Minimally Invasive Open Conversion for Late EVAR Failure

Abstract

Objective: With the increasing use of endovascular aortic aneurysm repair (EVAR), open repair after aortic stent grafting is of growing interest. The surgical conversion treatment may be a very challenging process with high mortality and in-hospital complication rates. The aim of this article is to present our experience in patients with EVAR failure treated by minimally invasive open conversion (MOC) and its technical aspects.

Methods: A retrospective study was conducted on a prospectively compiled computerized database of consecutive patients treated by MOC at our institution between May 2014 and June 2018. Indications for treatment were endoleaks with sac growth at least >5 mm in the last 6 months and failure of previous endovascular tentative for aneurysm sealing. Demographics of the patients, reason for conversion, previous endovascular procedures, surgical outcomes, and survival were reviewed. MOC was performed by a small abdominal incision, infrarenal clamping, and partial explantation of the endograft in all patients.

Results: A total of 10 patients were treated during the study period. The mean interval to MOC after EVAR was 45.1 months (range, 14-128). Indications for MOC included type Ia endoleak in three patients (30%), persistent type II EL in four (40%), and type III EL in one patient (10%), indeterminate or type V EL in two (20%). At 30 days, no deaths or reinterventions were reported, and major complication rate was 10% (one postoperative pneumonia). At mean follow-up of 22.9 ± 15.9 months, no reinterventions were described. Death rate was (20%) with one aneurysm-related death (10%) for graft infection 32 months after MOC and one (10%) cardiac event at 18 months.

Conclusions: Despite the potential high risk of open conversion, MOC appears to be a safe surgical solution for EVAR failure. This potentially challenging operation may be improved with minimally invasive techniques that are presented.