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Abstract
Relining of a previously placed surgical graft or endograft for an abdominal aortic aneurysm (AAA) is a reintervention to treat progression of disease or failure of the primary (endo)graft. Endovascular Aneurysm Sealing (EVAS) relining is a technique with potential advantages due to the absence of a bifurcation, the possibility for a unilateral approach, and sealing concept of the endobags. The purpose of this study was to describe the nationwide experience with EVAS relining of previous AAA repair in the Netherlands. A retrospective analysis of all patients who underwent EVAS relining in 7 high volume vascular centres in the Netherlands between 2014 and 2019 was performed. Primary outcomes were technical and clinical success. Secondary outcomes were perioperative outcomes, complications and survival. Thirty-three patients underwent EVAS relining of open (n=10) or endovascular (n=23) repair. 26 were elective cases, 5 were urgent and 2 were acute (ruptured). Mean time between primary treatment and EVAS relining was 99 ± 74 months. Indications after open repair were proximal progression of disease (n=7) and graft defect (n=3). Indications after EVAR were type IA (n=10), type IB (n=3), type IIIA (n=4), type IIIB (n=3) endoleak, and endotension (n=3). 18 patients underwent regular EVAS, 4 unilateral EVAS and 11 chimney-EVAS. In-hospital mortality was 6% (both patients with rAAA). Technical success was achieved in 97%. Median follow-up after EVAS relining was 20 months (range 0-43). Freedom from reintervention at 1-year and 2-year were 83% and 61% and the estimated survival 79% and 71%, respectively. EVAS relining after open repair had a clinical success of 90% at 1-year and of 70% at latest follow-up, while after EVAR clinical success rates were 70% and 52%, respectively. EVAS relining of previous AAA repair is associated with high technical success, however with limited clinical success at median follow-up of 20 months. Clinical success was higher in patients with EVAS relining after open repair than after EVAR. In patients with failed AAA repair, EVAS relining should only be considered, when established techniques such as fenestrated repair or open conversion are not available or indicated.
Highlights
Endovascular Aneurysm Repair (EVAR) has become the most frequently used procedure for the treatment of an abdominal aortic aneurysm (AAA) with favourable perioperative morbidity and mortality rates in comparison to open repair1–3
The objective of the current study is to describe the nationwide Dutch experience with relining of a previous open or endovascular AAA repair using Endovascular Aneurysm Sealing (EVAS)
When comparing the results after EVAS relining of failing open repair versus EVAR, our results suggest better outcomes in the group of patients with previous open repair
Summary
Endovascular Aneurysm Repair (EVAR) has become the most frequently used procedure for the treatment of an abdominal aortic aneurysm (AAA) with favourable perioperative morbidity and mortality rates in comparison to open repair. The endovascular aneurysm sealing (EVAS, Endologix Inc, Irvine, CA, USA) system was originally developed to lower the risk of endoleaks by completely filling the aortic aneurysm sac. It has been used either alone or in combination with chimney grafts, the latter is outside the instruction (IFU) for use of the device. Mid- and long-term results were less favourable because of complications such as type I endoleaks and stent graft migration and displacement17,19–30 Concerns about these results initially led to a refinement of the IFU and a temporary recall of the device.
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