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Approaches to late surgical conversion after endovascular exclusion of thoracic and abdominal aortic aneurysms

Introduction: Endovascular repair of aortic aneurysms is a good treatment option for patients who may not otherwise tolerate open aneurysmectomy. However, the rate of reintervention after aneurysm exclusion is significant: 9-10% for thoracic stent grafts and 20% for abdominal aortic endografts at 2 years. This review summarizes our experience with important technical issues related to stent graft removal.
Methods: We retrospectively collected data from a series of endograft explantations performed at 3 institutions over a 10-year period. Surgical approach, and procedural details were identified and analyzed.
Results: Twenty-one patients (median age, 72 years) who underwent removal of thoracic (n=8) and abdominal aortic (n=13) stent grafts were identified. Reasons for conversion included type I endoleak (57%), component separation (10%), and erosion into lung with ensueing infection (10%). Time to explantation was longer for abdominal aortic than thoracic devices (median time, 28.0 versus 5.5 months). Circulatory arrest was only necessary in 1 case, left heart bypass in 3. Mean blood loss was 3879 mL for the abdominal explants and 3875 mL for the thoracic explants. Among the 13 abdominal procedures, a transperitoneal approach was used in 11, and retroperitoneal and thoracoabdominal approaches were used once each. A thoracoabdominal was used in all 9 thoracic cases. Repair of the abdominal aorta was performed with either removal of the entire endograft or incorporation of iliac limbs into the repair. Overall mortality was 29% and included 1 (5%) patient in the thoracic group and 5 (24%) patients in the abdominal group. Postoperative outcomes included 3 myocardial infarctions and 1 stroke. Multiorgan failure, including renal failure, developed in 3 patients. No patient had postoperative paraplegia.

Conclusion: Although endografts are generally durable, the consequences of surgical conversion can be devastating. Proper planning is crucial and involves considering the approach, use of circulatory arrest, left heart bypass, and renal perfusion. Mortality rates remain significant because of the complex and often urgent nature of the repair.