Late Surgical Conversion Research Articles

A Retrospective Analysis of Late Open Conversions Following Failed Endovascular Aneurysm Repair.

The incidence of late open surgical conversions (OSCs) has recently increased. Vascular surgeons face additional technical challenges in late conversion surgery of failed endovascular aneurysm repair (EVAR) due to the presence of a previously deployed endograft. Based on our institutional experience, this study aimed to delineate methods to improve late open conversion outcomes, proposing solutions for technical challenges. All preoperative OSC data on failed EVARs operated in our Cardiovascular Surgery Clinic between January 2017 and January 2024 were evaluated retrospectively. Study endpoints included early (30-day or in-hospital) and late follow-up outcomes. Early outcomes included perioperative mortality and morbidities, intensive care unit (ICU) period, and length of hospital stay (LOS). The main outcome of interest during follow-up was overall survival. Sixteen patients in our hospital, comprising eight elective and eight emergency procedures, underwent OSCs following EVAR. The difference between the 30-day mortality rates for the elective and urgent late conversions was significant (p < 0.001). Of these patients, 15 were male, with a mean age of 70.8 years (range: 62-80). Preoperative cardiac shock status and low hematocrit level (<20%) were independent mortality factors (p < 0.001). The ICU period was 8.7 ± 5.3 days (2-20 days) on average, and LOS was 17.3 ± 8.4 (6-29 days) days on average. The mean time to open surgical conversion in this cohort was 44.4 ± 16.8 months. The 5-year overall survival rate was 43.75%. The incidence of open surgical conversion is notably growing. Emergent open surgical conversions exhibit poorer mortality outcomes compared to elective procedures. Further data are essential to evaluate the ramifications of expanding the use of EVAR beyond the instructions for use (IFU) guidelines. The procedures involving patients who challenge the IFU criteria should be conducted at experienced centers and require close monitoring. Open surgical repair (OSR) as the initial treatment opportunity could be an alternative strategy for improving outcomes in this patient cohort.

Midterm Outcomes for Funnel-EVAR.

The funnel technique, the hybrid assembly of a thoracic and abdominal aortic endograft, is advantageous for frail patients where efficient oversizing is not possible for infrarenal wide aortic necks over 34 mm. We sought to determine the advantages and disadvantages of the Funnel-endovascular aneurysm repair (EVAR) technique using 60 mm length thoracic endograft. This retrospective study included 22 patients, all frail with high comorbidities, who were operated on with the Funnel technique using the 60 mm Lifetech Ankura thoracic endograft, in 7 urgent and 15 elective cases from January 2018. There were no exclusion criteria except having an age 60 years. Primary endpoints were the technical success and early mortality and morbidity; secondary endpoints were late outcomes such as endoleak, migration, late open surgical conversion, successful sac shrinkage, and enlargement at the infrarenal aortic neck diameter. The patients' mean age was 72.6 7.3 years (62-86 years), with a mean aneurysm diameter of 83.2 16.8 mm and mean infrarenal aortic diameter of 38.7 2.4 mm. There was no early mortality. Technical success was 100%. 21 standard bifurcated and one aorto-uni-iliac abdominal endograft were deployed. The mean fluoroscopy time was 14.3 5.2 minutes. Mean follow-up was 32.8 19.6 months, with no endovascular complications. There was no Type-1a or Type-3 endoleak, migration, infrarenal aortic neck diameter enlargement, or aneurysm sac enlargement. During the follow-up, three patients died, but there was no aneurysm-related mortality. Funnel-EVAR is effective and safe for patients with a wide infrarenal aortic neck diameter when assessing midterm outcomes. Therefore, it should be part of the armamentarium of a vascular surgeon in patients with wide aortic necks 34 mm.

Late surgical conversion after failed endovascular aortic repair: Our single-institutional experience

