December 12, 2008

Treatment options for delayed AAA rupture following endovascular repair: Outcomes of a prospective analysis

Manish Mehta, MD, R. Clement Darling, III, MD, Sean P. Roddy, MD, Philip Sk Paty, MD, John B. Taggert, MD, Yaron Sternbach, MD, Kathleen J. Ozsvath, MD, Paul B. Kreienberg, MD, Benjamin B. Chang, MD, Dhiraj M. Shah, MD.
Albany Medical College, Albany, NY, USA.

Purpose: Delayed abdominal aortic aneurysm (AAA) rupture is a well recognized complication of endovascular aneurysm repair (EVAR). We wanted to evaluate the frequency, etiology, and outcomes of delayed AAA rupture following EVAR, and identify treatment options that facilitate improved survival.
Methods: From 2002-2007, 1431 patients underwent elective and emergent EVAR. At a mean follow-up of 26 months, 27 (1.9%) patients presented with delayed AAA rupture and required repair by either open surgical conversion, or endovascular means. All data was prospectively collected in a vascular registry and outcomes analyzed.
Results: Over a mean follow-up of 27 months, the incidence of delayed AAA rupture after elective EVAR was 1.8% (24 of 1360 patients), and after emergent EVAR for r-AAA was 4.2% (3 of 71 patients). Of the 27 delayed AAA rupture patients, 20 (74%) were considered ‘lost to follow-up’, and at presentation 17 (63%) patients had a Type I endoleak with stentgraft migration from attachment sites, 15 (55%) patients underwent open surgical repair via retroperitoneal approach with partial (n=8, 53%) or complete (n=7, 47%) stentgraft explants and aortoiliac reconstruction, 11 (41%) patients underwent a second EVAR, and 1 (4%) patient refused treatment and died. Supraceliac aortic clamp was required in 3 (20%) patients with open surgical conversion, and supraceliac occlusion balloon was required in 2 (18%) patients with EVAR. There were 3 (11%) postoperative deaths; 2 following open surgical conversion, and 1 following EVAR. One additional redo-EVAR patient has undergone successful elective conversion to open surgical repair for persistent type II endoleak and increase in AAA size.
Conclusions: Delayed AAA rupture following EVAR can be successfully managed in most patients by open surgical conversion, or secondary EVAR. The approach to each patient should be individualized; complete stentgraft explant is not necessary in most patients, a secondary EVAR for delayed AAA rupture with or without an elective conversion to open surgical repair remains a viable option. Vigilant routine follow-up is needed for all patients after EVAR.

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