Secondary Endovascular Conversions for Failed Open Repair

Abstract

Late aortic and graft-related complications after open aortic repair are not infrequent and a significant number of them are missed, diagnosed at a very late stage, or present as urgent complications such as aortic rupture or aorto-enteric fistula. Once a late complication is diagnosed and reintervention is necessary, both open and endovascular strategies are possible. Open reintervention is complex and usually associated with very high rates of morbidity and mortality. Endovascular techniques may offer several solutions for these cases, which may be tailored to the patient and specific complication. In this review, we aim to summarize current indications, options, and strategies for endovascular salvage after failed or complicated open surgical repair.

Fig. 1

Schematic representation of the use of the “banana technique” to exclude a residual common iliac aneurysm after open abdominal aortic repair with an aorto-bi-femoral configuration. In this case, to preserve the hypogastric artery, a covered self-expanding stent graft is placed from the external to the internal iliac artery, thus excluding the common iliac and resembling a banana in shape. ( A ) Schematic representation of a residual common iliac aneurysm after open aortic repair with aorto-bifemoral reconstruction and common iliac artery proximal ligation with late degeneration. ( B ) Schematic representation of the “banana technique” excluding the common iliac artery aneurysm with a self-expanding covered stent from the external to the internal iliac artery.

Fig. 2

Patient with a chronic residual aortic arch dissection with aneurysmal degeneration following proximal aortic repair of a Type A aortic dissection in a patient with right aberrant subclavian artery and Kommerell's diverticulum. ( A ) Three-dimensional (3D) reconstruction of the preoperative computed tomography (CT) angiography demonstrating the aortic arch postdissection aneurysm and Kommerell's diverticulum. ( B ) Axial view of the CT angiography showing the aortic arch postdissection aneurysm and Kommerell's diverticulum ( arrow ). ( C ) 3D reconstruction of the postoperative CT angiography after endovascular aortic arch repair. A COOK a-branch with two inner branches for the right common carotid artery (CCA) and left CCA with additional left CCA to left subclavian bypass and right CCA to right subclavian bypass, with proximal occlusion of both subclavian arteries using plugs.

Fig. 3

Patient with a suture line pseudoaneurysm ( arrow ) after previous proximal aorta and hemiarch repair, with chronic occlusion of the brachiocephalic trunk ( dotted arrow ) submitted to an endovascular arch repair using a COOK a-branch with two inner branches for the left common carotid artery and left subclavian artery with additional left axillary artery to right axillary artery bypass (performed in a staged repair) to revascularize both the right cerebral hemisphere and upper limb. ( A ) Preoperative three-dimensional computed tomography angiography reconstruction. ( B ) Initial aortic arch angiogram showing the suture line pseudoaneurysm ( arrow ) and the occlusion of the brachiocephalic trunk ( dotted arrow ). ( C ) Final angiographic control of the endovascular aortic arch repair (note that the proximal sealing was achieved before the sharp angulation of the previous anastomosis between the hemiarch repair and the proximal ascending aortic repair).

Fig. 4

Patient with a prior open thoracoabdominal aortic repair who developed a visceral patch aneurysmal degeneration with additional para-anastomotic aneurysm at this level. The patient had left renal bypass at the level of the visceral patch and the right renal had been reimplanted 4 cm below the visceral patch. To address the anatomic constrains a physician modified T-Branch (COOK) was used by creating two additional fenestrations, one on the opposite side at the level between the celiac and mesenteric branch (intended for the left renal artery) and the other 4 cm below the visceral branches (intended for the right renal artery). At the end of the procedure both original renal branches were occluded with endovascular plugs. ( A and B ) Preoperative computed tomography angiography (CTA) demonstrating the visceral patch para-anastomotic aneurysm. ( C ) Three-dimensional (3D) reconstruction of preoperative CTA. ( D and E ) On table modification of the T-branch device with fenestration reenforcement using a double-looped goose-neck snare sutured with 4–0 ethibond suture. ( F ) Final angiographic control. ( G ) Postoperative 3D CTA reconstruction.