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Interactive CardioVascular and Thoracic Surgery Advance Access published June 24, 2014

Late open conversion after endovascular aneurysm repair


Spiridon Botsiosa,b,*, Yvonne Bausbacka, Michael Piorkowskia, Martin Wernera, Daniela Branzana,
Dierk Scheinerta and Andrej Schmidta
a
b

Center of Vascular Medicine, Angiology and Vascular Surgery, Park Hospital Leipzig, Leipzig, Germany
Faculty of Health, Witten/Herdecke University, Witten, Germany

* Corresponding author. Department of Vascular Surgery, Hospital Waldbrl, Dr.-Goldenbogen-Str. 10, 51545 Waldbrl, Germany. Tel: +49-2291/82-1401;
fax: +49-2291/82-1499; e-mail: botsios@arcor.de (S. Botsios).
Received 21 January 2014; received in revised form 11 May 2014; accepted 21 May 2014

Abstract
OBJECTIVES: Endovascular treatment of the infrarenal abdominal aorta (endovascular repair, EVAR) has emerged as an alternative to open
surgery. However, a small subset of patients exists who undergo conversion either in the rst 30 postoperative days or later during the
course of postoperative surveillance. In the present study, we review our experience with late conversion operations.
METHODS: Between December 2004 and August 2012, 411 EVARs were performed. During the same time interval, nine patients (males)
with a mean age of 71 years (range, 5979 years) required late open conversion. The median interval between EVAR and the conversion
operation was 34 months (range 1460 months).
RESULTS: The indications for late conversion included persistent proximal type I endoleak (n = 2), type II endoleak with sac enlargement
(n = 1), aneurysm rupture (n = 1), endotension (n = 2), stent-graft thrombosis (n = 1) and stent-graft infection (n = 2). Complete stent-graft
explantation was performed in ve patients. Eight patients underwent elective conversion. One patient presenting with rupture had an
emergency operation. The 30-day mortality rate was 0%.
CONCLUSIONS: Late open conversion after EVAR can be performed safely and successfully. Complete stent-graft explantation may be our
preferred treatment option, but it is not always necessary, except in cases presenting with graft infection.
Keywords: Aneurysm Endovascular treatment Abdominal aorta Complications Open conversion

INTRODUCTION
Endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs) has emerged as an alternative to open surgery.
Technological advances have resulted in EVAR becoming the rstchoice therapy in patients with favourable aortoiliac morphology.
Early advantages of EVAR over open surgery include shorter procedure duration, less pain, reduced blood loss, shorter hospitalization, more rapid recovery and signicantly lower 30-day mortality
and morbidity rate [1]. By contrast, the main drawbacks of EVAR are
regular and persistent follow-up and the substantial need for reinterventions to treat endoleaks, migration, graft disconnection, stent
fractures, graft thrombosis and infection, which increase with
follow-up duration [2].
Most secondary interventions after EVAR are successfully
addressed with percutaneous interventional techniques; however,
a small subset of patients (0.74.0%) will require an open conversion with explantation of the stent graft during the course of postoperative surveillance [37].
In the present study, we review our single-centre experience
with late conversion operations after EVAR with emphasis on the
incidence, surgical management and clinical course.

Presented at the 62th International Congress of the European Society for


Cardiovascular Surgery, Regensburg, Germany, 1113 April 2013.

PATIENTS AND METHODS


Patients
During the 8-year period from December 2004 to August 2012,
411 EVARs were performed. Of these 411 patients, eight (1.9%)
underwent late open conversion. During the same time interval,
one additional patient who underwent EVAR at another institution
was referred to our hospital with aneurysm rupture. In this study, all
patients were prospectively registered and retrospectively reviewed.
Late conversion has been dened as an AAA open repair performed at least 30 days after EVAR. The mean age of the patients
who underwent late open conversion was 71 6 years (range, 59
79 years), and all were men. The preoperative characteristics of
patients are listed in Table 1.
In our clinical practice, open conversion was considered a
nal resort when secondary endovascular procedures had failed
or were inappropriate. Indications for late conversions included
persistent proximal type I endoleak (n = 2), type II endoleak
(n = 2) with one of them presenting with rupture, endotension
(n = 2), stent-graft infection (n = 2) and complete stent-graft
thrombosis (n = 1). Eight patients underwent elective open
conversion. Aneurysm sac enlargement occurred in all patients
with endoleaks or observed endotension (Fig. 1). The median

