Endograft Preservation Research Articles

Late Open Semi-conversion with Endograft Preservation for (Type II) Endoleaks with Late Aneurysm Sac Enlargement after EVAR - Indications, Method and Results in Our Own Patient Collective

EVAR (endovascular aortic repair) is the most common method for treating an abdominal aortic aneurysm, but according to the latest findings it carries the risk of subsequent complications. These can be caused by (late) aneurysm sac growth. If conservative and surgical therapies fail to treat the aneurysm sac growth, open conversion is necessary to prevent aneurysm rupture. There are several options for open conversion, in which the EVAR prosthesis can be completely preserved or is (partially) removed. Late open semi-conversion with complete in-situ preservation of the EVAR-prosthesis and gathering of the aneurysm sac are a less invasive method than complete conversion and may be performed instead for selected patients. The aim of the present work is to present the surgical method, including indications and technical information, as well as the presentation of the results in our recent patient collective.All patients semi-converted in our department of vascular surgery and phlebology due to (type II) endoleak were included. All data are presented as n (%) or median (range).Between 6/2019 and 3/2023, 13 patients underwent semi-conversion 6 (2-12) years (median, range) after the initial EVAR. The aneurysm sac diameter at the time of semi-conversion was 69mm (58-95mm), the operating time was 114min (97-147min), the blood loss was 100ml (100-1500ml). Five (38%) patients received blood transfusion intraoperatively and 2 (15%) postoperatively. The stay in the intensive care unit lasted 1 (1-5) days, the hospitalisation time was 8 (6-11) days. Postoperative complications were intestinal atony (3 [23%], 1 [8%] with nausea/emesis and gastric tube insertion), anaemia (2 [15%]), hyponatraemia (2 [15%]), delirium (1 [8%]), COVID-19 infection (1 [8%]) and 1 [8%] intra-abdominal postoperative bleeding with the indication for surgical revision and the transfusion of 8 erythrocyte concentrates.Semi-conversion is a safe and practicable surgical method with few severe complications for a selected group of patients, which should be considered as an alternative to more invasive methods with (partial) removal of the EVAR-prosthesis. Further long-term studies comparing semi-conversion to full conversion are needed to demonstrate its benefits.

Surgical Treatment of Sac Enlargement Due to Type II Endoleaks Following Endovascular Aneurysm Repair

An aneurysm sac enlargement caused by type II endoleak (T2EL) following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms may cause serious complications such as rupture. Consequently, methods that preoperatively prevent or postoperatively treat T2EL have been employed. When significant aneurysm enlargement occurs due to persistent T2EL, embolization is first performed through several access points. However, although these endovascular reinterventions have a high technical success rate and are safe, their effectiveness remains questionable. When such endovascular procedures fail to stabilize sac enlargement, open surgical conversion (OSC) becomes the last-resort treatment option. We review several strategies of OSC for the repair of T2EL following EVAR. Among the three main OSC procedures, namely, complete endograft removal, partial endograft removal, and complete endograft preservation, partial endograft removal under infrarenal clamping was considered the most appropriate owing to its less invasiveness and durability.

Two decades of experience in explantation and graft preserving strategies following primary endovascular aneurysm repair and lessons learned.

We aim to scrutinize our evolving re-intervention strategies following primary endovascular aortic aneurysm repair (EVAR) - EVAR GORE SalvAge Fabric Technique (ARAFAT), aortic sac double breasting with endograft preservation, and stent-graft explantation. We performed 1,555 aortic interventions over the study period, including 910 EVARs. Factors associated with the need for reintervention and the likelihood of chronic fabric fatigue failure (CFFF) were investigated. Using conventional and innovative diagnostic modalities with Prone contrASt enHanced computed tomography Angiography (PASHA), 136 endoleaks (ELs) were identified (15 type I, 98 type II; 18 type III; 5 type IV). Forty-four (4.84%) patients underwent re-intervention post-primary EVAR; 18 ARAFATs, 12 double breastings, and 14 explantations. Choice of re-intervention was based on patient fitness and mode of failure. Mean EL detection duration following primary EVAR was 53.3 ± 6.82 months, while mean time to re-intervention was 70.20 ± 6.98 months. The mean sac size before the primary EVAR and re-intervention was 6.00 ± 1.75 cm and 7.51 ± 1.94 cm, respectively. Polyester (61.40%) was the most commonly employed stent-graft material. Use of more than three modular stent-graft components (3.42 ± 1.31, p = 0.846); with the proximal stent-graft diameter of 31.6 ± 3.80 cm (p = 0.651) and the use of iliac limbs more than 17 mm (p = 0.364), all added together are contributing factors. We had one peri-operative mortality following explantation due to sepsis-induced multiorgan failure. Our re-intervention strategies matured from stent graft explantation to graft preservation with endovascular relining of the stent-graft. Graft preservation with aortic sacotomy and double breasting were used to manage concealed ELs due to aortic hygroma.

