Minimally Invasive Open Conversion for Late EVAR Failure

Abstract

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. 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 >5mm in the last 6months 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. A total of 10 patients were treated during the study period. The mean interval to MOC after EVAR was 45.1months (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±15.9months, no reinterventions were described. Death rate was (20%) with one aneurysm-related death (10%) for graft infection 32months after MOC and one (10%) cardiac event at 18months. 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.