Technique for safe open conversion after failed EVAR and TEVAR

Background As endovascular aortic repair has evolved in the last two decades as a valid alternative to open surgery for the treatment of disease of both the abdominal and thoracic aorta, graft-related early and late complications have been increasingly observed. Aim of this study is to report the incidence and outcomes of open surgical conversion following previous EVAR and TEVAR. Methods Between 2005 and 2012, 53 and 14 patients underwent late open conversion at our Institution after EVAR and TEVAR, respectively, representing the study population of this retrospective single center analysis. Thirty-nine (58.2%) of them underwent index procedure in other centers (21 in EVAR group, 18 in TEVAR). Results In the EVAR group, indications for late open conversion were type I and III endoleak in 33 cases, type II endoleak with aneurysm growth in 13 cases, material failure in four cases and endograft infection in three. In the TEVAR group, indications were type I and III endoleak in three cases, aneurysmal progression in two, endograft thrombosis in one, endograft infection/fistula in four, or endograft-induced retrograde dissection in four cases. The mean time from the index procedure to reintervention was 16.3 months. In the TEVAR group, complete endograft explantation with aortic in situ repair was performed in eight cases, open conversion with aortic repair with the proximal endograft end left in site in two cases, and open ascending and arch repair with the entire endograft left in site in four cases of retrograde arch dissection. In the EVAR group, we performed an aortic in situ repair in 52 cases (11 patients with aorto-aortic straight graft and 41 patients with aorto-bifemoral bifurcated graft), in one case was performed extra-anatomic reconstruction before aortic stump ligation. Different surgical approaches were used depending on the endografts features. Associated enteric, esophageal or bronchial repair was performed in all cases of suspected fistulization. The risk of late reinterventions was increased in patients with connective tissue disorders and dissections, in the TEVAR group. In the EVAR group, 30-day mortality was 1.9%, with a major morbidity rate of 32% (17 cases), mainly due to acute renal failure (13 cases with one patient requiring hemodialysis). In the TEVAR group, 30-day mortality was 14.2%, with a major morbidity of 28.6% (four cases). Mortality was higher in patients with infection/fistula (50% vs 4.2%). Conclusions The risk of late complications requiring an open conversion is not negligible after endovascular treatment of aortic pathologies and a close surveillance is mandatory. Morbidity and mortality rates in our series have been acceptable in elective non-infected cases. Mortality in case of infected endograft and fistulas has been higher. Careful follow-up and aggressive management with treatment of associated lesions when present improve the outcomes.