The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

ORIGINAL ARTICLE

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Interactive CardioVascular and Thoracic Surgery (2014) 15


doi:10.1093/icvts/ivu203

S. Botsios et al. / Interactive CardioVascular and Thoracic Surgery

Table 1: Baseline demographic and clinical characteristics


Preoperative data

Value

Total patients
Age, mean SD (range) (years)
Gender (male: female)
Interval between EVAR and late conversion,
mean SD (range) (months)
Indications for late conversion
Urgent
Elective
ASA class
III
IV
Medical comorbidities
Coronary artery disease
Congestive heart failure
Renal insufficiency (creatinine >1.5 mg/dl)
Hypertension
Diabetes mellitus
Hyperlipidaemia

9
71 6 (5979)
9: 0
34.3 15.9 (1460)

1
8
3
6
1
1
6
8
2
2

ASA: American Society of Anesthesiologists; EVAR: endovascular repair;


SD: standard deviation.

Figure 1: Open conversion for endotension. (A) The aneurysm was opened
without aortic cross-clamping. No blood can be detected. (B) Partial stent-graft
explantation. Both iliac limbs were transected at the level of the common iliac
artery orice.

interval of time between initial EVAR and late conversion was


34 16 months (range, 1460 months). Explanted stent grafts
included Talent (Medtronic) in three patients, Anaconda
(Terumo Corp.), Excluder (W. L. Gore) in two patients each,

and Endurant (Medtronic), Ovation (Trivascular) in one


patient each.
All conversion procedures were performed under general anaesthesia by an experienced vascular surgeon, and all patients
during the time of conversion were haemodynamically stable.
Patient details for late open conversion are in chronological order
and are summarized in Table 2.

Surgical procedure
The surgical approach included a midline transperitoneal exposure in all cases. Proximal aortic control was obtained by crossclamping the supracoeliac aorta in one case or the suprarenal
aorta in 5 cases with step-wise distal clamping when the proximal
anastomosis was completed to reduce visceral and renal ischaemic time. In two patients, cross-clamping of the infrarenal aorta
was possible. In one patient, aortic control was achieved by inating an intraluminal aortic occlusion balloon. The balloon was
inserted in the suprarenal aorta via the trans-brachial approach
before opening the aneurysm.
Distal back-ow control could be achieved by exposure and
clamping of the iliac arteries below the stent graft before opening
the aneurysm sac in two cases in which complete stent-graft explantation for stent-graft infection was indicated. In the remaining
seven patients, distal arterial control was achieved using clamps
on the iliac graft limbs within the aneurysm sac.
The aneurysm sac was opened by a longitudinal aortotomy, the
mural thrombus was evacuated and back-bleeding lumbar arteries
were oversewn.
The main body of the stent graft was attempted to be removed
by traction alone, using the clamp-and-pull method. In only one
patient, the proximal part of the main body was left in situ during
the late conversion because it was impossible to remove it
without aortic wall damage. In the same manner, it was attempted
to remove all iliac graft limbs completely by traction and manual
compression of the iliac artery. In four patients in whom iliac xation was not amenable to manual explantation, both iliac graft
limbs were transected at the level of the common iliac artery
orice, and distal arterial control was achieved using Fogarty balloons on the iliac grafts.
Five of the nine patients (55%) underwent complete stent-graft
explantation, including two patients with infected prostheses, and
a partial stent-graft explantation was performed in four patients.
Wire cutters were used to divide the metallic stent components,
the main body and the two iliac limbs of the stent graft.
After complete stent-graft explantation, aortic reconstruction
was completed with interposition of a Dacron tube graft in two
cases and a Dacron bifurcated graft in three cases.
The tube graft was used in two patients who presented with
stent-graft infection. Aortic reconstruction after partial stent-graft
explantation with interposition of a Dacron bifurcated aortoiliac
graft was performed. In all cases, both iliac limbs were left in situ
because removal of the well-incorporated stent graft was impossible. The distal ends of the new bifurcated graft were sewn to the
residual stent grafts as well as to the common iliac artery at the
orice level with Teon felt strips. Additionally, in one patient, the
suprarenal part of the stent graft was left in place because stent-graft
removal was impossible, and the proximal end of the bifurcated
aortoiliac graft was sewn to the residual stent graft as well as to the
infrarenal aortic wall with Teon felt strips.

