Académique Documents
Professionnel Documents
Culture Documents
Center of Vascular Medicine, Angiology and Vascular Surgery, Park Hospital Leipzig, Leipzig, Germany
Faculty of Health, Witten/Herdecke University, Witten, Germany
* Corresponding author. Department of Vascular Surgery, Hospital Waldbrl, Dr.-Goldenbogen-Str. 10, 51545 Waldbrl, Germany. Tel: +49-2291/82-1401;
fax: +49-2291/82-1499; e-mail: botsios@arcor.de (S. Botsios).
Received 21 January 2014; received in revised form 11 May 2014; accepted 21 May 2014
Abstract
OBJECTIVES: Endovascular treatment of the infrarenal abdominal aorta (endovascular repair, EVAR) has emerged as an alternative to open
surgery. However, a small subset of patients exists who undergo conversion either in the rst 30 postoperative days or later during the
course of postoperative surveillance. In the present study, we review our experience with late conversion operations.
METHODS: Between December 2004 and August 2012, 411 EVARs were performed. During the same time interval, nine patients (males)
with a mean age of 71 years (range, 5979 years) required late open conversion. The median interval between EVAR and the conversion
operation was 34 months (range 1460 months).
RESULTS: The indications for late conversion included persistent proximal type I endoleak (n = 2), type II endoleak with sac enlargement
(n = 1), aneurysm rupture (n = 1), endotension (n = 2), stent-graft thrombosis (n = 1) and stent-graft infection (n = 2). Complete stent-graft
explantation was performed in ve patients. Eight patients underwent elective conversion. One patient presenting with rupture had an
emergency operation. The 30-day mortality rate was 0%.
CONCLUSIONS: Late open conversion after EVAR can be performed safely and successfully. Complete stent-graft explantation may be our
preferred treatment option, but it is not always necessary, except in cases presenting with graft infection.
Keywords: Aneurysm Endovascular treatment Abdominal aorta Complications Open conversion
INTRODUCTION
Endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs) has emerged as an alternative to open surgery.
Technological advances have resulted in EVAR becoming the rstchoice therapy in patients with favourable aortoiliac morphology.
Early advantages of EVAR over open surgery include shorter procedure duration, less pain, reduced blood loss, shorter hospitalization, more rapid recovery and signicantly lower 30-day mortality
and morbidity rate [1]. By contrast, the main drawbacks of EVAR are
regular and persistent follow-up and the substantial need for reinterventions to treat endoleaks, migration, graft disconnection, stent
fractures, graft thrombosis and infection, which increase with
follow-up duration [2].
Most secondary interventions after EVAR are successfully
addressed with percutaneous interventional techniques; however,
a small subset of patients (0.74.0%) will require an open conversion with explantation of the stent graft during the course of postoperative surveillance [37].
In the present study, we review our single-centre experience
with late conversion operations after EVAR with emphasis on the
incidence, surgical management and clinical course.
The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ORIGINAL ARTICLE
Value
Total patients
Age, mean SD (range) (years)
Gender (male: female)
Interval between EVAR and late conversion,
mean SD (range) (months)
Indications for late conversion
Urgent
Elective
ASA class
III
IV
Medical comorbidities
Coronary artery disease
Congestive heart failure
Renal insufficiency (creatinine >1.5 mg/dl)
Hypertension
Diabetes mellitus
Hyperlipidaemia
9
71 6 (5979)
9: 0
34.3 15.9 (1460)
1
8
3
6
1
1
6
8
2
2
Figure 1: Open conversion for endotension. (A) The aneurysm was opened
without aortic cross-clamping. No blood can be detected. (B) Partial stent-graft
explantation. Both iliac limbs were transected at the level of the common iliac
artery orice.
Surgical procedure
The surgical approach included a midline transperitoneal exposure in all cases. Proximal aortic control was obtained by crossclamping the supracoeliac aorta in one case or the suprarenal
aorta in 5 cases with step-wise distal clamping when the proximal
anastomosis was completed to reduce visceral and renal ischaemic time. In two patients, cross-clamping of the infrarenal aorta
was possible. In one patient, aortic control was achieved by inating an intraluminal aortic occlusion balloon. The balloon was
inserted in the suprarenal aorta via the trans-brachial approach
before opening the aneurysm.
