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Contemporary Outcomes of Open Conversion after Failed Endovascular Aortic Aneurysm Repair from a High-Volume Aortic Treatment Center
Michael J. Fassler1, Salvatore T. Scali
1, Griffin P. Stinson
1, Christopher R. Jacobs
2, Martin R. Back
1, Scott A. Berceli
1, Michol A. Cooper
1, Benjamin N. Jacobs
1, Samir K. Shah
1, Zain Shahid
1, Gilbert R. Upchurch Jr.
1, Thomas S. Huber
1
1University of Florida - Division of Vascular Surgery and Endovascular Therapy, Gainesville, FL 2Mayo Clinic - Jacksonville - Division of Vascular Surgery and Endovascular Therapy, Jacksonville, FL
INTRODUCTION: Open conversion after failed endovascular aneurysm repair(EVAR) has been associated with higher morbidity and mortality than primary open repair. Prior series report 6%-10% elective mortality and 2-3-fold higher risk in non-elective cases. These concerns have increased enthusiasm for various endovascular salvage techniques; however, high-volume centers have reported excellent outcomes after native AAA repair, which may also impact their EVAR conversion(EVAR-c) results. While worse outcomes are expected in non-elective presentations, comparing these groups highlights distinct patient characteristics, technical demands, and outcomes which may inform management of failing EVAR. Therefore, we reviewed our single-center experience to characterize operative strategies, complications, and survival after EVAR-c.
METHODS: We performed a retrospective review of all consecutive EVAR-c at our high-volume aortic center(2000-2024). Patients were stratified as elective vs. non-elective presentation(rupture, infection, and/or aorto-enteric fistula). The primary outcome was 30-day mortality. Secondary outcomes included complications, 90-day mortality, discharge disposition, and survival.
RESULTS: 294 EVAR-c were performed: 193 elective(66%) and 101 non-elective(34%). Median age was 73-years; 84% were male. Comorbidities were comparable between groups(
Table). Non-elective indications included rupture(54%), mycotic aneurysm(32%), and aorto-enteric fistula(10%); Elective cases were predominantly for endoleak(85% for any type; either type 1a and/or 1b in 60%). Median AAA diameter at conversion was 7.3cm[IQR 6.1-8.5], and similar for either cohort. Elective conversion occurred later after index EVAR (60-months[IQR 31-104]) vs. non-elective, 34-months[IQR 6-73];p<.001). Non-elective procedures required more complex reconstructions, including greater incidence of supra-mesenteric cross-clamping(67% vs. 50%;p=.006), total graft explantation(59% vs. 21%;p<.001), and adjunctive intraoperative procedure use(49% vs. 30%, p=.002) in addition to higher blood loss(3.0L vs. 2.0L;p<.001), transfusion requirements(5[3,8] vs. 2[0,3];p<.001), and operative time(4.4[3.0,5.4] vs. 3.2[2.5,4.5] hours;p<.001).30-day mortality was 19% for non-elective vs. 5% for elective EVAR-c(p=.001); 90-day mortality was 25% vs. 10%(p=.001). Median LOS was 11-days[IQR 8-17](non-elective 14 vs. elective, 10;p<.001). Complications were more frequent after non-elective operations(79% vs. 55%;p<.001), including gastrointestinal morbidity(33% vs. 7%;p<.001) and new hemodialysis requirement(15% vs. 6%;p=.02). Correspondingly, discharge to a facility was more likely after non-elective cases(67% vs. 40%;p<.0001). Overall 5-year survival for non-elective and elective procedures was 66±5% and 80±3%, respectively, with curves converging after 90-days(
Figure; log-rank p-value=.007).
CONCLUSIONS: EVAR-c is resource-intensive, with high complication rates and prolonged hospitalization, particularly after non-elective procedures. Elective conversion, however, can be accomplished with low mortality, acceptable morbidity and are associated with excellent long-term survival at high-volume centers. Though outcomes differ by presentation, these comparisons highlight distinct phenotypes, technical challenges, and resource needs. These findings support early recognition of failing EVAR, timely elective referral, and concentration to specialized aortic centers to achieve optimal outcomes.
