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Comparing Outcomes of Open Explant and Fenestrated Endovascular Repair for Infrarenal Endovascular Aortic Repair Failure
Sebouh Bazikian, Olamide Alabi, Stephen Hayes, Adriana Gutierrez Yllu, Nina Agafonovas, Luke Brewster, Manuel Garcia-Toca, Yazan Duwayri
Emory University, Atlanta, GA
BackgroundFailure after endovascular aneurysm repair (EVAR) mandates secondary intervention. Two broad strategies are used: open graft explantation with aortic reconstruction (“open explant”) and fenestrated endovascular repair (“endovascular salvage”). We compared outcomes using real-world data from a high-volume academic center, incorporating uniquely detailed imaging and anatomic data.
MethodsPatients treated between 2004 and 2024 for failed EVAR with either open explant or endovascular salvage were reviewed. Demographics, procedural characteristics, imaging variables, and outcomes were compared using appropriate statistical tests. Sensitivity analyses excluded interventions performed for infection. Cox regression evaluated associations between repair method and reintervention at 1 and 3 years.
ResultsAmong 139 patients with failed EVAR, 91 (65.5%) underwent open explant and 48 (34.5%) underwent endovascular salvage. Endovascular salvage patients were older (median age 77.9 vs 73.5 years, p=0.003) and more frequently had chronic kidney disease (CKD) (43.8% vs 18.7%, p=0.002); other baseline comorbidities were similar. Open explant was more commonly emergent (26.4% vs 6.3%, p=0.004). Indications for rupture (8.8% vs 2.1%, p=0.20) and infection (14.3% vs 0%, p=0.02) were more common. Endovascular salvage more often addressed type Ia endoleaks (66.7% vs 40.7%, p=0.004), whereas open explant was more frequently performed for type II (15.4% vs 2.1%, p=0.016) and type V endoleaks (7.7% vs 0%, p=0.049). Proximal aortic involvement was predominantly zones 8–9 overall. Zone distributions differed (p=0.026), with more zone 5 involvement in endovascular salvage cases (15.9% vs 3.95%). Median number of aortic zones treated were similar (2 vs 2; p=0.99). Neck angulation (27.5° vs 26.0°, p=0.63), maximal aortic diameter (71.0 mm vs 71.5 mm, p=0.83), and renal-to-EVAR bifurcation length (57.8 mm vs 62.2 mm, p=0.30) were comparable.
Perioperative outcomes favored endovascular salvage: shorter hospital stay (median 4 (3–7.5) vs 12 (8–21) days, p<0.001) and ICU stay (median 2 vs 5 days, p<0.001), with fewer overall complications (12.5% vs 45.1%, p<0.001), including cardiac (8.3% vs 25.3%, p=0.016), pulmonary (2.1% vs 18.7%, p=0.006), renal (2.1% vs 16.5%, p=0.011), and infectious events (2.1% vs 16.5%, p=0.011). Compared with endovascular salvage, open explant had similar freedom from reintervention at 1 year (HR 0.38; 95% CI 0.13–1.15, p=0.086) and at 3 years (HR 0.38; 95% CI 0.53–2.77, p=0.34). It was also similar when infection as the repair indication was excluded (HR 0.74; 95% CI 0.09–6.01).
Thirty-day mortality was higher after open explant (11.0% vs 0%, p=0.017) at 30 days, whereas overall mortality at 1 year was similar between groups (15.38% vs 14.58%, p=0.900). Overall mortality was similar between groups when procedures for infection were excluded (p=0.49).
ConclusionEndovascular salvage was associated with more favorable outcomes, considering that anatomic features were broadly comparable and endovascular salvage patients were older with higher rates of CKD. However, reintervention by 1 year and overall 1-year mortality were similar. These real-world data suggest fenestrated endovascular repair is a safer short-term strategy for EVAR failure within a high-volume center. Long-term durability appears comparable; thus, patient-specific factors and indication should guide therapy.
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