Objectives: In this study, we report our single-center experience with late surgical conversion (SC) after endovascular aneurysm repair (EVAR) and risk factors for reintervention. Patients and methods: Between January 2007 and December 2017, a total of 98 patients (94 males, 4 females; mean age: 69.1±8.6 years; range, 35 to 86 years) who underwent infrarenal EVAR were retrospectively analyzed. During the study period, additional eight patients who underwent EVAR at an external center were referred to our center. Overall, nine patients underwent late SC. In the late SC group, stent grafts used for EVAR were Endurant™ (n=5), Talent™ (n=2), Powerlink™, and Anaconda™ (n=1). Results: The mean time from initial EVAR to open conversion was 45.3±35.4 months. Four (44.4%) patients presented with more than one different concomitant indications. The most frequent reason for the late SC was type 3 endoleak (n=5, 55.5%). Late SC was performed electively in five (55.5%) patients. Partial stent graft removal was performed in three (33.3%), complete removal in three (33.3%), and complete preservation of the stent graft in three (33.3%) patients. Among 98 patients, the mean aneurysm diameter was significantly higher in those with late complication and undergoing second EVAR (p=0.001). The cut-off value for second EVAR was ≥66 mm with a sensitivity of 88.89% and specificity of 71.91% (p=0.001). Conclusion: The surveillance program after EVAR is of utmost importance to ensure that patients do not need urgent conversion, particularly in patients with an initial aneurysm diameter of ≥66 mm.

Otvorena reparacija aneurizme aorte u endovaskularnoj eri

Open repair (OR) of aortic aneurysms is still relatively mutilating and risky in older and high-risk patients. Since the introduction of EVAR, a significantly lower perioperative mortality has been noted. Apart from advantages, endovascular treatment has some disadvantages as well, due to which OR still has a very important role in the endovascular era. In a vast majority of the patients younger than 65, with good overall condition, long life expectancy and favorable anatomy, as well as in patients with hostile aneurysm neck anatomy, heritable connective tissue disorders, complete thrombosis of abdominal aortic aneurysm (AAA) and potent accessory renal arteries, OR is the first treatment option in comparison with the endovascular treatment. EVAR is recommended as the first treatment option in patients with inflammatory aneurysms and OR should be considered only in better shaped patients with inflammatory AAA and significant hydronephrosis. Late open surgical conversion (LOSC) is a noted event after endovascular treatment and is associated with a significantly higher perioperative mortality and other serious perioperative complications compared to primary OR. Multicenter randomized controlled trials (RCT) did not find a significant difference regarding 30-day mortality between open and endovascular repair of ruptured AAA. However, not all ruptured AAA are suitable for endovascular repair. In a hemodynamically unstable patients, when there is no time for MDCT angiography, EVAR is not possible, and OR is the only option. The incidence of abdominal compartment syndrome after OR is significantly lower in comparison with EVAR thanks to surgical evacuation and drainage of retroperitoneal hematoma. The improvement of the results of aortic aneurysm treatment largely depends on the volume of yearly aortic operations. Having in mind all the mentioned advantages and disadvantages of OR and endovascular repair, we can conclude that in high volume centers, younger generations of vascular surgeons should be educated in standard and complex open aortic surgery.

Otvoreno hirurško lečenje aneurizmi abdominalne aorte u endovaskularnoj eri

In addition to the well-known benefits, endovascular treatment (EVAR) of abdominal aortic aneurysms has its drawbacks and limitations. That is why open surgery (OS) still has a very important place. OS should be considered as the first treatment option for degenerative AAAs with either favorable or unfavorable anatomy in low-risk patients with long life expectancy. When it comes to inflammatory AAA, OS is indicated only in patients at low risk and hydronephrosis. OS is the "gold standard" for the definitive treatment of mycotic AAAs. In cases of complete thrombosis AAA is the only viable OS. OS is the method of choice in AAA with associated significant accessory renal arteries. OS is the method of choice for the treatment of AAA in patients with connective tissue disorders. Different types of endolic, infection, collapse and stent graft migration, or aneurysmal sac rupture, require late open surgical conversion after EVAR. OS is indicated if patients with RAAA are severely hemodynamically unstable, if they do not have a favorable anatomy, or if they have a large retroperitoneal hematoma. OS AAA can be performed only in centers with a large volume of work by experienced surgeons. The younger generation of vascular surgeons must be educated for both EVAR and OH AAA.

Open surgical conversion and management of patients with ruptured abdominal aortic aneurysm after previous endovascular aneurysm repair

Introduction/Objective. The objective was to present the results and technical considerations from high-volume center when performing late open surgical conversion (LOSC) after endovascular aneurysm repair (EVAR) in ruptured abdominal aortic aneurysm (RAAA) patients. Methods. This was a single center retrospective study. LOSC was performed whenever eventual endovascular reintervention failed, was not feasible due to hostile anatomy and unavailability of specific endograft materials, or when patient was hemodynamically unstable necessitating emergent surgery. Results. All previously implanted EVARs had bimodular configuration with suprarenal fixation. Total endograft explantation was performed in 40% of patients. Hospital mortality was 20%. Both patients who died had total endograft explantation with supraceliac clamp lasting more than 30 minutes. 30-day mortality was 30%, with one more patient who died from pulmonary embolism after hospital discharge and two hospital deaths were due to myocardial infarction. Conclusion. LOSC due to RAAA after previous EVAR carries greater mortality for the patient, suggesting multifactorial impacts on the outcome. The appropriate choice of surgical method and technical success are of ultimate importance, with total graft explantation having negative impact on patient?s survival.

