title: Late open conversion and explantation of abdominal aortic stent grafts.
abstract: OBJECTIVE
  To evaluate indications for, operative strategy during, and outcomes following late open surgical conversion following endovascular aneurysm repair (EVAR).
  
  
  METHODS
  Between 2002 and 2009, patients undergoing open abdominal aortic aneurysm repair at a university hospital were entered prospectively into a database which was examined to identify patients undergoing open conversion >30 days after EVAR.
  
  
  RESULTS
  Over 7 years, 21 patients required late open conversion of EVAR. The average patient age was 75 years (range, 59-88), and there were 16 male (76%) patients. The mean interval to conversion was 33.4 months (range, 2-73). Eight patients (38%) presented with proximal type I endoleak; 4 patients (19%) presented with type II endoleak and aneurysm expansion; 5 patients (24%) presented with graft migration and aneurysm expansion; and 5 patients (24%) presented with de novo visceral aneurysms. Rupture (1) and infection (1) were also observed. There were five (24%) emergent cases. Most patients (12/21, 57%) had more than one reason for conversion. There were no perioperative deaths; three patients (14%) had major complications. Grafts requiring conversion were AneuRx (6; Medtronic AVE, Santa Rosa, Calif), Zenith (6; Cook Inc, Bloomington, Ind), Talent (3; Medtronic), Excluder (2; W. L. Gore, Flagstaff, Ariz), Anaconda (1; TERUMO Corp, Ann Arbor, Mich), Ancure (1; Guidant, Menlo Park, Calif), Quantum LP (1; Cordis Corp, Miami Lakes, Fla), and Powerlink (1; Endologix, Irvine, Calif). The surgical approach was retroperitoneal in 16 (76%) and transperitoneal in four (19%) patients. Initial proximal aortic control was supraceliac (9/21), suprarenal (7/21), or infrarenal (5/21), with stepwise distal clamping to reduce ischemic time. Complete endograft removal was performed in 17/21 patients; in 4/21 the distal anastomosis was performed to the endograft after proximal segment explantation. Reconstruction was completed with tube (19/21) or aortoiliac (2/21) grafts; in one case, homograft was used. Mean intraoperative blood loss was 1.9 L (range, 0.4-6.5 L), mean intensive care unit (ICU) stay was 3 days (range, 2-6), and the mean hospital stay was 10 days (range, 4-39).
  
  
  CONCLUSIONS
  While technically challenging, delayed open conversion of EVAR can be accomplished with low morbidity and mortality in both the elective and emergent settings. These results reinforce the justification for long-term surveillance of endografts following EVAR.
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA. clayton.brinster@uphs.upenn.edu
authors.forename: Clayton J
authors.initials: CJ
authors.lastname: Brinster
authors.forename: Ronald M
authors.initials: RM
authors.lastname: Fairman
authors.forename: Edward Y
authors.initials: EY
authors.lastname: Woo
authors.forename: Grace J
authors.initials: GJ
authors.lastname: Wang
authors.forename: Jerffrey P
authors.initials: JP
authors.lastname: Carpenter
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Jackson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001019:Aortic Rupture / Q000209:etiology / Q000601:surgery; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D020878:Device Removal; D057867:Endoleak / Q000209:etiology / Q000601:surgery; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation*; D005260:Female; D005548:Foreign-Body Migration / Q000209:etiology / Q000601:surgery; D006785:Hospitals, University; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015143:Philadelphia; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery*; D011474:Prosthesis Design; D016459:Prosthesis-Related Infections / Q000209:etiology / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents; D013997:Time Factors; D017211:Treatment Failure