Surgical Conversion Following Endovascular Aortic Aneurysm Repair: A 12-year Experience

Juan Carlos Jimenez, MD, Wesley S. Moore, MD, William J. Quinones-Baldrich, M.D..
UCLA Med Ctr, Dept of Surgery, Los Angeles, CA, USA.

Objective: Review outcomes of patients requiring surgical conversion after endovascular abdominal aortic aneurysm (AAA) repair.
Methods: Records for all patients undergoing open conversion after endovascular AAA repair were reviewed.
Results: From 1993 to 2006, 470 patients underwent endovascular repair for AAA. Sixteen patients (mean age 77.5 + 6.4 yrs) required surgical conversion with complete (9) or partial graft removal (7). Five patients required immediate conversion (acute) and 11 underwent delayed conversion 4 to 72 months after endovascular repair. Mean aneurysm size was 7.1 + 1.4 cm in diameter. Indications for conversion were: endoleak with increasing aneurysm size (n=9, 64%), deployment failure (n=5, 36%), retroperitoneal bleeding (n=3, 21%), and infection (n=1, 7%). Supra-renal aortic cross clamping was required in two patients (14%) and one or both iliac limbs were retained in 7 patients (44%). An aortic occlusion balloon placed through the body of the existing endograft facilitated proximal control in 3 patients. There were two perioperative deaths in the acute conversion group ((2/5; 40%) and no deaths in the delayed conversion group (p=0.04). Mean length of hospital stay was 9.7 days. Mean follow-up was 49.3 months. Actuarial 5yr survival was 81%. Retained endovascular components in patients with partial graft removal remained stable during follow up.
Conclusions: Surgical conversion following endovascular AAA repair can be performed without suprarenal clamping in the majority of patients. Endovascular aortic control with a balloon avoids suprarenal exposure. Partial endograft removal in selected patients facilitates open conversion and appears durable. Acute conversion is associated with increased mortality.

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