Surgical “New Aortic Carrefour Technique” for Late Open Conversion After Endovascular Aortic Repair

Abstract

The aim of the study is to report the early and midterm outcomes of late open conversion (LOC) after endovascular aortic repair (EVAR) using the "new aortic carrefour technique" (NACT) for preservation of the stent-graft iliac limbs. Late conversions were defined as explants >6months after previous EVAR. Patients treated for elective or urgent LOC after EVAR with the NACT at a single center (2009-2019), and with ≥6months of follow-up, were included. Briefly, after completing the proximal aortic anastomosis, the endograft iliac limbs were truncated and sutured together to create a "new aortic carrefour" (Veraldi's technique). A Dacron-knitted straight graft was therefore sutured to the newly created aortic bifurcation. Outcomes of interest were as follows: immediate technical success, intraoperative characteristics, and reinterventions. Results are reported as the number (and percentages) or median (and interquartile range [IQR]). During the study period, 433 patients underwent standard EVAR for abdominal aortic aneurysm and 20 underwent LOC. Of these, 9 consecutive patients were deemed suitable and treated with NACT. The indication for conversion was endoleak in 6 (type IA n=1, type II n=4, type III n=1), complete graft thrombosis (n=2), and one case of sac enlargement without any clear signs of endoleak at computed tomography angiography. Of these cases, six were treated electively, while three were treated in urgent setting including one case of rupture. The median procedure, aortic cross-clamping, and distal anastomosis times were 280minutes (IQR: 225-290), 24minutes (IQR: 22-29), and 15minutes (IQR: 14-18), respectively. The median blood loss was 1,600mL (IQR: 700-1,900), and the median hospital stay was 8days (IQR 7-12). None of the patients died and neither required unplanned reintervention within 30days. At a median imaging follow-up of 13months (IQR 8-43), there were no reinterventions due to residual leaks or technical defects. One patient died during follow-up, and the recorded cause of death was heart failure. The use of the NACT with preservation of the original endograft iliac limbs for LOC after EVAR is a safe and feasible technique, which results in a low perioperative morbidity and mortality rate in selected patients. The technique is effective during midterm follow-up and might represent a valuable tool to expand the armamentarium of vascular surgeons for surgical regrafting after EVAR.