title: Secondary conversion of the Gore Excluder to operative abdominal aortic aneurysm repair.
abstract: OBJECTIVE
  Reports continue to document the occurrence of major adverse events after endovascular aortic aneurysm repair. Although many of these problems can be successfully managed through endovascular salvage, operative conversion with explantation of the endoprosthesis remains necessary in some patients. We report herein a review of all patients initially enrolled in multicenter US clinical trials of the Excluder endograft who underwent secondary conversion to open surgical repair.
  
  
  METHODS
  Clinical data and relevant medical records of patients enrolled in phase I and II multicenter US clinical trials of the Excluder endograft were retrospectively reviewed for adverse events and further narrowed to those patients who underwent secondary operative conversion. Hospital records, operative and anesthesia reports, and all imaging studies were analyzed at initial implantation and at the time of subsequent open surgical repair.
  
  
  RESULTS
  Late open conversion was performed in 16 (2.7%) of the 594 patients enrolled in the Excluder clinical trials. Presumed endotension accounted for 8 of 16 of secondary conversions. In two of these patients, however, an endoleak was identified at the time of open surgical repair. Of the remaining eight patients, two underwent conversion for device infection, five for persistent endoleak, and one for aneurysm rupture. The overall 30-day mortality was 6.25% (1/16), with one death occurring in a patient with a ruptured aneurysm. Of patients who underwent conversion because of endotension, the maximal abdominal aortic aneurysm diameter (mean +/- SD) at the time of initial implantation and subsequent graft removal was 61 +/- 11 mm and 70 +/- 10 mm, respectively. The mean time to open conversion for treatment of endotension was 37 +/- 12 months (range, 20-50 months; median, 42 months). Freedom from conversion was 98.6% and 96.7% at 24 and 48 months, respectively.
  
  
  CONCLUSIONS
  Endotension in the absence of a demonstrable endoleak has been a major indication for late surgical conversion in patients treated with the Excluder endograft. Given the potential presence of an undetected endoleak and the possible effects of progressive sac enlargement on long-term device stability, continued close surveillance of patients with assumed endotension is required. Should changes in device design eliminate endotension, a further reduction in the already low incidence of late open conversion of the Excluder endograft can be anticipated.
authors.affiliation: Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Li Sheng
authors.initials: LS
authors.lastname: Kong
authors.forename: Douglas
authors.initials: D
authors.lastname: MacMillan
authors.forename: Karthik
authors.initials: K
authors.lastname: Kasirajan
authors.forename: Ross
authors.initials: R
authors.lastname: Milner
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Dodson
authors.forename: Atef A
authors.initials: AA
authors.lastname: Salam
authors.forename: Robert B
authors.initials: RB
authors.lastname: Smith
authors.forename: Elliot L
authors.initials: EL
authors.lastname: Chaikof
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality* / Q000628:therapy*; D001027:Aortography; D021721:Balloon Occlusion / Q000295:instrumentation* / Q000379:methods; D001807:Blood Vessel Prosthesis / Q000009:adverse effects*; D017321:Clinical Trials, Phase I as Topic; D017322:Clinical Trials, Phase II as Topic; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012086:Reoperation; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods*