Elective open surgical conversion for type Ia endoleak after endovascular aneurysm repair (EVAR) is not associated with increased morbidity or mortality compared with open juxtarenal aneurysm repair in appropriately selected patients, according to a study published in the Journal of Vascular Surgery. Open surgical conversion patients required longer procedure times and received more plasma transfusions.
In the paper, the authors, led by Salvatore T Scali, Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, USA, write that type Ia endoleak after EVAR can be a challenging complication to manage, and due to concerns regarding morbidity and mortality of open surgical conversion, reports of complex endoluminal salvage techniques are increasing.
“Despite development of these endovascular remedial strategies, many patients ultimately require open surgical conversion. The purpose of this analysis was to assess the outcomes of elective open surgical conversion for type Ia endoleak and compare them with elective primary open juxtarenal aneurysm repair to determine if these concerns are warranted,” they say.
From 2000 to 2012, 54 patients underwent EVAR and open surgical conversion at median time of 27 months (interquartile range, 9–55 months). Indications included endograft thrombosis in 2 (4%), intraoperative EVAR failure in 3 (6%), rupture in 5 (9%), graft infection in 6 (11%), and type Ia endoleak in 25 (all: 38 [70%]).
“Because many open surgical conversions are performed for emergency indications without endovascular options, we chose elective type Ia endoleak patients as our study group. These 25 patients were compared with an elective open juxtarenal aneurysm repair cohort matched by anatomy and comorbidities,” Scali et al write.
The primary endpoint was 30-day and one-year mortality. Secondary endpoints included early complications, cross-clamp time, procedure time, blood loss, and length of stay.
Demographic and comorbidity data in the open surgical conversion and open juxtarenal aneurysm repair groups did not differ, with the exception that open juxtarenal aneurysm repair patients presented with smaller aneurysm diameter and a higher rate of chronic obstructive pulmonary disease (p=0.03).
Open surgical conversion patients more frequently underwent a nontube graft repair (open surgical conversion, n=20 [80%] vs. open juxtarenal aneurysm repair, n=6 [24%]; p=0.0002), required longer procedure times (p=0.03), and received more plasma transfusions (p=0.03). The 30-day mortality was 4% in both groups, and a similar rate of major complications occurred (open surgical conversion, n=9 [36%] vs open juxtarenal aneurysm repair, n=8 [32%]; p=1). One-year survival was 83% in open surgical conversion and 91% in open juxtarenal aneurysm repair (p=0.65).
In their conclusion, the investigators say that despite many advances in EVAR technology, the need for open surgical conversion persists and will likely become more common as older-generation devices fail or providers attempt EVAR in more anatomically complex patients.
“Elective open surgical conversion for type Ia endoleak can be technically challenging but is not associated with increased morbidity or mortality compared with open juxtarenal aneurysm repair in appropriately selected patients. These results should be considered before pursuing complex endovascular remediation of EVAR failures,” they conclude.
Speaking to Vascular News, Scali said that this manuscript brings attention to the clinical decision making that surrounds management of type Ia endoleak after EVAR. He commented: “As the dwell time for older generation grafts increase and providers push the envelope of conventional EVAR, we may see a steady increase in the rate of EVAR conversion. Currently, there are many different off-label endovascular techniques that are used to manage type Ia endoleak and often, patients undergo multiple remedial salvage procedures that may or may not be successful. This increases resource utilisation, cost, extends time that the patient has an unrepaired aneurysm and may complicate subsequent open conversion. It is clear that open conversion is technically more complex than native juxtarenal aneurysm repair; however, this preliminary analysis would support more timely conversion in appropriately selected patients since comparable results can be achieved.”
Scali explained that his group is currently analysing the Vascular Quality Initiative (VQI) database using Medicare claims data to understand the long-term outcomes of open aneurysm repair and EVAR.
“These efforts will provide insight about the rates of aortic-related reintervention and mortality after EVAR, as well as provide greater statistical power to better understand the risk of conversion. What is most needed is to understand the modes of failure and selection bias that leads to open conversion with specific focus on graft-specific, aortic morphologic and patient level factors. Insight about these questions will hopefully come from iterative analyses of the VQI database and industry-sponsored registries,” he said.