Increasing Use of Open Conversion for Late Complications After Endovascular Aortic Aneurysm Repair
Abhisekh Mohapatra, MD, Darve Robinson, BA, Othman Abdul-Malak, MD, Michael C. Madigan, MD, Efthimios D. Avgerinos, MD, Rabih A. Chaer, MD, Michael J. Singh, MD, Michel S. Makaroun, MD.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
OBJECTIVES: Open procedures are often required for late complications after endovascular abdominal aortic aneurysm repair (EVAR). Our aim is to describe the indications for open interventions and their post-operative outcomes, and to identify factors that can predict mortality after open conversion.
METHODS: We reviewed patients from 2002-2017 who underwent any surgical abdominal aortic operation after a previous EVAR. Baseline characteristics, pre-operative imaging, procedural details, and post-operative outcomes were reviewed. The primary endpoint was 30-day mortality.
RESULTS: 81 patients underwent open conversion 3.9 ± 3.3 years after EVAR. The numbers increased significantly in recent years, with 18 cases performed in 2016 (Figure). 44.7% of patients had undergone 1.9 ± 1.0 prior endovascular interventions. The indication for surgical conversion was an endoleak in 66 patients (81.5%) and infection in 13 (16.1%). One patient had a limb occlusion and another a proximal aneurysm. 30-day mortality was 21.0% and was highest in 17 ruptures (41.2%) and 13 infections (46.2%). In a multivariate logistic regression model, independent predictors of 30-day mortality were rupture (OR 6.16, 95% CI 1.41-26.98, P = .02), endograft infection (OR 11.64, 95% CI 2.38-56.90, P = .002), and use of a supraceliac clamp (OR 4.70, 95% CI 1.26-17.49, P = .02). Transient acute kidney injury (15.6%) and prolonged intubation (11.7%) were the most common post-operative complications.
In 49 patients treated for endoleak without rupture, 31 underwent endograft explantation while 18 had a limited intervention (branch vessel ligation for type II endoleak in 16, external banding of the aneurysm neck for type IA endoleak in 7). Mortality was 6.5% when the endograft was explanted and 5.6% when it was not (P = 1.00). Over 2.3 ± 2.9 years of follow-up, only one re-intervention was required (proximal cuff placement for new type IA endoleak after branch vessel ligation). Survival was 91.0% at one year and 81.7% at five years.
CONCLUSIONS: Open conversion is playing an increasing role in the management of late EVAR complications. In patients without rupture or infection, both limited conversions and total explantation have a low mortality and good long-term durability. 
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