Single-center Review Of Explant After Failed Endovascular Aneurysm Repair
Lauren J. Farley, MD, Lauren A. Harry, MD, James Brooks, MD, Murray Shames, MD, Marcelo Giarelli, RN.
USF, Tampa, FL, USA.
OBJECTIVES: Historically, late endovascular abdominal aortic aneurysm repair (EVAR) endograft explant has been described as an operation with significant morbidity and mortality. The objective of this study is to analyze descriptive outcomes of EVAR explants performed at a single center.
METHODS: A retrospective, single-center review of EVAR explants at a tertiary vascular referral center was performed between January 1st, 2015 and December 31st, 2019. Data collected included patient demographics, endograft manufacturer, configuration, reason for explant, extent of removal, post-operative length of stay, 30-day mortality and complications.
RESULTS: During the study period, 43 patients (93% men) underwent EVAR explant. The mean age was 73 years old (range, 49-87 years). Types of explanted endografts included 16 Excluder (W. L. Gore & Associates, Flagstaff, AZ), 8 Talent (Medtronic, Minneapolis, MN), 6 Endurant (Medtronic), 6 AneuRx (Medtronic), 3 Zenith (Cook Medical, Bloomington, IN), 3 AFX2 (Endologix, Irvine, CA), 1 Ovation (Endologix). Overall 30-day mortality was 19%, with elective case mortality at 9%, nonelective case mortality of 19%, and rupture mortality of 33%. The majority of explants (51%) were due to endoleak(type I, 68%; type II, 23%; type III, 9%; type IV, 5%; multiple, 14%). Explant due to infection represented 35% of the cohort, while explant due to rupture was 14%. Complete removal of endograft was performed in 27 patients (63%) and partial removal in the remaining 16 patients. Most endografts removed were placed in 2014 (17.1%) and a majority were explanted after July 2017 (56.8%). Elevated post-operative lactate was associated with increased mortality (p<0.05). Only 2 of the 43(4.65%) explants had initial EVARs performed at our institution whereas the other 41 were placed at outside institutions.
CONCLUSIONS: Although endograft explant after EVAR continues to have significant morbidity and mortality, our institution has a lower nonelective case mortality compared to many other reported data likely owing to improvement in technique and post-operative care since our study looks at cases performed in the last 5 years rather than earlier. Intra-operative factors such as blood loss, packed red blood cell transfusion and supraceliac clamp time did not significantly contribute to 30-day mortality. Expectedly, elevated post-operative lactate was significantly associated with increased mortality whereas post-operative complications such as need for dialysis and respiratory failure were not.
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