Influence Of Aortic Center Designation On Referrals For Failed Endovascular Aortic Aneurysm Repair
Charles J. Bailey, MD, Saranya Sundaram, Chetan Dargan, MD, Marcelo Giarelli, Murray L. Shames, MD.
University of South Florida / Tampa General Hospital, Tampa, FL, USA.
Objectives: Aortic Center designation is associated with increased volume of aortic cases. This study examines the impact of an Aortic Center on referrals and outcomes in treatment of failed endovascular aortic aneurysm repair (EVAR). Methods: Retrospective review of a prospective database was conducted to identify all patients treated at an Aortic Center in management of failed EVAR between January 2015 and December 2019. Patient demographics, mode of EVAR failure, method of aortic repair, and 30-day morbidities and mortality were examined.Results:In the study period our Aortic Center completed 929 repairs of abdominal aortic aneurysm (AAA), with 159 procedures (17.1%) performed for failure of prior EVAR. Failed EVAR were referred from outside facilities in 127 of 159 cases (79.8%). Of the 159 treated, 140 patients were male (88%), with an average age of 79 years and increased rates of hypertension (83%) and prior tobacco abuse (93%). Mode of EVAR failure was most commonly due to endoleak (N=136, 85.5%), with proximal Type I(a) the most frequent (N=95, 69.8%). Operative management of failed EVAR included both open explant (N=43, 27%) and endovascular therapies (N=116, 73%). Endovascular salvage utilized proximal cuff (N=38, 32.7%), proximal cuff with parallel branch grafts (N=35, 30.1%), relining of prior EVAR (N=23, 19.8%), proximal cuff with EndoAnchors (N=14, 12%), and proximal extension with fenestrated endograft (N=6, 5.1%). Major adverse postoperative events were experienced in both open (N=17, 39.5%) and endovascular treatment arms (N=26, 22.4%). Endovascular salvage was most frequently complicated by persistence of endoleak (N=17,14.6%), with highest rates in repairs utilizing proximal cuff with EndoAnchors (21.4%) and proximal cuff with parallel branch grafts (20%). Re-intervention within 30-days was required in 8 of 17 (47%) patients with persistent endoleak. No perioperative morbidity or mortality was noted for patients treated with fenestrated endograft. Overall, 30-day mortality for re-intervention after failed EVAR was 8.2%. Mortality at 30-days was increased in open versus endovascular repair (N=11, 25.5% vs. N=2, 1.7%; p<.0001), and in patients requiring emergent versus elective open endograft explant (N=9, 50% vs. N=2, 8%; p<.0001).Conclusions:Management of failed EVAR is a common referral to a designated Aortic Center, with secondary repair associated with increased postoperative morbidity and adverse events. Adherence to endograft instructions for use (IFU) at index AAA repair may decrease rates of failed EVAR and high-risk re-interventions.
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