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Objectives : We sought to validate the use of a selected treatment algorithm for proximal fixation loss after EVAR with long term CT-based follow-up of endograft stability and AAA exclusion.
Methods : A retrospective review was performed of 107 patients who underwent 117 secondary procedures for proximal fixation loss from 2001-2013. Fixation loss was defined as development of type 1A endoleak (n=28), reduction in proximal endograft fixation length to < 10mm (n=50), or both (n=39). A selected algorithm for endovascular management included proximal extension cuff for a primary device < 25mm below the renal arteries (RA) or aorto-uni-iliac (AUI) conversion for migration >25mm. Aortobi-iliac re-lining was performed for proximal fixation loss with inadequate distal fixation (<20mm) and suspected structural device failure. Proximal extensions with renal revascularization was performed when there was adequate pararenal aorta but required RA coverage. Open aortic neck plications were done for recalcitrant 1A leaks. CT-based follow-up was performed at 1, 6 and annual intervals.
Results : Fixation loss occurred at an average of 55 + 32mo following initial EVAR with a AAA size of 6.9 + 1.7cm. Most cases were associated with disadvantaged infra-renal neck anatomy. Previous embolization of Type 2 leaks had occurred in 20 (35.9%) cases. Concurrent type 2 leaks were present in 44 (37.6%) cases with 22 (18.8%) of those having had a prior embolization, and 9 (7.7%) requiring additional embolization for sac growth post-secondary intervention. Secondary procedures included 65 proximal cuffs (42 single, 13 multiple cuffs), 22 AUI, 8 re-linings, 10 plications, and a single coil embolization. Eleven partial explants were necessary (9 after failed endovascular salvage at referring institutions). Intra-operative adjuncts included 31 distal iliac extensions and 14 renal stents (7 chimney endografts, 7 bare metal). Thirty-day mortality was 1.9% (n=2). Follow-up averaged 24 + 23mo (range to 94 mo.) AAA sac regression (>5mm diameter) occurred after intervention in 41 cases, 44 with unchanged diameters, 21 experiencing growth (11 unknown). Ten (8.5%) tertiary procedures were done for recurrent fixation loss. Two late ruptures occurred due to other source endoleaks. Two device explants were performed for continued aortic sac expansion. No late AAA-related deaths occurred.
Conclusion : Successful salvage of proximal neck endograft fixation can be achieved using a selected treatment algorithm with mandatory CT-based ongoing surveillance.