Infrarenal endograft clamping in late open conversions after endovascular abdominal aneurysm repair.

The aim of this study was to report the technical aspects and outcomes of late open conversion (LOC) after endovascular aneurysm repair (EVAR) in a single center by using exclusively infrarenal clamping of the endograft as an alternative to suprarenal or supraceliac aortic clamping. A retrospective analysis of EVAR requiring late explantation (>30 days) from January 1996 to October 2016 was performed. Patients' demographics, type of endograft, duration of implantation, reason for removal, extent of stent graft removal, type of reconstruction, 30-day mortality, postoperative complications, and long-term survival were obtained for analysis. During the study period, 28 patients required LOC. The mean age at conversion was 75.11 ± 6.65 years; 26 of 28 (92.86%) were male. Grafts were excised after a median of 41.4 months (range, 5.97-112.67 months), with 21 of 28 explantations (75%) performed electively. Multiple types of EVAR devices have been explanted; suprarenal fixation was present in 75% of the cases. The indication for LOC was the presence of an endoleak in 27 cases (20 type I, 4 type II associated with aneurysm growth, 3 type III, and 3 endotensions; in 3 cases, multiple types of endoleak were present) and graft thrombosis in 1 case. All patients underwent a transperitoneal approach with infrarenal clamping. No patient required revascularization of visceral or renal vessels. Complete removal of the stent graft was performed in 8 of 28 cases, partial removal in the remaining 20 cases (with conservation of the proximal portion in 16 of 20 cases). Technical success was 100%. Overall 30-day mortality was 7.14% (2/28). The 30-day mortality was 9.5% in elective patients and 0% in the urgent setting; this difference was not statistically significant (P = .56). Postoperative kidney injury rate was 7.7% (2/26). Mean follow-up was 47.37 ± 55.67 months (range, 0.23-175.07 months). The estimated 5-year survival rate was 78%. No aneurysm-related death or additional procedure occurred during follow-up. LOC after EVAR using infrarenal clamping of the endograft is a feasible and effective technique, with satisfactory postoperative mortality and morbidity. This method allows simplification of the surgical technique and may avoid renal and visceral complications related to suprarenal or supraceliac clamping.

Perini P ，de Troia A ，Tecchio T ，Azzarone M ，Bianchini Massoni C ，Salcuni P ，Freyrie A ... -  《-》

Late open conversions after endovascular abdominal aneurysm repair in an urgent setting.

We report a multicenter experience of urgent late open conversion (LOC), with the goal of identifying the mode of presentation, technical aspects, and outcomes of this cohort of patients. A retrospective analysis of endovascular aneurysm repair (EVAR) requiring LOC (>30 days after implantation) from 1996 to 2016 in six vascular centers was performed. Patients with aneurysm rupture or other conditions requiring urgent surgery (<24 hours) were included. Patient demographics, time interval between EVAR and LOC, endograft characteristics, previous attempts at endovascular correction, indications, operative technique, 30-day mortality and morbidity, and long-term survival were analyzed. There were 42 patients (88.1% men; mean age, 75.8 ± 9.0 years) included. Among the 42 explanted grafts, 33 were bifurcated, 1 tube, 6 aortouni-iliac, and 2 side-branch devices. Suprarenal fixation was present in 78.6%. Twelve patients (28.6%) underwent endovascular reintervention before LOC. Indications for urgent LOC were aneurysm rupture in 24 of the 42 cases (57.1%), endograft infection in 11 (26.2%), endoleak associated with aneurysm growth and pain in 6 (14.3%), and recurrent endograft thrombosis in 2 (4.8%). The proximal aortic cross-clamping site was infrarenal in 38.1% of cases, suprarenal in 19.1%, and supraceliac in 42.9%. Complete removal of the endograft was performed in 32 patients (76.2%) and partial removal in 10 (proximal preservation in 7 of 10). Reconstructions were performed with Dacron grafts in 33 of the 42 cases, cryopreserved arterial allografts in 5, and endograft removal associated with prosthetic axillobifemoral bypass in 4. The 30-day mortality was 23.8%; hemorrhagic shock was an independent risk factor of early mortality (odds ratio, 10.5; 95% confidence interval, 1.5-73.7; P = .018). During a mean follow-up of 23.9 ± 36.0 months, two late aneurysm-related deaths occurred. The estimated 1- and 5-year survival rates were 62.1% and 46.1%, respectively. Urgent LOC after EVAR are associated with high postoperative mortality rates and poor long-term survival. Further studies are necessary to define the timing and the best treatment option for failing EVAR.

Perini P ，Gargiulo M ，Silingardi R ，Piccinini E ，Capelli P ，Fontana A ，Migliari M ，Masi G ，Scabini M ，Tusini N ，Faggioli G ，Freyrie A ... -  《-》

Strategies and outcomes for aortic endograft explantation.