Mid-Term Outcomes of Late Open Conversion with Endograft Preservation for Sac Enlargement after Endovascular Abdominal Aortic Aneurysm Repair

Late open conversion has sometimes been required for sac enlargement after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm. Though the open repair with endograft preservation is considered less invasive compared to endograft removal, the mid-term outcomes are still unclear. The aim of this study is to evaluate the mid-term outcomes of late open conversion with endograft preservation after EVAR. We reviewed patients who underwent late open conversion with endograft preservation for sac enlargement or rupture in our institution from May 2007 to December 2020. The open repair mainly consisted of ligation of lumber arteries or the median sacral artery and sacotomy. We additionally performed wrapping of plicated aneurysm with equine pericardium as much as possible. Patients were followed-up by a computed tomography scan and duplex ultrasound 1 and 6months postoperatively, and each year thereafter. Of the 1,087 patients who underwent EVAR, 23 patients with a mean age of 81.5years were included in this study. The mean duration post-EVAR was 35.6months. Sac wrapping with equine pericardium was performed in 14 patients (60.9%). We additionally performed wrapping of the endograft junction by a Dacron knitted fabric in 1 case with type III endoleak and aortic neck banding in 4 cases with type I endoleak. The 30-day mortality was 0% and the rate of major complications was 4%. All-cause mortality was 21.7% which included 1 aneurysm-related death during a mean follow-up of 38.5months. Sac re-enlargement was observed in 4 patients without the wrapping method. At 3years, the aneurysmal diameter in the nonwrapping group significantly increased, compared with the wrapping group (P=0.011). Late open conversion with endograft preservation is a feasible treatment; however, at times re-enlargement of the sac aneurysm occurs. The wrapping method has the potential to prevent sac re-enlargement after open conversion.

Abdominal aortic endograft infection. A decade of experience and literature review

IntroductionAortic endograft infection is an infrequent but life-threatening complication after endovascular abdominal aortic repair (EVAR). There is no consensus on management of endograft infection and little evidence has been published in our country. Endograft explantation is considered the “gold standar” treatment whereas percutaneous or surgical perigraft and sac drainage associated to antibiotics should be considered and alternative therapy. MethodsWe carried out a retrospective and descriptive review of abdominal aortic endograft infections at our tertiary center (Hospital Universitario Cruces) during last ten years (2010–2019). ResultsWe describe the clinical and microbiological characteristics of 10 EVAR infections, their management and outcomes. The incidence of graft infection after EVAR was 3%. The mean time to the clinical presentation of infection was 16.9 months (median 4.5 months). The microbiological diagnosis was reached in 100% of cases (predominance of gram-positive species). The overall mortality rate was 50% (although the survival rate was 100% after surgical drainage of the sac). ConclusionPerigraft or aneurysm sac aspiration culture show their diagnostic utility as microbiological diagnosis was reached in all cases despite of blood cultures being only positive in 50% of the samples. Surgical drainage and endograft preservation combined with antibiotherapy show remarkable results. The high heterogeneity in our case series makes difficult to offer general recommendations, thus far, a tailored approach to treatment is suggested.

Multicenter comparison between open conversions and semi-conversions for late endoleaks after endovascular aneurysm repair

Objective: The aim of this study is to compare early and follow-up outcomes of late open conversions (LOC, with complete or partial endograft explantation) and semi-conversions (SC, with endograft preservation) after endovascular aneurysm repair in a multicenter experience.