| Table. Patient Demographics & Comorbidities, Operative Details, and Outcomes after EVAR Conversion |
| Feature, No. (%) | | Overall (n=294) | | Non-elective (n=101) | | Elective (n=193) | | P-value |
| Age, years (median [IQR])* | | 73 [68, 79] | | 71 [65, 80] | | 74 [69, 79] | | .01 |
| Male sex | | 247 (84%) | | 85 (84%) | | 162 (84%) | | 1.0 |
| BMI, kg/m2 (median [IQR]) | | 27 [24, 31] | | 27 [23, 30] | | 27 [25, 31] | | .1 |
| Any cardiovascular risk factor | | 287 (98%) | | 97 (96%) | | 190 (98%) | | .3 |
| Coronary artery disease | | 121 (41%) | | 39 (39%) | | 82 (42%) | | .5 |
| Congestive heart failure | | 40 (14%) | | 17 (17%) | | 23 (12%) | | .3 |
| Chronic pulmonary disease | | 67 (23%) | | 23 (23%) | | 44 (23%) | | 1.0 |
| Renal insufficiency | | 87 (30%) | | 30 (30%) | | 57 (30%) | | 1.0 |
| Preoperative Statin | | 180 (61%) | | 45 (45%) | | 135 (70%) | | < .001 |
| Preoperative β-blocker | | 144 (49%) | | 40 (40%) | | 104 (54%) | | .03 |
| Operative Details | | | | | | | | |
| Retroperitoneal approach | | 226 (77%) | | 68 (67%) | | 158 (82%) | | .006 |
| Any supra-mesenteric clamp | | 165 (56%) | | 68 (67%) | | 97 (50%) | | .006 |
| Total graft explant | | 100 (34%) | | 60 (59%) | | 40 (21%) | | < .001 |
| Adjunctive intraoperative procedure* | | 107 (36%) | | 49 (49%) | | 58 (30%) | | .002 |
| In-situ reconstruction | | 288 (98%) | | 95 (94%) | | 193 (100%) | | .002 |
| Aorto-bi-iliac configuration | | 180 (61%) | | 54 (53%) | | 126 (65%) | | .06 |
| Aorto-bi-femoral configuration | | 6 (2%) | | 1 (1%) | | 5 (3%) | | .7 |
| Tube graft configuration | | 78 (27%) | | 21 (21%) | | 57 (30%) | | .1 |
| Extra-anatomic reconstruction | | 6 (2%) | | 6 (6%) | | 0 (0%) | | .002 |
| Dacron conduit | | 241 (82%) | | 58 (57%) | | 183 (95%) | | < .0001 |
| Rifampin-soaked Dacron | | 30 (10%) | | 21 (21%) | | 9 (4%) | | < .0001 |
| Autogenous vein/cadaveric | | 17 (6%) | | 16 (16%) | | 1 (1%) | | < .0001 |
| EBL, liters (median [IQR]) | | 2.1 [1.4, 4.0] | | 3.0 [1.6, 5.0] | | 2.0 [1.2, 3.0] | | < .001 |
| Intraoperative packed red cells, units | | 2 [1, 5] | | 5 [3, 8] | | 2 [0, 3] | | < .001 |
| Operative duration, hours (median [IQR]) | | 3.6 [2.7, 4.8] | | 4.4 [3.0, 5.4] | | 3.2 [2.5, 4.5] | | < .001 |
| Outcomes | | | | | | | | |
| Hospital LOS, days (median [IQR]) | | 11 [8, 17] | | 14 [10, 21] | | 10 [8, 15] | | < .001 |
| ICU LOS, days (median [IQR]) | | 6 [4, 10] | | 8 [5, 14] | | 5 [3, 8] | | < .001 |
| Any complication | | 186 (63%) | | 80 (79%) | | 106 (55%) | | < .001 |
| Neurologic complication | | 23 (8%) | | 13 (13%) | | 10 (5%) | | .04 |
| Cardiac complication | | 66 (22%) | | 21 (21%) | | 45 (23%) | | .7 |
| Pulmonary complication | | 66 (22%) | | 27 (27%) | | 39 (20%) | | .2 |
| GI complication | | 46 (16%) | | 33 (33%) | | 13 (7%) | | < .001 |
| New need for in-hospital HD | | 27 (9%) | | 15 (15%) | | 12 (6%) | | .02 |
| Infectious complication | | 46 (19%) | | 18 (22%) | | 28 (18%) | | .5 |
| Ischemic complication | | 12 (4%) | | 9 (9%) | | 3 (2%) | | .004 |
| Ancillary postop procedure | | 92 (31%) | | 53 (52%) | | 39 (20%) | | < .001 |
| 30-day mortality | | 28 (10%) | | 19 (19%) | | 9 (5%) | | <.001 |
| In-hospital mortality | | 30 (10%) | | 19 (19%) | | 11 (6%) | | .001 |
| 90-day mortality | | 44 (15%) | | 25 (25%) | | 19 (10%) | | .001 |
| *IQR, Interquartile range; Adjunctive intraoperative procedure included femoral vein harvest, adjunctive aorto-iliac/femoral-femoral bypass, distal lower extremity embolectomy, infrainguinal bypass, visceral/renal bypass, bowel repair/resection, and/or splenectomy |
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