Late surgical conversion of failed Multilayer Flow Modulator stenting in thoraco-abdominal aneurysms.

The aim of this study was to report the outcomes of open or hybrid repair of failed thoraco-abdominal aortic aneurysm endovascular treatment with Multilayer Flow Modulator (MFM) stents. All patients who underwent open or hybrid repair of a failed MFM aortic treatment were retrospectively analysed. Perioperative and postoperative data, as well as midterm survival, were assessed. Between 2013 and 2020, 39 patients received an open or hybrid conversion after endovascular treatment. Five of them [13%; 4 males; median age 68 years (interquartile range 66-76)] were previously treated with aortic MFM stents (Cardiatis, Isnes, Belgium). Among these, the median interval between index repair and conversion was 84 months (interquartile range 75-84). The median aneurysm diameter was 9.6 cm (interquartile range 8-10). Renovisceral vessels steno-occlusion was highly prevalent: 2 renal arteries were occluded; 3 coeliac trunks, 2 renal arteries and 1 superior mesenteric artery had a >70% ostial stenosis. Open standard thoraco-abdominal aneurysm conversion was performed in 3 fit patients, while a hybrid approach with visceral debranching and tube endografting was performed in 2 high-risk patients. Two patients (2 open repairs) died intraoperatively, and 1 (hybrid repair) postoperatively. The 2 successfully treated patients are alive at 4- and 34-month follow-up, respectively, with patent visceral branches. Open or hybrid thoraco-abdominal aortic aneurysm treatment after failed endovascular aortic repair with MFM stents might be the only surgical option to address sac enlargements and ruptures or branch-related failures. However, both procedures had a poor prognosis due to both the impaired preoperative patient's status and the surgical complexity in the presented series.

Video-Assisted Thoracic Surgery for Residual Aneurysm after Total Arch Replacement

Background: Residual aneurysms after graft replacement are rare, but they can be detrimental if they are saccular and large. The etiology of residual aneurysms remains unknown, and their management is controversial. One treatment option is late open surgical conversion; however, postoperative respiratory complications resulting from the dissection of pleural adhesions, which is frequently necessary with this approach, are often unavoidable. Case presentation: Herein, we report a case of open surgical repair of a residual distal aortic arch aneurysm that occurred after total arch replacement and thoracic endovascular aortic repair. Contrast-enhanced magnetic resonance imaging was not possible in this case due to the patient’s severe renal dysfunction; however, contrast-enhanced computed tomography using minimal contrast did not detect remarkable leakage through the graft or stent graft into the aneurysm. Late open surgical conversion using video-assisted thoracic surgery was performed by thoracic surgeons, and the adhesion between the aortic wall and the lung was safely and effectively dissected. Because there was no significant pulsation or evidence of feeding arteries in the aortic wall, the aortic wall was opened carefully. No bleeding or backflow from any branch arteries into the aneurysm was noted, so the aortic wall was ligated with continuous sutures. The patient recovered without experiencing any major complications. Conclusions: This case report demonstrates that video-assisted thoracic surgery is safe and effective for late open conversion in cases of residual aneurysm; furthermore, this case suggests that video-assisted thoracic surgery may be particularly beneficial for the dissection of adhesions between the aortic wall and lung in these cases.

Late Open Conversion Following Failure of EVAR and TEVAR: "State of the Art".

