Open descending thoracic or thoracoabdominal aortic approaches for complications of endovascular aortic procedures: 19-year experience

Endovascular aortic repair is increasingly being used to treat aneurysms, dissections, and traumatic injuries, despite its unknown long-term durability. We describe our 19-year experience with open descending thoracic and thoracoabdominal aortic repair after endovascular aortic repair. Between 1996 and 2015, 67 patients were treated with open distal arch, descending thoracic, or thoracoabdominal aortic repair, or extra-anatomic bypass repair with aortic extirpation for complications after endovascular repair of the thoracic (n = 45, 67%) or abdominal (n = 22, 33%) aorta. The median interval between procedures was 18.0 months (interquartile range, 3.9-44.9). Indications for open repair included expanding aneurysm (n = 56), infection (n = 11), fistula (n = 8), aneurysm rupture (n = 5), pseudoaneurysm (n = 2), and restenosis (n = 1). Open repair involved partial (n = 9, 13%) or complete (n = 56, 84%) device removal or device salvage (n = 2, 3%) through a thoracoabdominal (n = 58, 87%) or thoracotomy (n = 9, 13%) incision. Eight patients (12%) underwent emergency procedures. There were 3 early (operative) deaths (2 with preoperative device infection) and 19 late deaths during a median follow-up of 35.8 months (interquartile range, 16.8-52.8 months). Overall 1- and 5-year survivals were 85% ± 4% and 60% ± 8%, respectively. Four patients had open repair failures necessitating reoperation; 2 patients had preoperative infection, and both died (1 early and 1 late). Open repair for complications after endovascular procedures is not uncommon. Experienced centers can yield acceptable outcomes, especially in patients without infection. Close surveillance is mandatory after endovascular aortic repair.