endoleak (44.4%; 95% confidence interval, 41.4-47.3) and rupture (12.7%; 95% confidence interval, 10.4-15.1). The most common procedures were infrarenal aortic replacement (85.2%; 95% confidence interval, 82.6-87.7) with high use of supravisceral clamping (suprarenal, 25% [95% confidence interval, 21.9-28.1] and supraceliac, 20.7% [95% confidence interval, 17.8-23.6]), and axillobifemoral bypass with stent explant (6.9%; 95% confidence interval, 5.1-8.7). Operative mortality (in-hospital or 30-day) was 10.9% (95% confidence interval, 8.7-13.5). The most frequent morbidities were respiratory (11.4%; 95% confidence interval, 8.1-15.9) and renal (9.5%; 95% confidence interval, 8.1-15.9). Risk factors for mortality were supravisceral clamping (Z = 3.007; Q = 9.044; P = .003) and nonelective status (Z = 3.382; Q = 11.440; P = .001).

CONCLUSIONS

Endoleak is the main indication for SOAP, which mostly consists of infrarenal aortic replacement. Risk factors for operative mortality are nonelective status and supravisceral clamping.

Delayed open conversion after endovascular aortic repair

AIM

We present the clinical outcomes of patients who underwent delayed (>30 days) open surgical repair after endovascular aortic aneurysm repair.

METHODS

All patients receiving delayed open repair of infrarenal and juxtarenal aortic aneurysms after endovascular repair from July 2001 to December 2017 were retrospectively reviewed. Patients' baseline characteristics, indications for delayed open conversion, and time between endovascular repair and open conversion are described. Early outcomes included operative approach, morbidity, and mortality. Midterm outcomes included survival.

RESULTS

Twenty-two (3.3%) of 667 patients with prior infrarenal endovascular aortic aneurysm repair had delayed open conversion (20 elective and 2 emergency). The time from endovascular repair to open conversion was 60 ± 36 months. The indications were 6 (27%) type Ia endoleaks, 6 (27%) type II endoleaks with enlarging sac size, 2 (9%) endotensions, 7 (32%) unknown types of endoleak, and 1 (5%) graft infection. The 7 minutes unknown endoleaks were confirmed as lumbar leaks in 4 cases and fabric leaks in 3. Operative time was 222 ± 48 min with blood loss of 2211 ± 2057 mL. Hospital stay after conversion was 12 ± 8 days. There was no 30-day mortality. Estimated survival rates were 96%, 91%, 86%, 79% and 57% at 1, 2, 3, 4, and 5 years postoperatively.

CONCLUSION

Delayed conversion to open surgery after endovascular aortic aneurysm repair by endograft explantation appears to be safe with good short- and mid-term outcomes. With careful preoperative assessment, open conversion remained a realistic and viable option in patients with failed endovascular treatment.

Late open conversion in ruptured abdominal aortic aneurysm after endovascular repair

Despite technological advances, the long-term outcomes of endovascular aortic aneurysm repair (EVAR) are still debatable. Although most endograft failures after EVAR can be corrected with endovascular techniques, open conversion may still be required. A 70-year-old male patient presented at the emergency unit with abdominal pain. Twice, in the third and fourth years after the first repair, a stent graft had been placed over a non-adhesive portion of the stent graft due to type Ia endoleaks. In the most recent admission, a CT scan showed type III endoleak and ruptured aneurysm sac. On this occasion the patient underwent late open conversion. The failure was repaired with total preservation of the main endovascular graft body and interposition of a bifurcated dacron graft. This case demonstrates that lifelong radiographic surveillance should be considered in this subset of patients. Late open conversion following EVAR of ruptured abdominal aortic aneurysms can be performed safely.

Endograft Infection After Endovascular Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-analysis

Purpose: To report a meta-analysis of the published evidence on the outcomes of aortic endograft infection after endovascular aneurysm repair (EVAR). Methods: A search of electronic information sources (PubMed/MEDLINE, SCOPUS, CENTRAL) and bibliographic reference lists identified 12 studies reporting on 362 patients (mean age 72 years; 279 men). The methodological quality of the selected studies was assessed using the Newcastle-Ottawa scale. Endpoints were 30-day/in-hospital mortality and follow-up mortality. Pooled estimates are reported with the 95% confidence interval (CI). The review was registered at the International Prospective Register of Systematic Reviews in Health and Social Care (CRD42016034166). Results: The incidence of graft infection after EVAR was 0.6% (95% CI 0.4% to 0.8%). The time from implantation to diagnosis ranged from 1 to 128 months (mean 25). The majority of patients (293, 81%) underwent surgical treatment (95% CI 77% to 83%); 9 (2.5%) patients (95% CI 21% to 43%) received conservative treatment. Aortic replacement with a prosthetic graft was performed in 58% (95% CI 52% to 62%), whereas cryopreserved allografts and autologous grafts were used in 31% (95% CI 28% to 33%) and 11% (95% CI% 8 to 14%), respectively. Less than half of the patients (40%) had emergency surgery. The pooled estimate of 30-day/in-hospital mortality was 26.6% (95% CI 16.9% to 39.2%). The pooled 30-day/in-hospital mortality for 9 patients treated conservatively was 63.3% (95% CI 30.7% to 87.0%). The pooled overall follow-up mortality was 45.7% (95% CI 36.4% to 55.4%) vs 58.6% (95% CI 28.8% to 83.3%) for the 9 patients receiving conservative treatment. Conclusion: Aortic endograft infection is a rare complication after EVAR. Surgical treatment with complete explantation of the infected endograft seems to be the optimal management in selected patients. Supportive medical treatment without surgical intervention has a significant associated mortality.

EVAR and OPEN treatment of abdominal aortic aneurysm: What is the role of MMP-9 in the follow-up?

INTRODUCTION

The aim of our study is to verify the role of metalloproteinases in endovascular repair (EVAR) and OPEN surgery treatment for abdominal aortic aneurysm (AAA). Postoperatively, these enzymes could represent an important biomarker to adapt diagnostic tests and further investigations during follow-up.

MATERIAL AND METHOD

From 2004 to 2008, 55 patients were considered with AAA. Of these, 33 patients (mean age: 70.1 years), (mean AAA diameter: 5.4cm) were treated with OPEN surgery (group A) and 22 (mean age: 74.1 years) (mean AAA diameter: 5.1cm) were treated with EVAR. In 17 of them, there were no signs of endoleak (group B1), while in 5 patients, a presence of endoleak (group B2) was detected. Plasma samples were collected in order to determine MMP-9 activity. Enzyme immunoassay was performed preoperatively at 1, 3, 6 and 12 months. Patients treated conventionally were clinically examined after 1 and 12 months by ultrasound. Patients undergoing EVAR treatment were clinically examined by CT scan after 1, 3, 6 and 12 months. The analysis was done by assessing the interaction over time of the MMP-9 value in B1 and B2 groups.

RESULTS

The average values observed for MMP-9 were preoperatively and at 1, 3, 6 and 12 months, respectively: in group A 150.8ng/mL (SD=30.5), 252.5ng/mL (SD=25.2), 315.4ng/mL (SD=22.7), 295.3ng/mL (SD=26.8), 210.7ng/mL (SD=30.2); in group B1 105ng/mL (SD=10.8), 125.6ng/mL (SD=18), 85.8ng/mL (SD=19.9), 95ng/mL (SD=20.2), 80.4ng/mL (SD=15.6); in group B2 149ng/mL (29.2), 375.4ng/mL (SD=40.2), 215ng/mL (SD=35.9), 180ng/mL (SD=20.2), 175ng/mL (SD=33.4). The MMP-9 level was higher in group B2 compared to group B1 (P=0.01), suggesting a correlation with the presence of the endoleak.

CONCLUSIONS

This preliminary study shows that MMP-9 may be a biomarker of the presence of endoleak. Other further investigations and larger series are needed to show that metalloproteases could play a role in the follow-up of EVAR treated patients.

Late open conversion after endovascular abdominal aortic aneurysm repair

OBJECTIVE

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.

METHODS

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).

RESULTS

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 median follow-up of 26.4 months (range, 5-50.2 months).

CONCLUSIONS

The number of patients with failed EVAR and without further options for endovascular salvage is growing. Endoleak remains the most important weakness of EVAR as the leading cause of late open conversion. Such procedures, although technically demanding, are associated with relatively low mortality rates when performed electively. Open repair still represents a valuable solution for many patients with failed EVAR.