Distal back-ow control could be achieved by exposure and
clamping of the iliac arteries below the stent graft before opening
the aneurysm sac in two cases in which complete stent-graft explantation for stent-graft infection was indicated. In the remaining
seven patients, distal arterial control was achieved using clamps
on the iliac graft limbs within the aneurysm sac.
The aneurysm sac was opened by a longitudinal aortotomy, the
mural thrombus was evacuated and back-bleeding lumbar arteries
were oversewn.
The main body of the stent graft was attempted to be removed
by traction alone, using the clamp-and-pull method. In only one
patient, the proximal part of the main body was left in situ during
the late conversion because it was impossible to remove it
without aortic wall damage. In the same manner, it was attempted
to remove all iliac graft limbs completely by traction and manual
compression of the iliac artery. In four patients in whom iliac xation was not amenable to manual explantation, both iliac graft
limbs were transected at the level of the common iliac artery
orice, and distal arterial control was achieved using Fogarty balloons on the iliac grafts.
Five of the nine patients (55%) underwent complete stent-graft
explantation, including two patients with infected prostheses, and
a partial stent-graft explantation was performed in four patients.
Wire cutters were used to divide the metallic stent components,
the main body and the two iliac limbs of the stent graft.
After complete stent-graft explantation, aortic reconstruction
was completed with interposition of a Dacron tube graft in two
cases and a Dacron bifurcated graft in three cases.
The tube graft was used in two patients who presented with
stent-graft infection. Aortic reconstruction after partial stent-graft
explantation with interposition of a Dacron bifurcated aortoiliac
graft was performed. In all cases, both iliac limbs were left in situ
because removal of the well-incorporated stent graft was impossible. The distal ends of the new bifurcated graft were sewn to the
residual stent grafts as well as to the common iliac artery at the
orice level with Teon felt strips. Additionally, in one patient, the
suprarenal part of the stent graft was left in place because stent-graft
removal was impossible, and the proximal end of the bifurcated
aortoiliac graft was sewn to the residual stent graft as well as to the
infrarenal aortic wall with Teon felt strips.
Patient
Age (years)
Time from
EVAR (months)
Explantation of
stent graft
Complications
1
2
3
4
5
6
7
8
78
79
72
71
69
59
75
72
Endoleak type II
Endotension
Endotension
Rupture/endoleak type II
Stent-graft infection
Stent-graft thrombosis
Endoleak type IA
Endoleak type IA
36
41
53
37
32
22
14
60
Excluder
Talent
Talent
Excluder
Anaconda
Anaconda
Endurant I
Talent
Partial
Partial
Partial
Partial
Complete
Complete
Complete
Complete
64
Stent-graft infection
14
Ovation
Complete
None
None
None
Abdominal wound dehiscence
Pleural effusion
None
None
Reoperation for bleeding
Respiratory failure
Acute renal failure
None
RESULTS
All open conversions were completed uneventfully. There was no
mortality at 30 days. Three patients (33%) had perioperative complications. One patient required reoperation for abdominal wound
dehiscence 5 days after operation. Another patient developed
pleural effusion and underwent bilateral thoracocentesis, with subsequent resolution. A third patient developed bleeding requiring
surgical exploration on postoperative day 1. Additionally, this
patient developed acute renal failure requiring temporary renal dialysis, and respiratory failure requiring a prolonged intensive care
unit stay of 26 days.
The mean stay in the intensive care unit was 9 9 days (range
126 days). The mean duration of hospital stay was 22 12 days
(range 1452 days). Seven patients were discharged home, and
two were discharged to a rehabilitation clinic.
After discharge, none of the nine patients were lost to followup. The mean follow-up after conversion was 29 16 months
(range 461 months) and was conducted by direct patient or referring physician telephone contact (ending January 2013). All
patients were in excellent clinical condition, remained without
complications associated with open conversion and enjoyed a
good quality of life.
DISCUSSION
We report here the low incidence and favourable results of late
open conversion after EVAR failure.
EVAR has revolutionized aortic surgery. Currently, 20 years after
the rst successful endovascular treatment of AAA, the method is
performed with an increasing frequency as the rst-choice therapy
in patients with favourable aortoiliac morphology. However, the
risk of aneurysm growth and rupture after EVAR cannot be completely avoided.
Additionally, despite advances in stent-graft technology and
improved surgical techniques, late conversion to open surgery after
EVAR failure has been reported widely. In 2002, the European
ORIGINAL ARTICLE
Table 2: Details of patients undergoing late open conversion after endovascular aneurysm repair
REFERENCES
[1] Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT Jr, Matsumara JS,
Kohler TR et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009;302:153542.
