Objective

Three of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported.

Methods

This retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival.

Results

Sixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively.

Conclusions

Technically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.

中文翻译：

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血管内动脉瘤修复后选择性晚期开放转换与腹主动脉瘤的初次开放修复具有可比的结果。

客观的

四名肾下腹主动脉瘤患者中有三名现在接受血管内动脉瘤修复 (EVAR) 治疗。对于理论上不适合开放手术的人群，二次手术和手术转换的发生率正在增加。报告了在大容量三级血管单元中 EVAR 后晚期开放手术转换的适应症和结果。

方法

这项回顾性单中心研究包括 1996 年 1 月至 2018 年 7 月期间接受晚期开放转换的所有患者。数据收集自患者人口统计学、手术适应症、手术策略、围手术期结果和中期生存率的记录。

结果

包括平均年龄为 77.5 岁的连续 62 名患者（88.7% 为男性）。自指数 EVAR 以来的中位持续时间为 38.5 个月；65% 需要晚期开放转换的覆膜支架采用肾上固定。适应症包括 22.6% 的 IA 型、16.1% 的 IB 型和 45.2% 的 II 型内漏；12.9% 移植物血栓形成；和 14.5% 的假体感染。37.1% 的患者进行了完整的内移植物移植，54.8% 的患者进行了部分移植，而 8.1% 的支架移植物完全原位保存。队列中的总体 30 天死亡率为 12.9%（n = 8），选择性患者为 2.7%。全因发病率为 40.1%，住院时间中位数为 9 天。随访 28.4 个月（范围，1.8-187.3 个月）后，全因生存率为 58.8%。避免主动脉钳夹 ( P = .006) 和选择性手术 ( P  = .019) 与住院时间的显着减少相关。此外， 紧急情况下30 天死亡率 ( P  = .002)、术后肾功能障碍 ( P  = .004) 和肠缺血 ( P = .017) 的发生率增加。排除破裂或感染病例，1 年、2 年和 5 年的生存率估计分别为 97%、97% 和 71%。

结论

在技​​术上比初次开放手术更复杂，晚期开放转换是一种在大容量主动脉手术中心进行时会产生可接受的围手术期风险的手术。选择性开放转换与良好的早期和晚期结果相关。内移植物保存策略降低了围手术期的发病率。