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Increased Technical Complexity Of Evar Conversion Is Not Associated With Worse Outcomes Over Time At A High-volume Aortic Treatment Center
Griffin P. Stinson, BS, Michael J. Fassler, MD, Salvatore T. Scali, MD, Thomas S. Huber, thomas.huber.ufl.edu.
University of Florida, Gainesville, FL, USA.
OBJECTIVES:Open EVAR conversion(EVAR-c) remains essential when device failure occurs given its widespread adoption(including off-label use). However, changes in patient selection, endograft design, and remedial endovascular strategies may shift failure patterns and increase explant complexity. We hypothesized that over time(i) patient phenotypes undergoing EVAR-c would change and(ii) procedural complexity would increase; and(iii) that institutional experience and processes of care at our high-volume, aortic treatment center would mitigate adverse outcomes
METHODS:We divided consecutive EVAR-c into three eras with equal cohorts(n=98/era): Era-1(2002-2015; 64-elective, 34-non-elective), Era-2(2015-2020; 65-elective, 33-non-elective), and Era-3(2020-2025; 64-elective, 34-non-elective). We compared patient factors, anatomic/operative complexity, and outcomes. Fisher’s exact and Kruskal-Wallis/Mann-Whitney tests were applied for categorical and continuous variables, respectively. A nominal logistic regression generated odds ratios.
RESULTS:Age and comorbidity profiles were stable across eras(age medians: 73/76/72 yrs; incidence of all cardiovascular risk-factors were comparable but median time from index EVAR to referral for conversion increased(34→58→75 mos;p<0.001). Legacy infrarenal devices without active fixation disappeared(29%→15%→0%;p<.001), while unibody platforms increased(8%→ 17%→28%;p=.02). When trans-renal/suprarenal fixation(including fenestrated/branched) systems were grouped, their proportion was ~41%→41%→ 30%(p=.36). Elective indications were dominated by endoleak(any type, ~60%; type 1a was ~38% and stable; but multiple concurrent endoleaks increased: 3%→7%→13%;p=.01). The proportion of urgent/emergent conversions was unchanged(35%/34%/35%) but infectious(aorto-enteric fistula/mycotic aneurysm) indications increased(8%→14%→20%;p=.05). Operative complexity increased as evidenced by increased use of concomitant renal/mesenteric bypass(7%→21%→46%;p<0.001), any intraoperative adjunctive procedure(20%→30%→59%;p<0.0001), and application of a supra-mesenteric cross-clamp(50%→54%→64%;p=.1). Correspondingly, use of retroperitoneal exposure increased(67%→77%→87%;p=.006), However, operative duration decreased despite rising complexity(4.4→3.0→3.1 hrs;p<.001). Overall in-hospital(12%→10%→8%) and 30-day(11%→9%→7%) mortality remained stable across eras(p>0.5), with elective 30-day mortality improving(5%→2%→2%; odds ratio 1vs2(2.7,p=0.2), 2vs3(0.98,p=0.98), 1vs3(2.6,p=0.23)). Complications were similar(56%→65%→68%)(Figure).
CONCLUSIONS:Over time, EVAR conversions at our high-volume aortic treatment center involved later failures and more technically complex reconstructions, although short-term outcomes, particularly in elective cases, were stable or improved. These patterns likely reflect evolution in patient selection, operative strategy, and center experience. As EVAR is used in patients with greater anatomic/physiologic complexity, subsequent failure modes and referral patterns may continue to shift. Monitoring these temporal signals can inform device surveillance, referral timing, and conversion strategy while providing anticipated benchmarks for outcomes.
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