title: Late open conversion after failed endovascular aortic aneurysm repair.
abstract: OBJECTIVE
  Endovascular aortic aneurysm repair (EVAR) is widely used for the treatment of abdominal aortic aneurysms. Complications secondary to EVAR are also treated with endovascular techniques. When this is not applicable, open surgical repair is mandatory. This study aims to present our experience in open surgical repair after failed EVAR.
  
  
  METHODS
  Within the period from 2004 through 2013, 18 patients (17 men; mean age, 73.9 years) were operated on because of EVAR failure due to persistent type II endoleak (n = 10), type I or III endoleak (n = 3), mixed-type endoleaks (n = 2), stent graft thrombosis (n = 2), and aortoenteric fistulae (n = 1). Stent grafts used for EVAR were Zenith (n = 8), Talent (n = 4), Excluder (n = 4), and Anaconda (n = 2).
  
  
  RESULTS
  Mean time interval between EVAR and open conversion was 36 months (range, 2-120 months). Fifteen (83.3%) operations were elective, and three (16.7%) were urgent due to aneurysm rupture (n = 2) and aortoenteric fistula (n = 1). Six (33.3%) patients with type II endoleak were treated with simple ligation of the culprit vessels, without aortic clamping and stent graft explantation. In six (33.3%) patients, the stent graft was partially removed except from the segment attached to the proximal neck, while in five (27.8%) patients, complete removal of the stent graft was necessary. Finally, in one patient, with type III endoleak, a hybrid endovascular and open repair was performed. Clamping of the aorta was necessary in 12 (66.7%) patients (infrarenal, n = 10 or suprarenal, n = 2). Overall operative mortality was 5.6%. Postoperative complications included one abdominal wall defect requiring surgical revision and paroxysmal atrial fibrillation both in the same patient, and one case of pulmonary infection, requiring prolonged intubation and intensive care unit stay for 6 days.
  
  
  CONCLUSIONS
  Late open conversion after failed EVAR remains challenging. Avoidance of aortic cross-clamping and if possible, partial or total preservation of the stent graft may improve outcomes in terms of operative mortality and morbidity. Elective operations seem to be associated with better outcomes, prompting thus for close follow-up of EVAR patients and early decision for conversion if other options are doubtful.
authors.affiliation: First Department of Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece; Second Department of Propedeutic Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece. Electronic address: chklonaris@gmail.com.
authors.forename: Chris
authors.initials: C
authors.lastname: Klonaris
authors.affiliation: Second Department of Propedeutic Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece.
authors.forename: Stella
authors.initials: S
authors.lastname: Lioudaki
authors.affiliation: Second Department of Propedeutic Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece.
authors.forename: Athanasios
authors.initials: A
authors.lastname: Katsargyris
authors.affiliation: Second Department of Propedeutic Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece.
authors.forename: Emmanouil
authors.initials: E
authors.lastname: Psathas
authors.affiliation: First Department of Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece.
authors.forename: George
authors.initials: G
authors.lastname: Kouvelos
authors.affiliation: Second Department of Propedeutic Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece.
authors.forename: Mikes
authors.initials: M
authors.lastname: Doulaptsis
authors.affiliation: Second Department of Propedeutic Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece.
authors.forename: Chris
authors.initials: C
authors.lastname: Verikokos
authors.affiliation: Second Department of Propedeutic Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece.
authors.forename: Gregory
authors.initials: G
authors.lastname: Kouraklis
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000209:etiology / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D003250:Constriction; D020878:Device Removal; D017558:Elective Surgical Procedures; D004630:Emergencies; D057867:Endoleak / Q000209:etiology / Q000601:surgery; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000601:surgery; D017052:Hospital Mortality; D006801:Humans; D007412:Intestinal Fistula / Q000209:etiology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D013927:Thrombosis / Q000209:etiology / Q000601:surgery; D013997:Time Factors; D017211:Treatment Failure