title: Late graft explants in endovascular aneurysm repair.
abstract: OBJECTIVE
  With more than a decade of use of endovascular aneurysm repair (EVAR), we expect to see a rise in the number of failing endografts. We review a single-center experience with EVAR explants to identify patterns of presentation and understand operative outcomes that may alter clinical management.
  
  
  METHODS
  A retrospective analysis of EVARs requiring late explants, >1 month after implant, was performed. Patient demographics, type of graft, duration of implant, reason for removal, operative technique, length of stay, complications, and in-hospital and late mortality were reviewed.
  
  
  RESULTS
  During 1999 to 2012, 100 patients (91% men) required EVAR explant, of which 61 were placed at another institution. The average age was 75 years (range, 50-93 years). The median length of time since implantation was 41 months (range, 1-144 months). Explanted grafts included 25 AneuRx (Medtronic, Minneapolis, Minn), 25 Excluder (W. L. Gore & Associates, Flagstaff, Ariz), 17 Zenith (Cook Medical, Bloomington, Ind), 15 Talent (Medtronic), 10 Ancure (Guidant, Indianapolis, Ind), 4 Powerlink (Endologix, Irvine, Calif), 1 Endurant (Medtronic), 1 Quantum LP (Cordis, Miami Lakes, Fla), 1 Aorta Uni Iliac Rupture Graft (Cook Medical, Bloomington, Ind), and 1 homemade tube graft. Overall 30-day mortality was 17%, with an elective case mortality of 9.9%, nonelective case mortality of 37%, and 56% mortality for ruptures. Endoleak was the most common indication for explant, with one or more endoleaks present in 82% (type I, 40%; II, 30%; III, 22%; endotension, 6%; multiple, 16%). Other reasons for explant included infection (13%), acute thrombosis (4%), and claudication (1%). In the first 12 months, 23 patients required explants, with type I endoleak (48%) and infection (35%) the most frequent indication. Conversely, 22 patients required explants after 5 years, with type I (36%) and type III (32%) endoleak responsible for most indications.
  
  
  CONCLUSIONS
  The rate of EVAR late explants has increased during the past decade at our institution. Survival is higher when the explant is done electively compared with emergent repair. Difficulty in obtaining a seal at the initial EVAR often leads to failure ≤1 year, whereas progression of aneurysmal disease is the primary reason for failure >5 years.
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Turney
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
authors.forename: Sean P
authors.initials: SP
authors.lastname: Steenberge
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio. Electronic address: lydens@ccf.org.
authors.forename: Sean P
authors.initials: SP
authors.lastname: Lyden
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Eagleton
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
authors.forename: Sunita D
authors.initials: SD
authors.lastname: Srivastava
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
authors.forename: Timur P
authors.initials: TP
authors.lastname: Sarac
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Kelso
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Clair
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000783:Aneurysm / Q000401:mortality / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D020878:Device Removal / Q000009:adverse effects / Q000401:mortality; D018450:Disease Progression; D017558:Elective Surgical Procedures; D004630:Emergencies; D057867:Endoleak / Q000209:etiology / Q000601:surgery; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000601:surgery; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009820:Ohio; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D011475:Prosthesis Failure; D016459:Prosthesis-Related Infections / Q000209:etiology / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013927:Thrombosis / Q000209:etiology / Q000601:surgery; D013997:Time Factors; D017211:Treatment Failure