Acute and chronic open conversion after endovascular aortic aneurysm repair: A 14-year review

Objective This study reviewed outcomes of patients requiring surgical conversion after endovascular abdominal aortic aneurysm (AAA) repair. Methods Records for all patients undergoing open conversion after endovascular AAA repair were reviewed. Results From 1993 to 2006, 574 patients underwent endovascular repair for AAA. Seventeen patients, including three patients who underwent prior endovascular repair at other centers, required surgical conversion with complete (n = 9) or partial graft removal (n = 8). Five patients required immediate conversion (acute), and 12 underwent delayed conversion 4 to 72 months after endovascular repair. Indications for acute conversion were large type I endoleak (n = 3, 60%), including one patient with graft migration, and retroperitoneal bleeding (n = 2, 40%). Indications for chronic conversion were endoleak with increasing aneurysm size (n = 9, 75%), stent fracture without endoleak (n = 1, 8%), delayed retroperitoneal bleeding (n = 1, 8%), and infection (n = 1, 8%). Suprarenal aortic cross-clamping was required in two patients (12%), and endograft components were retained in eight (47%). An aortic occlusion balloon placed through the body of the existing endograft facilitated proximal control in three patients. There were two perioperative deaths in the acute conversion group (2/5; 40%) and none in the delayed conversion group ( P = .04). Five-year actuarial survival was 71.9%. Mean follow-up was 41.6 ± 32.2 months. Retained endovascular components in patients with partial graft removal remained stable during follow-up. Conclusions Surgical conversion after endovascular AAA repair can be performed without suprarenal clamping in most patients. Endovascular aortic control with a balloon avoids suprarenal exposure. Partial endograft removal in selected patients facilitates open conversion and appears durable. Acute conversion is associated with increased mortality.