title: Treatment options for delayed AAA rupture following endovascular repair.
abstract: OBJECTIVE
  Delayed abdominal aortic aneurysm (AAA) rupture is a well recognized complication of endovascular aneurysm repair (EVAR). We wanted to evaluate the frequency, etiology, and outcomes of delayed AAA rupture following EVAR, and identify treatment options that facilitate improved survival.
  
  
  METHODS
  From 2002 to 2009, 1768 patients underwent elective and emergent EVAR. At a mean follow-up of 29 months, 27 (1.5%) patients presented with delayed AAA rupture and required repair by either open surgical conversion or endovascular means. All data were prospectively collected in a vascular registry, and outcomes analyzed.
  
  
  RESULTS
  Over a mean follow-up of 29 months, the incidence of delayed AAA rupture after elective EVAR was 1.4% (24 of 1615 patients), and after emergent EVAR for ruptured AAA was 2.8% (3 of 106 patients). Of the 27 delayed AAA rupture patients, 20 (74%) were considered "lost to follow-up," and, at presentation, 17 (63%) patients had Type 1 endoleak with stent graft migration, three (11%) had Type 1 endoleak without stent graft migration, five (19%) had Type 2 endoleak, and two (7%) had undetermined etiology for aneurysm rupture. Fifteen (55%) patients underwent open surgical repair via retroperitoneal approach with partial (n = 8; 53%) or complete (n = 7; 47%) stent graft explants and aortoiliac reconstruction, 11 (41%) patients underwent a second EVAR, and one (4%) patient refused treatment and died. Supraceliac aortic clamp was required in three (20%) patients with open surgical conversion, and supraceliac occlusion balloon was required in two (18%) patients with EVAR. There were three (11%) postoperative deaths; two following open surgical conversion and one following EVAR. One additional redo-EVAR patient has undergone successful elective conversion to open surgical repair for persistent type II endoleak and increase in AAA size.
  
  
  CONCLUSIONS
  Delayed AAA rupture following EVAR can be successfully managed in most patients by open surgical conversion or secondary EVAR. The approach to each patient should be individualized; complete stent graft explant is not necessary in most patients; a secondary EVAR for delayed AAA rupture with or without an elective conversion to open surgical repair remains a viable option. Vigilant routine follow-up is needed for all patients after EVAR.
authors.affiliation: Institute for Vascular Health and Disease, Albany Medical College, The Vascular Group, Albany, NY 12208, USA. mehtam@albanyvascular.com
authors.forename: Manish
authors.initials: M
authors.lastname: Mehta
authors.forename: Philip S K
authors.initials: PS
authors.lastname: Paty
authors.forename: Sean P
authors.initials: SP
authors.lastname: Roddy
authors.forename: John B
authors.initials: JB
authors.lastname: Taggert
authors.forename: Yaron
authors.initials: Y
authors.lastname: Sternbach
authors.forename: Paul B
authors.initials: PB
authors.lastname: Kreienberg
authors.forename: Benjamin B
authors.initials: BB
authors.lastname: Chang
authors.forename: R Clement
authors.initials: RC
authors.lastname: Darling
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D001019:Aortic Rupture / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery* / Q000628:therapy; D021721:Balloon Occlusion; D019917:Blood Vessel Prosthesis Implantation; D005260:Female; D006439:Hemodynamics; D006801:Humans; D008297:Male; D012086:Reoperation; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome