Regarding “Management of failed endovascular aortic aneurysm repair with explantation or fenestrated-branched endovascular aortic aneurysm repair”

Abstract

In their paper, Dias et al1Dias A.P. Farivar B.S. Steenberge S.P. Brier C. Kuramochi Y. Lyden S.P. et al.Management of failed endovascular aortic aneurysm repair with explantation or fenestrated-branched endovascular aortic aneurysm repair.J Vasc Surg. 2018; 68: 1676-1687.e3Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar reported an outstanding experience of management of failed endovascular aneurysm repair (EVAR) with either open conversion or fenestrated-branched EVAR (F/B-EVAR) in 247 patients. This is the first and biggest series comparing both techniques after failed EVAR, and the authors are to be congratulated for their brilliant results in such complex cases. However, whether this comparison is fair enough is questionable. Indeed, each patient was not necessarily eligible for both techniques. Being restricted by anatomic requirements, F/B-EVAR was actually limited to some of the elective type I endoleaks when all emergent cases and infections—well known to be associated with worse outcomes2Ben Abdallah I. El Batti S. Abou-Rjeili M. Fabiani J.N. Julia P. Alsac J.M. Open conversion after endovascular abdominal aneurysm repair: an 8 year single centre experience.Eur J Vasc Endovasc Surg. 2017; 53: 831-836Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 3Kouvelos G. Koutsoumpelis A. Lazaris A. Matsagkas M. Late open conversion after endovascular abdominal aortic aneurysm repair.J Vasc Surg. 2015; 61: 1350-1356Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar—were treated by open conversion (47/162 [29%]). As a matter of fact, open conversion does address a wider range of failed EVAR configurations. The subanalysis regarding only elective and noninfectious explantations, showing similar postoperative mortality (6% vs 6%) in both groups, appears therefore the more relevant. Besides, surgical technique of open conversion has significantly evolved recently, leading to very low mortality rates (0%-3%) in elective cases.2Ben Abdallah I. El Batti S. Abou-Rjeili M. Fabiani J.N. Julia P. Alsac J.M. Open conversion after endovascular abdominal aneurysm repair: an 8 year single centre experience.Eur J Vasc Endovasc Surg. 2017; 53: 831-836Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 3Kouvelos G. Koutsoumpelis A. Lazaris A. Matsagkas M. Late open conversion after endovascular abdominal aortic aneurysm repair.J Vasc Surg. 2015; 61: 1350-1356Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar As represented by the series of Dias et al, the initial trend was to favor total explantation, involving supravisceral clamping and revascularization of visceral vessels; but more recently, partial explantation and infrarenal clamping,4Perini P. de Troia A. Tecchio T. Azzarone M. Bianchini Massoni C. Salcuni P. et al.Infrarenal endograft clamping in late open conversions after endovascular abdominal aneurysm repair.J Vasc Surg. 2017; 66: 1048-1055Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar both major details of the “neoneck” technique described by Bonvini et al,5Bonvini S. Wassermann V. Menegolo M. Scrivere P. Grego F. Piazza M. Surgical infrarenal “neo-neck” technique during elective conversion after EVAR with suprarenal fixation.Eur J Vasc Endovasc Surg. 2015; 50: 175-180Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar have been demonstrated to be of great value to simplify the procedure, avoiding therefore an extensive repair. Using this technique whenever possible, our team reported 0% mortality in elective open conversion.2Ben Abdallah I. El Batti S. Abou-Rjeili M. Fabiani J.N. Julia P. Alsac J.M. Open conversion after endovascular abdominal aneurysm repair: an 8 year single centre experience.Eur J Vasc Endovasc Surg. 2017; 53: 831-836Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Widespread use of this technique might continue to improve results of open conversion, standing a fair comparison with F/B-EVAR. In all, this study highlights the increasing need for aortic centers to master these two complementary techniques to provide each failed EVAR patient with the most appropriate one. Management of failed endovascular aortic aneurysm repair with explantation or fenestrated-branched endovascular aortic aneurysm repairJournal of Vascular SurgeryVol. 68Issue 6PreviewThe incidence of failed endovascular aneurysm repair (EVAR) is increasing, and understanding the different methods of management and repair is paramount. The objective of this study was to evaluate the clinical management and rescue of failed EVAR by either explantation or fenestrated-branched EVAR (F/B-EVAR). Full-Text PDF Open ArchiveReplyJournal of Vascular SurgeryVol. 69Issue 6PreviewWe read with interest the observations from Ben Abdallah et al. We thank them for the comments on the paper and for referencing their own experience with outstanding results.1 Full-Text PDF Open Archive