Multicenter comparison between open conversions and semi-conversions for late endoleaks after endovascular aneurysm repair

ObjectiveThe aim of this study is to compare early and follow-up outcomes of late open conversions (LOC, with complete or partial endograft explantation) and semi-conversions (SC, with endograft preservation) after endovascular aneurysm repair in a multicenter experience. MethodsAll LOC and SC performed from 1997 to 2020 in 11 vascular centers were compared. Endograft infections or thrombosis were excluded. Primary endpoints were early mortality and long-term survival estimates. Secondary endpoints were differences in postoperative complication rates and conversion-related complications during follow-up. ResultsIn the considered period, 347 patients underwent surgery for endovascular aneurysm repair complications. Among these, 270 were operated on for endoleaks (222 LOC, 48 SC). The two groups were homogeneous in terms of American Society of Anesthesiologists score (LOC, 3.2 ± 0.7; SC, 3 ± 0.5; P = .128) and main endograft characteristics (suprarenal fixation, bifurcated/aorto-uni-iliac configuration). The mean age was 75 ± 8 years for LOC and 79 ± 7 years for SC (P = .009). Reasons for LOC were: 62.2% (138/222) type I endoleak, 21.6% (48/222) type II endoleak, 7.7% (17/222) type III endoleak, and 8.5% (19/222) endotension. Indications for SC were: 64.6% (31/48) type II endoleak, 33.3% (16/48) type I endoleak, and 2.1% (1/48) type III endoleak. Thirty-day mortality was 12.2% (27/222) in the LOC group, and 10.4% (5/48) in the SC group (P = .73). Postoperative complication rate was higher in the LOC group (45.5% vs 29.2%; P = .04). The estimated survival rate after LOC was 80% at 1 year and 64% at 5 years; after SC, it was 72% at 1 year and 37% at 5 years (log-rank P = .01). During the median follow-up of 21.5 months (interquartile range, 2.4-61 months), an endoleak after SC was found in the 38.3% of the cases; sac growth was recorded in the 27.7% of SC patients. ConclusionsSC has an early benefit over LOC in terms of reduced postoperative complications but has a significantly inferior mid-term survival. The high rates of persistent and/or recurrent endoleaks reduce SC durability.

Partial open conversion with proximal aortic banding and endograft preservation is a safe option for the treatment of persistent type II endoleaks.

We have described our technique of open partial conversion (OPC; n = 5) with aortic banding and endograft preservation for the treatment of type II endoleaks. OPC significantly reduced the aortic clamping time (5.0 vs 32.5 minutes; P = .01) relative to endograft explantation (n = 2). Cross-clamping was avoided entirely in three of the procedures. The patients treated with OPC showed a trend toward a decreased operative time (4.8 vs 5.9 hours) and shorter hospital stay (5.7 vs 7.4 days). Follow-up computed tomography scans were available for three of the five OPC patients, which showed resolution of the type II endoleak. The findings from the present study have further demonstrated the safety of OPC for the treatment of type II endoleaks.

Infección de endoprótesis aórtica abdominal. Experiencia de una década y revisión de la literatura

IntroductionAortic endograft infection is an infrequent but life-threatening complication after endovascular abdominal aortic repair (EVAR). There is no consensus on management of endograft infection and little evidence has been published in our country. Endograft explantation is considered the “gold standard” treatment whereas percutaneous or surgical perigraft and sac drainage associated to antibiotics should be considered and alternative therapy. MethodsWe carried out a retrospective and descriptive review of abdominal aortic endograft infections at our tertiary center (Hospital Universitario Cruces) during last ten years (2010–2019). ResultsWe describe the clinical and microbiological characteristics of 10 EVAR infections, their management and outcomes. The incidence of graft infection after EVAR was 3%. The mean time to the clinical presentation of infection was 16.9 months (median 4.5 months). The microbiological diagnosis was reached in 100% of cases (predominance of gram-positive species). The overall mortality rate was 50% (although the survival rate was 100% after surgical drainage of the sac). ConclusionsPerigraft or aneurysm sac aspiration culture shows their diagnostic utility as microbiological diagnosis was reached in all cases despite of blood cultures being only positive in 50% of the samples. Surgical drainage and endograft preservation combined with antibiotherapy show remarkable results. The high heterogeneity in our case series makes difficult to offer general recommendations, thus far, a tailored approach to treatment is suggested.

