Aortic Endograft Explantation Research Articles

Twenty-three Years of Experience in Aortic Endograft Explantation

Twenty-three Years of Experience in Aortic Endograft Explantation

Single Centre Experience with Infected Abdominal Aortic Endograft Explantation

Single Centre Experience with Infected Abdominal Aortic Endograft Explantation

Partial and complete explantation of aortic endografts in the modern era.

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.

Referral Centre Experience with Infected Abdominal Aortic Endograft Explantation

The increasing use of endovascular aneurysm repair (EVAR) appears to be associated with the burden of vascular endograft infections. Complete stent graft explantation is recommended but leads to significant mortality. This study aimed to assess the technical challenges, complications, and mortality rate following infected endograft explantation. Patients who underwent abdominal aortic endograft explantation for infection at the Bordeaux University Hospital from July 2008 to December 2020 were included retrospectively in this single centre observational study. The diagnosis was established based on the MAGIC criteria. The primary endpoint was 30 day mortality. Secondary endpoints were 90 day and in hospital mortality, survival, and re-infection. Thirty-four patients were included, median age 69 years (interquartile range [IQR] 65, 76), with four (12%) treated as an emergency. The median time from EVAR to explantation was 17.5 months (4.5 - 36.3). In situ reconstruction was carried out with prosthetic grafts in 24 patients (71%, including 23 antimicrobial grafts combining silver and triclosan), and biological grafts in 10 (five femoral veins, four arterial allografts, three bovine patches, one biosynthetic graft). Seventeen aorto-enteric fistulae (AEnF) were addressed with direct repair of the intestinal tract (n= 10/17; 59%) or resection and anastomosis (n= 7/17; 41%). The culture was polymicrobial in 12 patients (35%) and remained sterile in four (12%). The 30 day and in hospital mortality rates were 21% (n= 7) and 27% (n= 9). Twenty-five patients (73%) presented with early post-operative complications, requiring 16 revision procedures (47%). Over a median follow up of 16.2 months (IQR 8.3, 33.6), the mortality rate was 35% (n= 12; 11 aortic related; 32%), with two re-infections (6%), both after biological reconstruction (one for an AEnF). Early morbidity and mortality remain high after complete infected endograft explantation, even in a high volume centre. Comparison with other treatment modalities in large multicentre cohorts might be of interest.

Partial and Complete Explantation of Aortic Endografts in the Modern Era

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.

Strategies and outcomes for aortic endograft explantation

BackgroundFailure of endovascular aneurysm repairs (EVARs) requiring open conversion remains a major challenge. We analyzed indications for repair, operative strategies, and outcomes with a focus on iliac artery degeneration after endograft removal. MethodsA prospective, institutional database was reviewed to identify patients who underwent explantation of a failed EVAR device. Demographics, reason for failure, operative details including extent of endograft removal, and complications/survival were examined. Postexplantation computed tomography imaging was evaluated for iliac artery degeneration. ResultsThere were 32 patients who underwent explantation from 2002 to 2017. Six patients were treated emergently for rupture. The majority were elderly (average age, 76 ± 8.5 years), white (100%) men (91%) who had their EVAR graft inserted 45.5 months (range, 0.3-86 months) before open conversion, usually at an outside institution (75%). Explanted endografts included nine AneuRx (Medtronic, Minneapolis, Minn), nine Excluder (W. L. Gore & Associates, Flagstaff, Ariz), four Endurant (Medtronic), three Zenith (Cook Medical, Bloomington, Ind), three Powerlink/AFX (Endologix, Irvine, Calif), one Aorfix (Lombard Medical, Oxfordshire, United Kingdom), one Talent (Medtronic), and two unknown. Failure was due to endoleak in 91% (type I, 38%; type II, 28%; type III, 13%; type V, 13%), infection in 6%, and occlusion/kinking in 3%. A previous attempt at endovascular salvage of EVAR occurred in 12 (37.5%) patients. Operative approach was transabdominal in 69% and retroperitoneal in 31%. Initial aortic clamp position was supraceliac in 31%, suprarenal in 31%, and infrarenal in 38%. Most patients had complete removal of their endograft (n = 19 [59%]), with 22 (69%) having at least the iliac limbs removed. Grafts with suprarenal fixation were more likely to have the upper main body left in situ (67% vs 17%; P = .029). The 30-day mortality was 6.3% (3.8% elective, 16.7% ruptured), and 31% had a major complication. Of the 23 patients who had follow-up imaging, there was a trend for more iliac degeneration (>5 mm in growth) in those who had the iliac limbs removed (29.4% vs 0%; P = .184). Three patients with iliac limb removal required subsequent iliac endovascular intervention (two for rupture). Patients who presented with a rupture had a decreased 5-year overall survival (33%) compared with those who were converted electively (59%). ConclusionsBoth complete and partial endograft explantation, although morbid procedures, can be performed safely. Postoperative imaging surveillance is important, especially if the endograft has been removed from the iliac arteries, as degeneration can occur.