S. Botsios et al. / Interactive CardioVascular and Thoracic Surgery

Patient

Age (years)

Indication for conversion

Time from
EVAR (months)

Type of stent graft

Explantation of
stent graft

Complications

1
2
3
4
5
6
7
8

78
79
72
71
69
59
75
72

Endoleak type II
Endotension
Endotension
Rupture/endoleak type II
Stent-graft infection
Stent-graft thrombosis
Endoleak type IA
Endoleak type IA

36
41
53
37
32
22
14
60

Excluder
Talent
Talent
Excluder
Anaconda
Anaconda
Endurant I
Talent

Partial
Partial
Partial
Partial
Complete
Complete
Complete
Complete

64

Stent-graft infection

14

Ovation

Complete

None
None
None
Abdominal wound dehiscence
Pleural effusion
None
None
Reoperation for bleeding
Respiratory failure
Acute renal failure
None

EVAR: endovascular repair.

The mean duration of the procedure was 250 70 min (range,


156355 min).

RESULTS
All open conversions were completed uneventfully. There was no
mortality at 30 days. Three patients (33%) had perioperative complications. One patient required reoperation for abdominal wound
dehiscence 5 days after operation. Another patient developed
pleural effusion and underwent bilateral thoracocentesis, with subsequent resolution. A third patient developed bleeding requiring
surgical exploration on postoperative day 1. Additionally, this
patient developed acute renal failure requiring temporary renal dialysis, and respiratory failure requiring a prolonged intensive care
unit stay of 26 days.
The mean stay in the intensive care unit was 9 9 days (range
126 days). The mean duration of hospital stay was 22 12 days
(range 1452 days). Seven patients were discharged home, and
two were discharged to a rehabilitation clinic.
After discharge, none of the nine patients were lost to followup. The mean follow-up after conversion was 29 16 months
(range 461 months) and was conducted by direct patient or referring physician telephone contact (ending January 2013). All
patients were in excellent clinical condition, remained without
complications associated with open conversion and enjoyed a
good quality of life.

DISCUSSION
We report here the low incidence and favourable results of late
open conversion after EVAR failure.
EVAR has revolutionized aortic surgery. Currently, 20 years after
the rst successful endovascular treatment of AAA, the method is
performed with an increasing frequency as the rst-choice therapy
in patients with favourable aortoiliac morphology. However, the
risk of aneurysm growth and rupture after EVAR cannot be completely avoided.
Additionally, despite advances in stent-graft technology and
improved surgical techniques, late conversion to open surgery after
EVAR failure has been reported widely. In 2002, the European

centres for vascular surgery that maintain the EUROSTAR (European


Collaborators on Stent-Graft Techniques for Abdominal Aortic
Aneurysm Repair) registry reported 4291 patients with EVAR
between 1996 and 2002 and an annual rate for late conversion to
open repair of 2% [8]. A more recent review of 15 series published
between 2002 and 2009 showed that late open conversion occurred in 0.422% of patients following EVAR, with an overall rate of
1.9% [9].
In our series of 411 patients treated with stent grafts, late conversion (at least 30 days after EVAR) occurred in eight cases. The
late conversion rate of 1.9% is similar to the results of both of the
other series with long-term follow-up.
Late open conversions are indicated for many reasons, including aneurysm enlargement, with or without a documented endoleak, stent-graft migration or disconnection, thrombosis or
infection of the stent graft and aneurysm rupture [3, 5, 9, 10].
The decision for late conversion has to be made after considering the comorbidities, indication for conversion and management
of the surgical procedure.
The most important question to be answered is whether the
clinical condition of the patient is suitable for this maximally invasive surgery.
The management of late conversion after EVAR may be more
demanding than a standard elective operation, particularly when
performed in cases with associated periaortic inammatory reaction or stent-graft incorporation into the vessel wall [5].
Various surgical strategies for the management of late EVAR
conversion have been reported. Based on our experience, three
important points are worthy of review and should be mentioned.
The rst important point concerns surgical exposure of the
aneurysm. Surgical exposure of the aneurysm can be achieved
either through a transperitoneal or retroperitoneal approach.
Previous series have preferred a transperitoneal approach to
enable excellent exposure of the distal iliac arteries [11, 12],
whereas others have preferred a retroperitoneal approach to
achieve continuous control of the aorta [13, 14]. Kelso et al. suggested that both approaches for aneurysm exposure are equally
effective in cases of late conversion, and their use depends on
surgeon preference [5]. We used only the transperitoneal approach without difculty because we have more experience of
open repair involving infrarenal AAAs and are familiar with this
technique.

