Partial and Complete Explantation of Aortic Endografts in the Modern Era

Abstract

Despite the progressive advancement of devices for endovascular aortic repair (EVAR), endografts continue to fail, requiring explant. We present a single-institutional experience of EVAR explants, characterizing the modern failure modes, presentation, and outcomes for partial and complete EVAR explantation. A retrospective analysis was performed of all EVARs explanted at an urban quaternary center from 2001 to 2020. The patient and graft characteristics, indications, and perioperative and long-term outcomes were analyzed. Partial vs complete explants were performed per surgeon discretion without a predefined protocol. The decision was informed by patient risk factors, aneurysm presentation (asymptomatic, symptomatic, or ruptured), and anatomic and intraoperative factors, including endoleak type or the presence of infection. From 2001 to 2020, 53 explants met the inclusion and exclusion criteria. More than one half (58.4%) were explants of EVAR devices placed at outside institutions, designated non–index explants. Most of the patients were male (84.9%); their median age was 74 years (range, 53-96 years). More than one half of the explants (62.3%) had been performed in the second decade of the study period. The most commonly explanted grafts were the Gore Excluder (n = 9; W.L. Gore, Flagstaff, Ariz), Cook Zenith (n = 8; Cook Medical, Bloomington, Ind), Endologix AFX (n = 7; Endologix, Irvine, Calif), and Medtronic AneuRx and Endurant (n = 6 each; Medtronic, Dublin, Ireland). Most (77.4%) were explanted because of neck degeneration or sac expansion. Five were explanted because of initial seal failure, five for symptomatic expansion, seven for rupture, and one for infection. The mean implant duration was 4.2 years, although the range was wide (standard deviation, 2.7 years), but similar between index and non–index explants (4.2 vs 4.1 years). Partial explantation was performed in 60.4%, with the implant duration slightly longer (4.3 years vs 3.9 years) for complete explants. Partial explantation was more frequent for index explants (68.2% vs 54.8%). Partial explants resulted in greater mean intraoperative blood loss (3.7 L vs 2.5 L) and a greater incidence of acute kidney injury (34.4% vs 19.0%). The mean length of stay was 9.0 days. The mean intensive care unit length of stay was 4.6 days and was longer for non–index (5.1 vs 3.8 days) and for partial explants (5.1 vs 3.9 days). Two patients had died within 30 days after non–index explantation (one partial and one complete). The 30-day readmission rate was lower for non–index explants (6.5% vs 15.8%) and similar between partial and complete explants (9.4% vs 9.5%), without accounting for non–index readmissions. Explants of EVAR devices have increased over time at our institution. Partial explantation was performed in more than one half of the cases, per operating surgeon discretion, demonstrating greater blood loss, more frequent acute kidney injury, and longer intensive care unit stays.