Lessons Learned from Open Surgical Conversion after Failed Previous EVAR

Delayed open conversion (OpC) after endovascular aortic aneurysm repair (EVAR) is becoming increasingly common worldwide. We reviewed our experience to characterize the perioperative spectrum of OpC repairs. A retrospective analysis of a prospectively maintained institutional database to identify patients who underwent late OpC after failed EVAR was performed. Patient and aneurysm baseline characteristics, mechanism of failure, perioperative details, including type of repair/complications/survival, and late outcomes were examined. From January 2003 to January 2020, 38 male patients (mean age, 75±7years; range, 60-90) required late OpC. Interval time from initial EVAR to OpC was 63.6±33.8months (range, 17-120). Mean diameter of the aneurysms was 82.2±22.1mm before OpC compared with 62.9±13mm before endograft implantation. Mechanisms of failure were type Ia, Ib, II, and III endoleaks in 14 (36.8%), 9 (23.7%), 4 (10.5%), and 1 (2.6%) patient(s), respectively; infection in 3 (7.9%), leg ischemia in 2 (5.3%), and multiple causes in 5 (13.2%) patients. We observed 4 (10.5%) asymptomatic, 16 (42.1%) symptomatic, and 18 (47.3%) ruptured aneurysms. Four patients (10.5%) had stable contained ruptures, whereas the remaining 13 (34.2%) and 1 additional patient (2.6%) with aortoenteric fistula presented with hemorrhagic shock (class ≥II). Total endograft explantation, endograft preservation, or proximal/distal partial graft removal was performed in 16 (42.1%), 10 (26.3%), and 2 (5.2%)/9 (23.7%) of patients, respectively. Technical success was 100%, excluding an early postaortic clamping death. Overall, 30-day mortality was 21.1% (8 of 38) and significantly higher in patients with hemorrhagic shock or hemodynamic instability at presentation (P=0.04 and P=0.009, respectively) and in patients who had endografts with hooks/barbs or experiencing higher postoperative complication rate (P=0.02 and P=0.006, respectively). By definition, procedure success was 81.1%. Mean follow-up was 37.6±39.8months. By the end of the study, we recorded 11 deaths (2 were aneurysm related). Despite high technical success, OpC has a significant mortality in patients presenting with hemorrhagic shock and had active fixation endografts or experiencing high complication rate. Many other confounding factors may play a role.

Elective late open conversion after endovascular aneurysm repair is associated with comparable outcomes to primary open repair of abdominal aortic aneurysms

ObjectiveThree of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported. MethodsThis retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival. ResultsSixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively. ConclusionsTechnically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.

Novel open technique for repair of endograft migration

Widespread adoption of endovascular aneurysm repair has led to increased incidence of late complications, such as endograft migration. Treatment options have to be tailored to the patient's health, quality of proximal aorta, and extent of migration. Complete or partial endograft removal is associated with significant morbidity and mortality. We describe a case in which open repair with endograft preservation was employed, with the additional benefit of a sutured proximal anastomosis.

Novel Open Technique for Repair of Endograft Migration

Abstract Widespread adoption of endovascular aneurysm repair has led to increased incidence of late complications, such as endograft migration. Treatment options have to be tailored to the patient's health, quality of proximal aorta, and extent of migration. Complete or partial endograft removal is associated with significant morbidity and mortality. We describe a case in which open repair with endograft preservation was employed, with the additional benefit of a sutured proximal anastomosis.

Preservation of the infected thoracic aortic endograft with thoracoscopic drainage and continuous irrigation

The gold standard for aortic endograft infection includes the excision of infected endograft, debridement, and reconstruction. However, these methods are not always the best option for patients with poor clinical status. We assessed the suitability of alternative methods for managing aortic endograft infection. The patient was a 72-year-old man whose previous abdominal surgeries provoked recurrent cholangitis. The patient had also undergone thoracic endovascular aortic repair (TEVAR). One month after the TEVAR, he was readmitted with high-grade fever and diagnosed with endograft infection. Due to his frail condition, we chose a less invasive and conservative strategy; thoracoscopic drainage with endograft preservation, followed by continuous irrigation. He recovered well, and has survived more than 2 years after the drainage procedure. In unstable patients or those with severe comorbidities who cannot tolerate endograft excision, thoracoscopic drainage with endograft preservation is less invasive, and can be a bridging or temporary solution.