A multicenter experience with infected abdominal aortic endograft explantation

ObjectiveEndovascular aneurysm repair (EVAR) is widely used with excellent results, but its infectious complications can be devastating. In this paper, we report a multicenter experience with infected EVAR, symptoms, and options for explantation and their outcome. MethodsWe have reviewed all consecutive endograft explants for infection at 11 French university centers following EVAR, defined as index EVAR, from 1998 to 2015. Diagnosis of infected aortic endograft was made on the basis of clinical findings, cultures, imaging studies, and intraoperative findings. ResultsThirty-three patients with an infected aortic endograft were identified. In this group, at index EVAR, six patients (18%) presented with a groin or psoas infection and six patients (18%) presented with a general infection, including catheter-related infection (n = 3), prostatitis (n = 1), cholecystitis (n = 1), and pneumonia (n = 1). After index EVAR, eight patients underwent successful inferior mesenteric artery embolization for a type II endoleak within 6 months of index EVAR and one patient received an additional stent for a type Ib endoleak 1 week after index EVAR. Median time between the first clinical signs of infection and endograft explantation was 30 days (range, 1 day to 2.2 years). The most common presenting characteristics were pain and fever in 21 patients (64%) and fever alone in 8 patients (24%). Suprarenal fixation was present in 20 of 33 endografts (60%). All patients underwent endograft explantation, with bowel resection in 12 patients (36%) presenting with an endograft-enteric fistula. Methods of reconstruction were graft placement in situ in 30 patients and extra-anatomic bypass in 3 patients. In situ conduits were aortic cryopreserved allografts in 23, polyester silver graft in 5, and autogenous femoral vein in 2. Microbiology specimens obtained from the endograft and the aneurysm were positive in 24 patients (74%). Gram-positive organisms were the most commonly found in 18 patients (55%). Early mortality (30 days or in the hospital) was 39% (n = 13) in relation to graft blowout (n = 3), multiple organ failure (n = 6), colon necrosis (n = 3), and peripheral embolism (n = 1). At 1 year, the rates of patient survival, graft-related complications, and reinfection were 44%, 10%, and 5%, respectively. ConclusionsAbdominal aortic endograft explantation for infection is high risk and associated with graft-enteric fistula in one-third of the cases. Larger multicenter studies are needed to better understand the risk factors and to improve preventive measures at index EVAR and during follow-up.

IF04. A Multicenter Experience With Infected Abdominal Aortic Endograft Explantation

Endovascular abdominal endografts (EVAR) are widely used with excellent results, but infectious complications can be devastating, we report here a multicenter experience with infected EVARs, symptoms, options for explantation and their outcome. A retrospective analysis of all EVAR explants for infection from 1998 to 2015 at 11 French University centers was performed. Diagnosis of infected endograft (i-endograft) was made on clinical findings, cultures, imaging studies, and intraoperative findings at explantation. Thirty-three patients with an i-endograft were identified with a median age of 69 years (range 57-87 years). In this group, at index EVAR, four patients (12%) presented with a groin infection and six patients (18%) presented a general infection with bacteriemia in relation with a central venous catheter (n = 3), prostatitis (n = 1), cholecystitis (n = 1), and pneumonia (n = 1). After index EVAR, eight patients underwent successful inferior mesenteric artery embolization for a type II endoleak, and one patient received an additional stent for a type I B endoleak. Median time from EVAR to presentation was 414 days. The most common presenting characteristics were pain and fever in 21 patients (64%) and fever alone in seven patients (21%), which were present an average of 31 days before explantation. Seven types of different endografts were explanted. Three patients (9%) were treated in emergency. All patients underwent total i-endograft explantation, with bowel resection in 13 patients (39%) with an aortoenteric fistula. Methods of reconstruction were in situ in 30 patients and extra-anatomic in three. In situ conduits were aortic cryopreserved allografts in 23, polyester silver graft (Maquet) in 5, and femoral vein in 2. Thirty-seven organisms were found in 24 patients (73%) with a positive culture. Gram-positive organisms were the most common found in 18 (55%). The average number of organisms per patient with a positive culture was 1.5. Antimicrobial therapy consisted of 16 different antibiotics; 29 patients (88%) received two or more antibiotics. Early mortality (30 days or in-hospital) was 39% (n = 13) in relation with graft blow-out (n = 3), multiple organ failure (n = 6), colon necrosis (n = 3), and peripheral embolism (n = 1). At 13-month median follow-up (range, 1-75 months), patient survival, graft-related complications, and reinfection rates were 39%, 10%, and 5%, respectively. Abdominal aortic endograft explantation for infection is high risk. Further studies are needed to understand the risk factors and the preventive measures at index EVAR and during follow-up.TableCauses of death at 30 days or in-hospital after removal of the infected endograftCauses of deathPatients, No.Time, daysNew graft rupture32, 20, 40 Allograft22, 20 Autogenous vein140Sepsis (multiple organ failure)a62, 2, 12, 15, 45, 56Colon necrosisb35, 5, 15Lower limb ischemiac130aTwo reoperations for recurrent aortic sepsis.bThree colectomies.cBilateral trash foot, patient refused major amputation. Open table in a new tab

PC48. Emergent Aortic Endograft Explantation Due to Rupture: A Case Report and Video

PC48. Emergent Aortic Endograft Explantation Due to Rupture: A Case Report and Video

Outcomes After Late Explantation of Aortic Endografts Depend on Indication for Explantation

With the growing prevalence of endovascular repair for abdominal aortic aneurysm (AAA), the number of patients requiring graft explantation is increasing. Therefore, knowledge related to outcomes after explantation may lead to improvement in surgical options. In this study we compare our experience with explantation of aortic endografts, based on indication. The medical records of all aortic procedures performed at our center were queried during the period from 2002 to 2012. Relevant data from patients needing explantation of aortic endografts were analyzed using Fisher's exact test, t-test, and Kaplan-Meier analysis. Thirty-nine patients underwent aortic endograft explantation (64.1% men). Mean age was 71.9 years with a mean aneurysm size of 6.8 cm (range 3.5-10.7 cm). Hypertension (97.4%), hyperlipidemia (76.9%), and history of smoking (82%) were the most prevalent risk factors. Mean time to explant was 41.7 months (range 2.2-118.4 months). The primary explant indication was endoleak in 27 (69.2%) and infection in 12 (30.8%) patients. The endoleak group consisted of 13 type I, 8 type II, 1 type III, 4 endotension, 1 rupture, and 4 patients with multiple endoleaks. Seven patients were symptomatic, whereas 2 had ruptured aneurysms. Half of the patients in the infection group required supraceliac clamping for explantation. Operative blood loss (P = 0.08) and need for transfusion (P = 0.005) were significantly higher in the infection group. Thirty-day morbidity was 51.8% for the endoleak group and 83% for the infection group (P = 0.08). There were only 2 deaths in the cohort within 30 days, both in the infection group. Twenty-seven patients were alive at a mean follow-up of 1.9 years (range 0.1-8.4 years). Endograft explantation is a challenging operation with high morbidity and mortality. Furthermore, patients with an infectious etiology have significantly worse outcomes than those requiring explantation for endoleaks.

RR25. Outcomes following Late Explantation of Aortic Endografts Depend on the Indication

RR25. Outcomes following Late Explantation of Aortic Endografts Depend on the Indication