Abdominal endovascular aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR) have changed the aortic surgery, due to several advantages in terms of reduced morbidity and mortality. However, increasing rate of late complications requiring secondary procedures has been observed over time. Even if the majority of them may be treated by means of endovascular techniques, late open surgical conversion (LOSC) is required in specific situations. This paper aims to provide our single-center experience with LOSCs and an updated review of the literature. From 1995 to 2020, indications and outcomes of patients treated with LOSC for failed EVAR and TEVAR, at our institutions, were analyzed. LOSC was required to treat a broad range of complications that were classified into two main groups: "disease related" and "stent-graft (SG) related." Among the 121 patients treated with LOSC after EVAR, endoleak (75.2%) represented the most common indication. The overall 30-day mortality rate was 3.3%. A higher mortality rate was associated with infection after EVAR (p. 006). Among the 81 patients treated with LOSC after TEVAR, endoleak (32.1%) was the most common indication. The overall 30-day mortality rate was 13.6% with a higher incidence in the SG-related group (p. 02). LOSC is associated with an increased surgical complexity, in both the abdominal and thoracic area, that results in higher morbidity and mortality rates compared with standard open repair. Depending on the indication to LOSC, specific surgical maneuvers are required to improve clinical outcomes.

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.

The Safety of EVAS Surgical Conversion in a Comparative Monocentric Analysis

Endovascular aneurysm sealing (EVAS) was a widespread technology to treat abdominal aortic aneurysm. However, the particular morphology and structure of this endoprosthesis predisposed to proximal sealing defects with a high rate of reintervention or conversion to open surgery treatments. The purpose of this article is to report our experience on late open conversion of Nellix device, compared with the previous reported experience. Between September 2013 and February 2020, eight late open surgical conversions for endoleak (EL) were performed in our center: four of these were for EVAR. Four of these were EVAS devices required explantation and were included in the study. All excisions of infected abdominal aortic endograft were excluded. All patients were treated within the original instructions for use. Aorto-bi-iliac reconstruction was performed with a bifurcated Dacron graft in all the four cases. At 12months Doppler ultrasonography follow-up, good results at short term with preserved primary patency and freedom of re-intervention in three cases were reported. Only one patient died 16days after the procedure. Nevertheless, the endoprosthetic structure allows in three of our cases to clamp down the renal level, with a decrease of the time of lower limbs ischemia and greater safety of the open surgery repair procedure. The EVAS conversion is common, and a closer follow-up is required. The most recurrent open surgery indication is its migration and the EL type 1. The procedure is influenced by multiple comorbidities; emergency graft excision appears to increase morbidity and mortality, compared with elective surgical setting.

Late Open Conversion After Endovascular Abdominal Aortic Aneurysm Repair: Experience of Three High-Volume Centers

Retrospective review of three hospitals between January 1, 2010, and January 1, 2017. Late open surgical conversion proved necessary in 4.5% (31) of patients after endovascular aneurysm repair (EVAR). The most common indication was type I endoleak in two-thirds (20) of cases. The stent graft was completely removed in 58% (18) of patients. The 30-day mortality was 16% (five). Predictors of 30-day mortality were urgent surgery, rupture, and supraceliac clamping. Late open surgical conversion after EVAR is safe when it is performed electively but associated with high morbidity and mortality when it is performed urgently.

Long-term outcomes of endovascular aortic aneurysm repair with the Zenith AAA endovascular graft: a single-center study.

To present long-term results obtained with endovascular abdominal aortic aneurysm (AAA) repair (EVAR) using the Zenith AAA endovascular graft from a single institution. Between 2007 and 2013, 95 consecutive patients (median age 77years) underwent EVAR using Zenith. Data were prospectively collected and retrospectively analyzed until 2019. Primary outcomes were overall survival, freedom from AAA rupture, and freedom from AAA-related death. Secondary outcomes were freedom from late (> 30days) re-intervention and surgical conversion, and freedom from aneurysm sac growth (> 5mm). The initial technical success rate was 96.8%. There were no deaths or intraoperative conversions. Overall survival at 1, 3, 5, and 10years was 90.8%, 81.7%. 74.3%, and 57.2%, respectively. AAA rupture occurred in one patient (1.1%). Freedom from AAA-related death was 100% during the follow-up period. Freedom from aneurysm sac growth at 1, 3, 5, and 10years was 98.8%, 86.4%, 76.9%, 53.0%, respectively. Freedom from late re-intervention and open surgical conversion at 1, 3, 5, and 10years was 98.9%, 88.9%, 86.7, and 57.9%, respectively. EVAR with Zenith endografts represents a safe and durable means of AAA repair, and risk of rupture and aneurysm-related death are low.

Late surgical conversions after EVAR

Recent years have seen the liberalization of EVAR. Progress on the devices and in the teams supported this tendency which goes with an increase in the cases of explantation. There are relatively few papers on this subject and the precise analyses of the causes as well as the follow-up of the corresponding patients are essential.

