title: Elective endovascular aortic repair conversion for type Ia endoleak is not associated with increased morbidity or mortality compared with primary juxtarenal aneurysm repair.
abstract: OBJECTIVE
  Type Ia endoleak after endovascular aortic repair (EVAR) can be a challenging complication to manage, and due to concerns regarding morbidity and mortality of open surgical conversion (OSC), reports of complex endoluminal salvage techniques are increasing. Despite development of these endovascular remedial strategies, many patients ultimately require OSC. The purpose of this analysis was to outcomes of elective OSC for type Ia endoleak and compare them with elective primary open juxtarenal aneurysm repair (OJAR) to determine if these concerns are warranted.
  
  
  METHODS
  From 2000 to 2012, 54 patients underwent EVAR OSC at median time of 27 months (interquartile range, 9-55 months). Indications included endograft thrombosis in 2 (4%), intraoperative EVAR failure in 3 (6%), rupture in 5 (9%), graft infection in 6 (11%), and type Ia endoleak in 25 (all: 38 [70%]). Because many OSCs are performed for emergency indications without endovascular options, we chose elective type Ia endoleak patients as our study group. These 25 patients were compared with an elective OJAR cohort matched by anatomy and comorbidities. Primary end points were 30-day and 1-year mortality. Secondary end points included early complications, cross-clamp time, procedure time, blood loss, and length of stay.
  
  
  RESULTS
  Demographic and comorbidity data in the OSC and OJAR groups did not differ, with the exception that OJAR patients presented with smaller aneurysm diameter and a higher rate of chronic obstructive pulmonary disease (P = .03). OSC patients more frequently underwent a nontube graft repair (OSC, n = 20 [80%] vs OJAR, n = 6 [24%]; P = .0002), required longer procedure times (P = .03), and received more plasma transfusions (P = .03). The 30-day mortality was 4% in both groups (observed difference in rates, 0%; 95% confidence interval for difference in mortality rates, -14.0% to 14.0%; P = 1). A similar rate of major complications occurred (OSC, n = 9 [36%] vs OJAR, n = 8 [32%]; P = 1). One-year survival was 83% in OSC and 91% in OJAR (observed difference, 7%; 95% confidence interval, -15% to 29%; P = .65).
  
  
  CONCLUSIONS
  Despite many advances in EVAR technology, the need for OSC persists and will likely become more common as older-generation devices fail or providers attempt EVAR in more anatomically complex patients. Elective OSC for type Ia endoleak can be technically challenging but is not associated with increased morbidity or mortality compared with OJAR in appropriately selected patients. These results should be considered before pursuing complex endovascular remediation of EVAR failures.
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla. Electronic address: salvatore.scali@surgery.ufl.edu.
authors.forename: Salvatore T
authors.initials: ST
authors.lastname: Scali
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
authors.forename: Michael M
authors.initials: MM
authors.lastname: McNally
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Feezor
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
authors.forename: Catherine K
authors.initials: CK
authors.lastname: Chang
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
authors.forename: Alyson L
authors.initials: AL
authors.lastname: Waterman
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
authors.forename: Scott A
authors.initials: SA
authors.lastname: Berceli
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Huber
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
authors.forename: Adam W
authors.initials: AW
authors.lastname: Beck
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D016022:Case-Control Studies; D017558:Elective Surgical Procedures; D057867:Endoleak / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011475:Prosthesis Failure; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome