Ann Surg Treat Res.  2020 Dec;99(6):344-351. 10.4174/astr.2020.99.6.344.

Strategy to avoid open surgical conversion after endovascular aortic aneurysm repair for patients with infrarenal abdominal aortic aneurysm

Affiliations
  • 1Department of Surgery, Jeonbuk National University Hospital, Jeonju, Korea
  • 2Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
  • 3Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
  • 4Cardiac and Vascular Center, Samsung Medical Center, Seoul, Korea
  • 5Division of Vascular Surgery, Department of Surgery, Kangbuk Samsung Hospital, Seoul, Korea

Abstract

Purpose
Open surgical conversion (OSC) is the last treatment option for patients with endovascular aneurysm repair (EVAR) failure. We investigated the underlying causes of EVAR failure requiring OSC and attempted to determine strategies to avoid OSC after EVAR.
Methods
We retrospectively reviewed the database of patients who underwent OSC after EVAR from 2005 to 2018 in a single institution. Twenty-six OSCs were performed in 24 patients (median age, 74.5 years; 79.2% of males) who had undergone standard EVAR. We investigated pre-, intra-, and postoperative computed tomography or angiographic images and outcomes of the OSCs.
Results
Two main indications for OSC were persistent endoleak (50.0%) and endograft infection (EI) (38.5%). All 13 patients who underwent OSC due to endoleaks received EVAR outside of indications for use. Among 10 patients who underwent OSC due to EI, we found overlooked infection sources in 7 (70.0%) at the time of EVAR or during the surveillance period. OSC was performed at a median of 31.8 months (interquartile range, 9.4–69.8) after EVAR as an emergency (15.4%) or elective (84.6%) surgery. Aortic endograft was removed in 84.6% of cases (totally, 57.7%; partially, 26.9%), whereas it was preserved in 4 cases (15.4%). After 26 OSCs, 2 early deaths (7.7%) and 2 aortoenteric fistulae (7.7%) developed as major complications.
Conclusion
OSC after EVAR was associated with relatively higher perioperative morbidity and mortality. To avoid OSC after EVAR, we recommend careful assessment of coexisting infection sources and avoidance of EVAR for patients with especially unfavorable anatomy for EVAR, particularly the in proximal neck.

Keyword

Abdominal aortic aneurysm; Conversion to open surgery; Endovascular aneurysm repair

Figure

  • Fig. 1 Total explantation of aortic endograft and in situ aortoiliac reconstruction with a composite cryopreserved arterial allograft (CAA) for a patient with endograft infection at 71 months after endovascular aneurysm repair. (A) Explanted aortic endograft. (B) In situ aortoiliac reconstruction with a composite CAA. (C) Omental wrapping around the allograft.

  • Fig. 2 A CT image before endovascular aneurysm repair (EVAR) shows abdominal aortic aneurysm and coexisting right psoas abscess (arrow) in a patient who underwent open surgical conversion at 28 months after EVAR.

  • Fig. 3 The CT images in a patient with infected abdominal aortic aneurysm who underwent endovascular aneurysm repair (EVAR) after 17 days of antibiotic therapy at another hospital. (A) An axial CT image at the level of the left renal vein at 6 months after EVAR. (B) A new saccular aneurysm (arrow) at the anterior wall of the aorta at 7 months after EVAR, which displaced the left renal vein anteriorly.

  • Fig. 4 Three-dimensional reformatted CT images in a patient who presented with aortoenteric fistula after open surgical conversion (OSC) due to endograft infection. (A) A CT image at 7 months after OSC (total explantation of the aortic endograft and in situ aortoiliac reconstruction with cryopreserved allograft. (B) A CT image at 27 months after OSC showing focal dilatation (arrow) of the cryopreserved arterial allograft.


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