Late surgical conversions after abdominal endovascular aortic repair: underlying mechanisms, clinical results and strategies for prevention.

Our goal was to report our results of late surgical conversion after endovascular aneurysm repair (EVAR). Variables analysed included baseline data, preinterventional anatomy, type of endovascular intervention, indications for conversion, operative technique, postoperative complications and follow-up survival rate. Between April 2011 and May 2018, 16 patients with late complications after EVAR underwent open surgical conversion at our institution. The mean age was 73.6 [standard deviation (SD) 8.9] years. There were 3 (18.8%) female patients. In 15 patients, the indication for primary EVAR was abdominal aortic aneurysm, and in 1 patient, chronic abdominal aortic dissection. Five patients underwent secondary EVAR service interventions for endoleak treatment between the index EVAR and the final secondary surgical conversion. Thirteen patients underwent surgery in an elective setting and 3 patients underwent emergency surgery. The mean time from EVAR to open surgical conversion was 6.31 (SD 4.0) years (range 1.2-16.0 years). The most common indication for conversion was endoleak formation (n = 12, 75%), followed by 3 cases of aortic rupture (1 patient with primary type 1 endoleak) and 2 cases of stent graft infection-1 with and 1 without an aortoduodenal fistula. One patient died during emergency open surgery of cardiopulmonary instability. Three patients developed postoperative renal dysfunction with recovery of their renal function before discharge. The in-hospital mortality rate was 12.5%. The median follow-up was 16.5 months (interquartile range 21 months). Freedom from death and aortic reintervention was 100%, respectively. After careful review of the index computed tomography scans for EVAR, the majority of failures could have been anticipated due to trade-offs with regard to length, diameter, morphology, shape and angulation of the proximal and/or distal landing zone. Despite being a challenging operation, late surgical conversion after EVAR yields excellent results with regard to outcome and freedom from the need for further aortic interventions. An anticipative strategy adhering to current recommendations for using or refraining from using EVAR in patients with anatomical challenges will help reduce the need for secondary surgical conversions and keep them to minimum.

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.

Effectiveness of Ambulatory Tru-Close Thoracic Vent for the Outpatient Management of Pneumothorax: A Prospective Pilot Study.

ObjectiveThis study aimed to assess the technical feasibility, procedural safety, and long-term therapeutic efficacy of a small-sized ambulatory thoracic vent (TV) device for the treatment of pneumothorax.Materials and MethodsFrom November 2012 to July 2013, 18 consecutive patients (3 females, 15 males) aged 16–64 years (mean: 34.7 ± 14.9 years, median: 29 years) were enrolled prospectively. Of these, 15 patients had spontaneous pneumothorax and 3 had iatrogenic pneumothorax. A Tru-Close TV with a small-bore (11- or 13-Fr) catheter was inserted under bi-plane fluoroscopic assistance.ResultsTechnical success was achieved in all patients. Complete lung re-expansion was achieved at 24 hours in 88.9% of patients (16/18 patients). All patients tolerated the procedure and no major complications occurred. The patients' mean numeric pain intensity score was 2.4 (range: 0–5) in daily life activity during the TV treatment. All patients with spontaneous pneumothorax underwent outpatient follow-up. The mean time to TV removal was 4.7 (3–13) days. Early surgical conversion rate of 16.7% (3/18 patients) occurred in 2 patients with incomplete lung expansion and 1 patient with immediate pneumothorax recurrence post-TV removal; and late surgical conversion occurred in 2 of 18 patients (11.1%). The recurrence-free long-term success rate was 72.2% (13/18 patients) during a 3-year follow-up period from November 2012 to June 2016.ConclusionTV application was a simple, safe, and technically feasible procedure in an outpatient clinic, with an acceptable long-term recurrence-free rate. Thus, TV could be useful for the immediate treatment of pneumothorax.