Diagnosis and treatment of a patient with type IV endoleak as a late complication after endovascular aneurysm repair

Type IV endoleak is a very rare complication observed after implantation of aortobiiliac stent grafts. The difficult diagnosis of type IV endoleak leads to the application of many imaging methods in the diagnostic process. We present a case report of a patient who underwent implantation of an aortobiiliac stent graft in 2004. After surgery, the size of the aneurysm sac was monitored continually in the subsequent imaging studies. Progression of the aneurysm sac volume was detected in 2009. In a short period of time, the diameter of the aneurysm increased from 100 to 140 mm. Angio-computed tomography and angiography did not reveal the location of the endoleak. The attempt at localization and endovascular closure of the source of the endoleak failed. It was decided to treat the patient surgically. Intraoperatively, the source of the endoleak was visualized, and the endoleak was closed with surgical sutures.

Open Reintervention for Aneurysmal Sac Enlargement after EVAR

We performed a late open reintervention for aneurysmal sac enlargement due to persistent type 2 endoleak (PT2EL) after EVAR for 8 of 286 patients. Surgical techniques are as follows: (1) The entire aneurysmal body was exposed. (2) All the aortic branched vessels were ligated. (3) The aneurysmal sac was opened followed by the performance of complete hemostasis. (4) An equine pericardium was wrapped and sutured to the aneurysmal sac to for reinforcement. This method is considered to be one of the feasible options for the treatment of aneurysmal sac re-enlargement after EVAR.

Aneurysmal degeneration and type Ib endoleak with proximal aneurysm rupture: A case report, review of literature and technical suggestions

INTRODUCTION

Despite the reduction in mortality incidences of AAA in proportion to increased use of EVAR, the natural history of aneurysms with the presence of an endoleak post EVAR remains unclear. With a cumulative AAA rupture incidence of 2% at six years post EVAR, the lack of an immediate endoleak is not an indicator of success.

CASE REPORT

We present a case of an 80-year-old man who presented to the emergency department with generalised abdominal pain and hypotension. Four years earlier he had underwent an EVAR for a 6 cm infra-renal AAA. The computed tomography angiogram (CTA) illustrated aneurysmal dilatation of the left common iliac artery with extensive retroperitoneal haemorrhage. The patient was transferred to the operating room for an endovascular repair but due to significant episodes of haemodynamic instability, an emergency exploratory laparotomy was performed. To our surprise, there was a left-sided infra-renal anterolateral rupture of the aneurysm sac. The stent was explanted with difficulty from its fixed proximal aortic section down to left-sided common iliac artery. The fixed bare portion of the stent in the proximal aorta and in the right common iliac artery was left in-situ and the rest was integrated to a trouser graft with an end-to-end technique.

DISCUSSION

On detection of an endoleak, the aim should focus on their endovascular management, as open conversions are associated with high mortality and morbidity.

CONCLUSION

If open conversion is indicated, all technical aspects of the repair including partial stent extraction should be considered for best outcome.

Open surgery for abdominal aortic aneurysm in the era of endovascular repair: comparison with long term results of endovascular repair using zenith stentgraft

OBJECTIVE

Our study focuses on the long term result of open surgery and endovascular abdominal aortic aneurysm repair (EVAR) using the Zenith stentgraft.

PATIENTS AND METHODS

A total of 237 patients underwent elective abdominal aortic aneurysm (AAA) repair between April 1999 and December 2006. Nineteen patients underwent EVAR, whereas 218 patients underwent open surgery. The mean follow-up time for EVAR group was 73.8 ± 49 months (range; 25-150 months), and 69.7 ± 46 months (range; 1-156 months) for open surgery group.

RESULTS

One open surgery patient (1/218, 0.46%) died of aspiration pneumonia, whereas all the EVAR patients survived the operation. Remote complications requiring reintervention occurred in 8 patients (8/174, 4.6%) in open surgery group. Six EVAR patients (6/19, 31.6%) developed late aneurysm expansion, among whom four patients (4/19, 21.1%) required reinterventions after 3 or more years postoperatively. The need for reintervention persisted even at 11 years after initial EVAR. There was no significant intergroup difference in late mortality.

CONCLUSIONS

There was no statistically significant intergroup difference in early and long term mortality. Complications requiring reinterventions, however, were more frequent in EVAR than in open surgery, especially in the late period. Long term follow-up is mandatory for comparison of the clinical results between open surgery and EVAR.