Late conversion of aortic stent grafts

Objectives The frequency of late removal of endovascular abdominal aortic repair (EVAR) parallels the rise of endovascular aortic repair. Evaluation of outcomes for EVAR explants may identify risks for complications and alter clinical management. Methods A patient database was used to identify EVAR...

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Published in:Journal of vascular surgery 2009-03, Vol.49 (3), p.589-595
Main Authors: Kelso, Rebecca L., MD, Lyden, Sean P., MD, Butler, Brett, MD, Greenberg, Roy K., MD, Eagleton, Matthew J., MD, Clair, Daniel G., MD
Format: Article
Language:English
Subjects:
Aged
Aged, 80 and over
Aortic Aneurysm, Abdominal - mortality
Aortic Aneurysm, Abdominal - surgery
Biological and medical sciences
Blood and lymphatic vessels
Blood Vessel Prosthesis
Blood Vessel Prosthesis Implantation - adverse effects
Blood Vessel Prosthesis Implantation - instrumentation
Blood Vessel Prosthesis Implantation - mortality
Cardiology. Vascular system
Databases as Topic
Device Removal
Diseases of the aorta
Elective Surgical Procedures
Female
Humans
Length of Stay
Male
Medical sciences
Middle Aged
Prosthesis Design
Reoperation
Retrospective Studies
Stents
Surgery
Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases
Time Factors
Treatment Failure
Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels
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Summary:Objectives The frequency of late removal of endovascular abdominal aortic repair (EVAR) parallels the rise of endovascular aortic repair. Evaluation of outcomes for EVAR explants may identify risks for complications and alter clinical management. Methods A patient database was used to identify EVAR patients requiring explant >1 month after implant. A retrospective analysis was conducted of the type of graft, duration of implant, reason for removal, operative technique, death, and length of stay. Results During 1999 through 2007, 1606 EVARs were performed, and 25 patients required explantation, with an additional 16 referred from other institutions (N = 41). The average age was 73 years (range, 50-87 years); 90% were men. Grafts were excised after a median of 33.3 months (range, 3-93 months). Explanted grafts included 16 AneuRx (40%), 7 Ancure (17%), 6 Excluder (15%), 4 Zenith (10%), 4 Talent (10%), 1 Cook Aortomonoiliac rupture graft, 1 Endologix, 1 Quantum LP, and 1 homemade tube graft. Overall hospital mortality was 19% and occurred after conversion for rupture in 4, and in infected graft, aortoenteric fistula, repair of new aneurysm of the visceral segment, and claudication due to graft stenosis in one patient each. Elective EVAR-related mortality was 3.3%. Mortality was higher in patients with rupture compared with nonrupture (4 of 6 vs 3 of 35, P ≤ .01). Thirty patients (73%) had one or more endoleaks (type I, 16; II, 9; III, 9; endotension, 5). Migration (n = 10), rupture (n = 6), aortoenteric fistula (n = 3), infection (n = 1), limb thrombosis (n = 3), and claudication (n =1) were also factors. Proximal aortic control was above the endograft (supravisceral, 23; suprarenal, 12; infrarenal, 6). Reconstruction was an aortoiliac repair in 63% and tube graft in 25%. Grafts with suprarenal fixation required longer proximal aortic clamp time of 43 minutes vs 28 minutes for infrarenal fixation. Complete graft removal was achieved in 85%. Proximal or distal portions of the endograft were incorporated into the repair in the remaining six. Conclusion Elective EVAR conversion, although technically challenging may be done with mortality similar to primary open repair. Mortality for conversion for infected grafts and ruptured aneurysms remains high. EVAR is associated with continued risk of conversion, and surveillance may identify late complications that require removal, justifying lifelong monitoring. Aggressive management of late complications and elective con
ISSN:0741-5214
1097-6809
DOI:10.1016/j.jvs.2008.10.020