Editor's Choice – Late Open Surgical Conversion after Endovascular Abdominal Aortic Aneurysm Repair

Late open surgical conversion following endovascular aneurysm repair (EVAR) may occur more frequently after performing EVAR in anatomy outside the instructions for use (IFU). This study reviews predictors and outcomes of late open surgical conversion for failed EVAR. This retrospective cohort study reviewed all EVARs performed at the Ottawa Hospital between January 1999 and May 2015. Open surgical conversions >1 month post EVAR were identified. Variables analysed included indication for conversion, pre-intervention AAA anatomy, endovascular device and configuration, operative technique, re-interventions, complications, and death. Of 1060 consecutive EVARs performed, 16 required late open surgical conversion. Endografts implanted were Medtronic Talent (n = 8, 50.0%), Medtronic Endurant (n = 3, 18.8%), Cook Zenith (n = 4, 25.0%), and Terumo Anaconda (n = 1, 6.2%). Eleven grafts were bifurcated (68.8%), five were aorto-uni-iliac (31.2%). The median time to open surgical conversion was 3.1 (IQR 1.0-5.2) years. There was no significant difference in pre-EVAR rupture status (1.4% elective, 2.1% ruptured, p=.54). Indications for conversion included: Type 1 endoleak with sac expansion (n=4, 25.0%), Type 2 endoleak with expansion (n=2, 12.5%), migration (n=3, 18.8%), sac expansion without endoleak (n=2, 12.5%), graft infection (n=3, 18.8%), rupture (n=2, 12.5%). Nine patients (56.2%) underwent stent graft explantation with in situ surgical graft reconstruction, seven had endograft preserving open surgical intervention. The 30 day mortality was 18.8% (n=3, all of whom having had endograft preservation). Ten patients (62.5%) suffered major in hospital complications. One patient (6.5%) required post-conversion major surgical re-intervention. IFU adherence during initial EVAR was 43.8%, versus 79.0% (p<.01) among uncomplicated EVARs. Open surgical conversion following EVAR results in significant morbidity and mortality. IFU adherence of EVARs later requiring open surgical conversion is markedly low. More data are required to elucidate the impact of increasing liberalisation of EVAR outside of IFU.

Late conversion of endovascular to open repair of abdominal aortic aneurysms

Failure of endovascular repair (EVAR) of an abdominal aortic aneurysm can result in significant risk of morbidity and mortality. We review our experience with late conversions to open repair. We conducted a retrospective database review to identify all EVAR procedures performed between 1997 and 2010 and the number converted to open repair at our university-affiliated medical centre. Late conversion was defined as those occurring at least 30 days after initial EVAR. In all, 892 EVARs took place during the study period. Six patients (0.7%) required late conversion to open repair. Their mean age was 71 (range 58-83) years, and half were women. Half of the initial EVARs were for ruptured aneurysms. The median time to conversion was 15.6 (range 1.7-61.3) months. Indications for secondary conversion (50% urgent, 50% elective) included persistent type I endoleak (n = 3), combined type II and III endoleak (n = 1), graft thrombosis (n = 1) and aneurysm rupture (n = 1). Supraceliac clamping was required in most patients (67%), and the mean transfusion requirement was 2.6 units. Total endograft explantation occurred in 2 patients (33%), whereas partial or total endograft preservation occurred in 4 (67%). Median length of stay in hospital after conversion was 7 (range 6-73) days. There were no instances of early or in-hospital mortality following conversion. Our EVAR experience includes a low rate of late conversion to open repair, with most conversions being a result of persistent aneurysm perfusion. Although technically challenging, late conversion can be safe. Our experience supports ongoing surveillance after EVAR.