Failure of endovascular aneurysm repairs (EVARs) requiring open conversion remains a major challenge. We analyzed indications for repair, operative strategies, and outcomes with a focus on iliac artery degeneration after endograft removal. A prospective, institutional database was reviewed to identify patients who underwent explantation of a failed EVAR device. Demographics, reason for failure, operative details including extent of endograft removal, and complications/survival were examined. Postexplantation computed tomography imaging was evaluated for iliac artery degeneration. There were 32 patients who underwent explantation from 2002 to 2017. Six patients were treated emergently for rupture. The majority were elderly (average age, 76 ± 8.5 years), white (100%) men (91%) who had their EVAR graft inserted 45.5 months (range, 0.3-86 months) before open conversion, usually at an outside institution (75%). Explanted endografts included nine AneuRx (Medtronic, Minneapolis, Minn), nine Excluder (W. L. Gore & Associates, Flagstaff, Ariz), four Endurant (Medtronic), three Zenith (Cook Medical, Bloomington, Ind), three Powerlink/AFX (Endologix, Irvine, Calif), one Aorfix (Lombard Medical, Oxfordshire, United Kingdom), one Talent (Medtronic), and two unknown. Failure was due to endoleak in 91% (type I, 38%; type II, 28%; type III, 13%; type V, 13%), infection in 6%, and occlusion/kinking in 3%. A previous attempt at endovascular salvage of EVAR occurred in 12 (37.5%) patients. Operative approach was transabdominal in 69% and retroperitoneal in 31%. Initial aortic clamp position was supraceliac in 31%, suprarenal in 31%, and infrarenal in 38%. Most patients had complete removal of their endograft (n = 19 [59%]), with 22 (69%) having at least the iliac limbs removed. Grafts with suprarenal fixation were more likely to have the upper main body left in situ (67% vs 17%; P = .029). The 30-day mortality was 6.3% (3.8% elective, 16.7% ruptured), and 31% had a major complication. Of the 23 patients who had follow-up imaging, there was a trend for more iliac degeneration (>5 mm in growth) in those who had the iliac limbs removed (29.4% vs 0%; P = .184). Three patients with iliac limb removal required subsequent iliac endovascular intervention (two for rupture). Patients who presented with a rupture had a decreased 5-year overall survival (33%) compared with those who were converted electively (59%). Both complete and partial endograft explantation, although morbid procedures, can be performed safely. Postoperative imaging surveillance is important, especially if the endograft has been removed from the iliac arteries, as degeneration can occur.

Arnaoutakis DJ ，Sharma G ，Blackwood S ，Shah SK ，Menard M ，Ozaki CK ，Belkin M ... -  《-》

Surgical infrarenal "neo-neck" technique during elective conversion after EVAR with suprarenal fixation.

Conversion of a previous endovascular aneurysm repair (EVAR) with suprarenal fixation is a challenging situation even in the elective setting. The outcomes of a technique based on preservation of the first proximal covered stent of the endograft, used as a "neo-neck" for proximal anastomosis, are presented. From 2001 to 2014, nine patients underwent elective conversion of a previous suprarenally fixed EVAR. After supraceliac clamping, the aneurysm sac was opened and the endograft identified; the fabric was cut beyond the first covered stent together with its native aortic wall in order to create a "neo-neck." An aortic balloon was inflated into the visceral aorta to avoid back bleeding. A Dacron bifurcated tube graft (Intergard, Maquet) was then sutured to the neo-neck mimicking endobanding, passing the stitches into the aortic wall and the first covered stent. The mean age was 68 years (range, 52-84 years). The stent grafts removed were four Zenith (Cook Medical), three Endurant (Medtronic), and two E-vita (Jotec). The indication for conversion was type 1A (n = 2), type 2 (n = 2), and type 3 (n = 1) endoleak, complete endograft thrombosis (n = 2), and abdominal pain with sac enlargement with no radiological sign of endoleak (n = 2). Blood loss was 1,428 mL (range 500-3,000 mL); the visceral ischemic time to perform the proximal anastomosis was 23.5 min ± 2.3 min). The post-operative complication rate was 11% (n = 1/9) related to a case of sac wall bleeding requiring re-intervention; mortality at 30 days was 0%. At 22 months (range, 8-41) the computed tomography angiogram demonstrated no signs of leaks or anastomotic pseudoaneurysm. Preservation of the proximal covered stent of an endograft with suprarenal fixation used as an infrarenal "neo-neck" with incorporation of the aorta to the suture line during elective surgical explantation simplifies the procedure, and can be achieved with very low early morbidity and mortality; furthermore, it seems to be durable over mid-term follow up.

Bonvini S ，Wassermann V ，Menegolo M ，Scrivere P ，Grego F ，Piazza M ... -  《-》

Late open conversion and explantation of abdominal aortic stent grafts.

To evaluate indications for, operative strategy during, and outcomes following late open surgical conversion following endovascular aneurysm repair (EVAR). 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. 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). 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.

Brinster CJ ，Fairman RM ，Woo EY ，Wang GJ ，Carpenter JP ，Jackson BM ... -  《-》