[2] Verhoeven BA, Waasdorp EJ, Gorrepati ML, van Herwaarden JA, Vos JA,
Wille J et al. Long-term results of Talent endografts for endovascular abdominal aortic aneurysm repair. J Vas Surg 2011;53:2938.
[3] Forbes TL, Harrington DM, Harris JR, Derose G. Late conversion of endovascular to open repair of abdominal aortic aneurysms. Can J Surg 2012;
55:2548.
[4] Brinster CJ, Fairman RM, Woo EY, Wang GJ, Carpenter JP, Jackson BM. Late
open conversion and explantation of abdominal aortic stent grafts. J Vasc
Surg 2011;54:426.
[5] Kelso RL, Lyden SP, Butler B, Greenberg RK, Eagleton MJ, Clair DG. Late
conversion of aortic stent grafts. J Vasc Surg 2009;49:58995.
[6] Gambardella I, Blair PH, McKinley A, Makar R, Collins A, Ellis PK et al.
Successful delayed secondary open conversion after endovascular repair
using partial explantation technique: a single-center experience. Ann Vasc
Surg 2010;24:64654.
[7] Chaar CI, Eid R, Park T, Rhee RY, Abu-Hamad G, Tzeng E et al. Delayed
open conversions after endovascular abdominal aortic aneurysm repair. J
Vasc Surg 2012;55:15629.
[8] Enzler MA, van Marrewijk CJ, Buth J, Harris PL. Endovascular therapy of
aneurysms of the abdominal aorta: report of 4,291 patients of the Eurostar
Register. Vasa 2002;31:16772.
[9] Moulakakis KG, Dalainas I, Mylonas S, Giannakopoulos TG, Avgerinos ED,
Liapis CD. Conversion to open repair after endografting for abdominal
aortic aneurysm: a review of causes, incidence, results, and surgical techniques of reconstruction. J Endovasc Ther 2010;17:694702.
[10] Bckler D, Probst T, Weber H, Raithel D. Surgical conversion after endovascular grafting for abdominal aortic aneurysms. J Endovasc Ther 2002;9:
1118.
[11] Phade SV, Keldahl ML, Morasch MD, Rodriguez HE, Pearce WH, Kibbe MR
et al. Late abdominal aortic endograft explants: Indications and outcomes.
Surgery 2011;150:78895.
[12] De Vries JP, van Herwaarden JA, Overtoom TT, Vos JA, Moll FL, van de
Pavoordt ED. Clinical outcome and technical considerations of late
removal of abdominal aortic endografts: 8-year single-center experience.
Vascular 2005;13:13540.
[13] Mehta M, Paty PS, Roddy SP, Taggert JB, Sternbach Y, Kreienberg PB et al.
Treatment options for delayed AAA rupture following endovascular repair.
J Vasc Surg 2011;53:1420.
[14] Lyden SP, McNamara JM, Sternbach Y, Illig KA, Waldman DL, Green RM.
Technical considerations for late removal of aortic endografts. J Vasc Surg
2002;36:6748.
[15] Jimenez JC, Moore WS, Quinones-Baldrich WJ. Acute and chronic open
conversion after endovascular aortic aneurysm repair: a 14-year review. J
Vasc Surg 2007;46:6427.
[16] Lipsitz EC, Ohki T, Veith FJ, Suggs WD, Wain RA, Rhee SJ et al. Delayed
open conversion following endovascular aortoiliac aneurysm repair:
partial (or complete) endograft preservation as a useful adjunct. J Vasc
Surg 2003;38:11918.
[17] Tiesenhausen K, Hessinger M, Konstantiniuk P, Tomka M, Baumann A,
Thalhammer M et al. Surgical conversion of abdominal aortic stent-grafts:
outcome and technical considerations. Eur J Vasc Endovasc Surg 2006;31:
3641.
[18] Nabi D, Murphy EH, Pak J, Zarins CK. Open surgical repair after failed
endovascular aneurysm repair: is endograft removal necessary? J Vasc
Surg 2009;50:71421.
[19] Donas KP, Torsello G. Complications and reinterventions after EVAR: are
they decreasing in incidence? J Cardiovasc Surg (Torino) 2011;52:18992.
ORIGINAL ARTICLE