Seventeen Years’ Experience of Late Open Surgical Conversion after Failed Endovascular Abdominal Aortic Aneurysm Repair with 13 Variant Devices

To investigate the causes and results of late open surgical conversion (LOSC) after failed abdominal aortic aneurysm repair (EVAR) and to summarize our 17 years' experience with 13 various endografts. Retrospective data from August 1994 to January 2011 were analyzed at our center. The various devices' implant time, the types of devices, the rates and causes of LOSC, and the procedures and results of LOSC were analyzed and evaluated. A total of 1729 endovascular aneurysm repairs were performed in our single center (Nuremberg South Hospital) with 13 various devices within 17 years. The median follow-up period was 51 months (range 9-119 months). Among them, 77 patients with infrarenal abdominal aortic aneurysms received LOSC. The LOSC rate was 4.5 % (77 of 1729). The LOSC rates were significantly different before and after January 2002 (p < 0.001). The reasons of LOSC were mainly large type I endoleaks (n = 51) that were hard to repair by endovascular techniques. For the LOSC procedure, 71 cases were elective and 6 were emergent. The perioperative mortality was 5.2 % (4 of 77): 1 was elective (due to septic shock) and 3 were urgent (due to hemorrhagic shock). Large type I endoleaks were the main reasons for LOSC. The improvement of devices and operators' experience may decrease the LOSC rate. Urgent LOSC resulted in a high mortality rate, while selective LOSC was relatively safe with significantly lower mortality rate. Early intervention, full preparation, and timely LOSC are important for patients who require LOSC.

腹部大動脈瘤ステントグラフト内挿術後II型エンドリークに対して開腹下結紮術を行った1例

腹部大動脈瘤stent graft（以後SG）内挿術後のII型エンドリークは通常経過観察でよいとされるが，瘤径が拡大した場合には追加処置が必要となる．症例は78歳，女性．腎動脈下腹部大動脈瘤に対しSG内挿術を施行した．術中造影では1本の腰動脈が逆行性に造影されたが，瘤内は造影されず経過観察とした．術後3カ月目のCTでII型エンドリークを指摘，1年目に瘤径拡大を認め，瘤内へ逆流している第3，4腰動脈をコイル塞栓した．しかし，第4腰動脈のリークが残存し瘤径はその後も拡大したため，術後2年目に開腹手術を行った．瘤を切開すると，第4腰動脈からの逆流があり結紮処理した．術後CTでリークはなかった．腹部大動脈瘤へのSG治療増加に伴い，今後エンドリークへの処置を要する症例が増えると予想され，対処法を検討しておく必要があると考えられた．

EVAR Deployment in Anatomically Challenging Necks Outside the IFU

Treatment of abdominal aortic aneurysms with high-risk anatomy (neck length <10-15 mm, neck angle >60°) using commercially available devices has become increasingly common with expanding institutional experience. We examined whether placement of approved devices in short angled necks provides acceptable durability at early and intermediate time points. A total of 218 patients (197 men, 21 women) at a single academic center underwent endovascular aneurysm repair (EVAR) with a commercially available device between January 2004 and December 2007. Available medical records, pre- and postoperative imaging, and clinical follow-up were retrospectively reviewed. Patients were divided into those with suitable anatomy (instructions for use, IFU) for EVAR and those with high-risk anatomic aneurysm characteristics (non-IFU). IFU (n = 143) patients underwent repair with Excluder (40%), AneuRx (34%), and Zenith (26%) devices, whereas non-IFU (n = 75) were preferentially treated with Zenith (57%) over Excluder (25%) and AneuRx (17%). Demographics and medical comorbidities between the groups were similar. Operative mortality was 1.4% (2.1% IFU, 0% non-IFU) with mean follow-up of 35 months (range 12-72). Non-IFU patients tended to have larger sac diameters (46.7% ≥60 mm) with shorter (30.7% ≤10 mm), conical (49.3%), and more angled (68% >60°) necks (all P < .05 compared with IFU patients). Operative characteristics revealed that the non-IFU patients were more likely to be treated utilizing suprarenal fixation devices, to require placement of proximal cuffs (13.3% vs 2.1%, P = .003), and needed increased fluoroscopy time (31 vs 25 minutes, P = .02). Contrast dose was similar between groups (IFU = 118 mL, non-IFU = 119 mL, P = .95). There were no early or late surgical conversions. Rates of migration, endoleak, need for reintervention, sac regression, and freedom from aneurysm-related death were similar between the groups (P > .05). EVAR may be performed safely in high-risk patients with unfavorable neck anatomy using particular commercially available endografts. In our experience, the preferential use of active suprarenal fixation and aggressive use of proximal cuffs is associated with optimal results in these settings. Mid-term outcomes are comparable with those achieved in patients with suitable anatomy using a similar range of EVAR devices. Careful and mandatory long-term follow-up will be necessary to confirm the benefit of treating these high-risk anatomic patients.