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 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, with one infected endograft excluded. Patient and graft characteristics, indications, and perioperative and long-term outcomes were analyzed. Partial versus complete explants were performed per surgeon discretion without a predefined protocol. This process was informed by patient risk factors; asymptomatic, symptomatic, or ruptured aneurysm presentation; and anatomical or intraoperative factors, including endoleak type. From 2001 to 2020, 52 explants met the inclusion and exclusion criteria. More than one-half (57.7%) were explants of EVAR devices placed at outside institutions, designated nonindex explants. Most patients were male (86.5%), the median age was 74years (interquartile range, 70-78years). More than one-half (61.5%) were performed in the seconddecade of the study period. The most commonly explanted grafts were Gore Excluder (n= 9 grafts), Cook Zenith (n= 8), Endologix AFX (n= 7), Medtronic Endurant (n= 5), and Medtronic Talent (n= 5). Most grafts (78.8%) were explanted for neck degeneration or sac expansion. Five were explanted for initial seal failure, five for symptomatic expansion, and seven for rupture. The median implant duration was 4.2years, although ranging widely (interquartile range, 2.6-5.1years), but similar between index and nonindex explants (4.2years vs 4.1years). Partial explantation was performed in 61.5%, with implant duration slightly lower, 3.2years versus 4.4years for complete explants. Partial explantation was more frequent in index explants (68.2% vs 56.7%). The median length of stay was 8days. The median intensive care unit length of stay was 3days, without significant differences in nonindex explants (4days vs 3days) and partial explants (4days vs 3days). Thirty-day mortality occurred in two nonindex explants (one partial and one complete explant). Thirty-day readmission was similar between partial and complete explants (9.7% vs 5.0%), without accounting for nonindex readmissions. Long-term survival was comparable between partial and complete explants in Cox regression (hazard ratio, 2.45; 95% confidence interval, 0.79-7.56; P= .12). Explants of EVAR devices have increased over time at our institution. Partial explant was performed in more than one-half of cases, per operating surgeon discretion, demonstrating higher blood loss, more frequent acute kidney injury, and longer intensive care unit stays, however with comparable short-term mortality and long-term survival.