Late Surgical Conversions after EVAR: Underlying Mechanisms, Clinical Results, and Strategies for Prevention

Aim: To report our results of late surgical conversion after endovascular abdominal aortic repair (EVAR).

Methods: Variables analyzed included baseline data, pre-interventional anatomy, type of endovascular intervention, indication for conversion, operative technique, postoperative complications and follow-up survival.

Results: Between April 2011 and May 2018, sixteen patients with late complications after EVAR underwent open surgical conversion at our institution. Mean age was 73.6 ± 8.9 years. There were 3 (18.8%) female patients. In 15patients, the indication for primary EVAR was abdominal aortic aneurysm and in one patient chronic abdominal aortic dissection. Five patients underwent secondary EVAR service interventions for endoleak treatment between index EVAR and final secondary surgical conversion. Thirteen patients underwent surgery in an elective setting and tree patients underwent emergency surgery. Mean time from EVAR to open surgical conversion was 7.0 ± 4.2 years (ranged from 1.2 to 16.0 years). The most common indication for conversion was endoleak formation (n = 12, 75%), followed by three cases of aortic rupture (one patient with primary Type1 endoleak) and two cases of stent-graft infection one with and one without an aortoduodenal fistula. One patient died during emergency open surgery due to cardiopulmonary instability. Three patients developed postoperative renal dysfunction with recovery of their renal function before discharge. In-hospital mortality was 12.5%. The median follow-up is 24.4 ± 33.1 months (range 0–125 months). Freedom from late death and freedom from aortic reintervention were 100% respectively. After careful review of the index CT scans for EVAR, the majority of failures could have been anticipated due to trade-offs with regard to length, diameter, morphology, shape and angulation of the proximal and/ or distal landing zone.

Conclusions: Despite being a challenging operation, late surgical conversion after EVAR yields excellent results with regard to outcome and freedom from the need of further aortic interventions. An anticipative strategy adhering to current recommendations for using or refraining from using EVAR in challenging anatomies will help to reduce the need for secondary surgical conversions to a minimum.

No conflict of interest has been declared by the author(s).