ORIGINAL ARTICLE

Table 2: Details of patients undergoing late open conversion after endovascular aneurysm repair

S. Botsios et al. / Interactive CardioVascular and Thoracic Surgery

The second important point concerns the site of clamping to


achieve control of the aorta above the proximal xation zone. In
our opinion, as with those of others, temporary aortic clamping
above the stent graft is the procedure of choice. Proximal aortic
clamping far from the stent graft may enable better mobilization
of the xed proximal end of the stent graft during explantation
and allows more exibility for optimal reconstruction [10]. By contrast, direct clamping of the proximal aorta across the stent graft is
not recommended and can be dangerous because of insufcient
aortic control, possibly leading to irreparable damage to the juxtarenal aorta [3].
An alternative to aortic clamping proximal control is balloon occlusion in the supracoeliac aorta through the anterior wall of the
stent graft or a brachial or femoral approach [15, 16]. In our cases of
supravisceral or suprarenal aortic clamping immediately after stentgraft removal or after the completion of the proximal anastomosis,
the clamp must be switched to the infrarenal position to limit the
duration of renal and visceral ischaemia. In our series, only one
patient had temporary renal insufciency postoperatively.
Stent-graft removal is the third important point. The strategic
decision regarding complete or incomplete stent-graft explantation depends on the indication for conversion operation and the
individual intraoperative situation. Traditionally, late open conversion involves surgical exposure of the aneurysm, complete stentgraft removal and aortic replacement with a standard surgical
prosthetic tube or bifurcated graft. We believe that complete explantation of the stent graft is the safest surgical intervention for the
patient and prevents possible late complications during follow-up.
The risk of damaging the aorta or iliac arteries after complete stentgraft removal is minimal [10]. Although we prefer to remove the
entire stent graft, if possible, we also agree with Forbes et al. regarding complete stent-graft removal only when late conversion is indicated for stent-graft infection [3]. In the absence of stent-graft
infection, Jimenez et al. preferred partial preservation of wellincorporated stent-graft components because, after difcult complete removal, the arterial wall can become thin and denuded,
making anastomosis more complicated and increasing the chances
of anastomotic bleeding [15].
The potential advantages of partial explantation of the stent graft
are, in our opinion and those of others, the lower risk of intraoperative injury to the aorta and iliac arteries and the shorter duration of
aortic clamping time and operation time [6, 12, 17]. Some authors
report a preference for a partial or complete preservation of the
stent graft at the time of late conversion and also a relatively low
postoperative mortality rate [6, 15, 18]. In our series, after complete
explantation of the stent graft, the aorta was reconstructed with an
in situ prosthetic tube or bifurcated grafts.
Indeed, complete explantation of stent grafts, especially those
with suprarenal xation, can create problems during surgery due
to dense incorporation into the aortic wall. For one patient in our
series who had an endotension, removal of the suprarenal part of
the stent graft was impossible and a proximal anastomosis of the
bifurcated aortoiliac graft was performed with inclusion of both
the residual stent graft and the infrarenal aortic wall.
All patients after incomplete explantation of the stent graft
underwent reconstruction with in situ prosthetic bifurcated grafts.
In those cases, the prosthetic bifurcated grafts were anastomosed
to the stent graft to incorporate the native artery/aorta proximally,
and the orices of the common iliac arteries were attached to the
suture line using additional Teon felt strips.
The mortality rate of late conversion is difcult to estimate, and
is strongly dependent on several risk factors [19]. In a more recent

series of late conversion cases, the mortality rates varied from 0 to


19% [47]. Late conversion in the emergent setting in most series
appears to increase perioperative mortality compared with those
performed in the elective setting. Chaar et al. showed that, in
patients who underwent elective open conversion, the mortality
rate of 5% was comparable with the perioperative mortality after
primary elective open AAA repair [7]. This nding emphasizes the
value of lifelong follow-up not only for early detection of failed
EVAR, but also for an early decision regarding elective conversion.
In the present study, an early indication for open conversion
when secondary endovascular interventions have failed or were
inappropriate likely contributed to the absence of perioperative
mortality. In our experience and those of others, elective late conversion in experienced hands is a therapeutic option, particularly
in patients suitable for open surgery, and can be performed with
acceptable results; additionally, an early decision is recommended
for conversion under elective settings [5].
Our study had several limitations. It was a single-centre experience that evaluated only patients who required open conversion
after EVAR failure at our institution. Additionally, the rather small
number of patients with late conversion prevented us from
drawing statistically signicant conclusions from our results.
In conclusion, late open conversion after EVAR can be performed safely and successfully. The key factors inuencing the
success of the operation are preoperative planning tailored to the
individual clinical condition, an early indication for conversion,
the experience of the operator and surgical technique regarding
the approach, the clamping site and a complete or incomplete
stent-graft removal. Complete stent-graft removal may be our preferred treatment option, but it is not always necessary except in
cases presenting with graft infection.
Conict of interest: none declared.

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