Late open conversion and explantation of abdominal aortic stent grafts

Objectives: To evaluate indications for, operative strategy during, and outcomes following late open surgical conversion following endovascular aneurysm repair (EVAR). Methods: Between 2002 and 2009, patients undergoing open abdominal aortic aneurysm repair at a university hospital were entered prospectively into a database which was examined to identify patients undergoing open conversion >30 days after EVAR. Results: Over 7 years, 21 patients required late open conversion of EVAR. The average patient age was 75 years (range, 59-88), and there were 16 male (76%) patients. The mean interval to conversion was 33.4 months (range, 2-73). Eight patients (38%) presented with proximal type I endoleak; 4 patients (19%) presented with type II endoleak and aneurysm expansion; 5 patients (24%) presented with graft migration and aneurysm expansion; and 5 patients (24%) presented with de novo visceral aneurysms. Rupture (1) and infection (1) were also observed. There were five (24%) emergent cases. Most patients (12/21, 57%) had more than one reason for conversion. There were no perioperative deaths; three patients (14%) had major complications. Grafts requiring conversion were AneuRx (6; Medtronic AVE, Santa Rosa, Calif), Zenith (6; Cook Inc, Bloomington, Ind), Talent (3; Medtronic), Excluder (2; W. L. Gore, Flagstaff, Ariz), Anaconda (1; TERUMO Corp, Ann Arbor, Mich), Ancure (1; Guidant, Menlo Park, Calif), Quantum LP (1; Cordis Corp, Miami Lakes, Fla), and Powerlink (1; Endologix, Irvine, Calif). The surgical approach was retroperitoneal in 16 (76%) and transperitoneal in four (19%) patients. Initial proximal aortic control was supraceliac (9/21), suprarenal (7/21), or infrarenal (5/21), with stepwise distal clamping to reduce ischemic time. Complete endograft removal was performed in 17/21 patients; in 4/21 the distal anastomosis was performed to the endograft after proximal segment explantation. Reconstruction was completed with tube (19/21) or aortoiliac (2/21) grafts; in one case, homograft was used. Mean intraoperative blood loss was 1.9 L (range, 0.4-6.5 L), mean intensive care unit (ICU) stay was 3 days (range, 2-6), and the mean hospital stay was 10 days (range, 4-39). Conclusions: While technically challenging, delayed open conversion of EVAR can be accomplished with low morbidity and mortality in both the elective and emergent settings. These results reinforce the justification for long-term surveillance of endografts following EVAR.