Delayed open conversions after endovascular abdominal aortic aneurysm repair

Secondary interventions after endovascular aneurysm repair (EVAR) remain a concern. Most are simple catheter-based procedures, but in some instances, open conversions (OCs) are required and carry a worse outcome. We reviewed our experience to characterize these OCs. A retrospective review was conducted of all patients who underwent an OC after a previous EVAR for an aneurysm-related indication from 2001 to 2010. Clinical outcomes are reported. Data were reviewed for 44 patients (77% men) with a mean age of 74 years (range, 55-90 years). The average time from EVAR to the first OC was 45 months (range, 2-190 months). In six patients (14%), the initial EVAR was at another institution. The endografts used were Ancure in 16, Excluder in 13, AneuRx in eight, Zenith in three, Lifepath in one, Renu in one, and undetermined in two. Twenty-two patients had previously undergone a total of 32 endovascular reinterventions before their index OC. Indications for OC were aneurysm expansion in 28 (64%), rupture in 12 (27%), and infection in four (9%). The endograft was preserved in situ in 10 patients (23%). Explantation was partial in 18 (41%) or complete in 16 (36%). Endograft preservation was used for type II endoleak in all but one patient by selective ligation of the culprit arteries (lumbar in four, inferior mesenteric artery in five, and middle sacral in one). Proximal neck banding was performed in one type Ia endoleak. Overall morbidity was 55%, and mortality was 18%. No deaths occurred in a subgroup of patients who underwent endograft preservation with selective ligation of culprit vessels for type II endoleak. Intraoperative complications included bowel injury in two, bleeding in two, splenectomy in one, and ureteral injury in one. At a mean follow-up of 20 months, two patients underwent additional procedures after the index OC: one after endograft preservation and one after partial explantation. None of the patients who underwent elective OC with endograft preservation required subsequent endograft explantation. Most OCs after EVAR are associated with significant morbidity and mortality, except when electively treating an isolated type II endoleak with ligation of branches and preservation of the endograft.

Percutaneous Drainage of Aortic Aneurysm Sac Abscesses Following Endovascular Aneurysm Repair

To report preliminary experiences with the treatment of aortic aneurysm sac abscesses following prior endovascular aortic aneurysm repair (EVAR) using computerized tomography (CT)-guided percutaneous drainage. Three patients aged 73 to 78 years with aortic aneurysm sac infections following prior EVAR, 2 of which were associated with aortoduodenal fistula, underwent CT-guided percutaneous drainage and catheter placement. One patient had complete resolution of the aortic aneurysm sac abscess following percutaneous drainage; 1 patient was stabilized to eventual extraanatomic bypass, graft explantation, and fistula repair; and 1 patient was temporized to debridement and fistula repair with endograft preservation. CT-guided percutaneous drainage may be a helpful therapy in selected patients for the treatment of aortic aneurysm sac infections following EVAR.

Open surgical repair after failed endovascular aneurysm repair: Is endograft removal necessary?

Open surgical repair after failed endovascular aneurysm repair (EVAR) usually involves complete endograft removal and replacement with a prosthetic surgical graft. This is associated with significant morbidity and mortality. We have used an alternative strategy focused on limiting the magnitude of surgical repair by preserving the functioning portion of the endograft and avoiding aortic cross-clamping, when possible. Between January 2000 and 2008, patients requiring delayed conversion after EVAR at our institution were managed with (1) complete endograft preservation and external wrap of the aortic neck to secure a proximal seal, or (2) partial endograft removal with interposition grafting from the infrarenal aortic neck to the remaining endograft. Records of all patients were retrospectively reviewed for demographics, operative details, and outcomes. During this time, 12 patients were treated with delayed open surgical conversion. The indication for conversion in all patients was a type I endoleak with aneurysm enlargement not amendable to percutaneous intervention. Mean age was 81 +/- 6.2 years (range, 61-90 years). Average time to conversion was 44.7 months (range, 7-80 months). Complete endograft preservation was attempted in eight patients and was successful in six (75%). The two patients that failed this approach, as well as four additional patients who were not candidates for this approach, underwent partial endograft excision and replacement with an interposition graft sutured to the remaining portion of the stent graft. Complete endograft removal was not required in any patients. There was one post-operative mortality (8.3%) and one significant post-operative morbidity (8.3%). Mean intensive care unit and hospital stays were 2.8 +/- 3.9 days (range, 1-15 days) and 8.4 +/- 5.8 days (range, 3-26 days), respectively. Open surgical repair of failed EVAR can be accomplished with preservation of all or a significant portion of the endograft in most patients. This may limit the magnitude of the repair procedure and may reduce morbidity and mortality.

Aortic Endograft Infection: Open Surgical Management with Endograft Preservation

We report successful management of aortic endograft infection without graft explantation or extra-anatomic bypass. A 66 year-old male who had undergone endovascular repair of an aortic aneurysm presented with abdominal pain and raised inflammatory markers following embolisation of a type-2 'endoleak'. CT scanning revealed a left psoas fluid collection. Endograft infection was diagnosed. Following failure of CT-guided drainage and conservative management, surgical drainage with irrigation drain placement was undertaken with preservation of the endograft. There was no evidence of recurrent infection after follow-up at 30 months. Aortic endograft infection may be managed without endograft removal and extra-anatomic bypass.