title: Infective etiology affects outcomes of late open conversion after failed endovascular aneurysm repair.
abstract: OBJECTIVE
  To retrospectively review all patients undergoing late open conversion (LOC) after endovascular aneurysm repair (EVAR) in order to identify any clinical or technical predictors of poor outcome.
  
  
  METHODS
  Twenty-six consecutive patients (24 men; mean age 74.7 ± 8.3 years) underwent LOC between June 2006 and April 2013 at our institution. The mean interval from index EVAR to LOC was 40.4 ± 29.2 months (range 5-93 months). The indication for LOC was endoleak in 14 (54%) patients and infection in 12 (46%): 2 (8%) patients with endoleak had a ruptured aneurysm and 6 (23%) patients with infection had a recurrent secondary aortoesophageal fistula (sAEF).
  
  
  RESULTS
  In all 12 cases of infection and in 12 of 14 endoleaks, the entire endograft was explanted. A rifampin-soaked Dacron silver graft was implanted in all patients with infection. Patients with any infection and with recurrent AEF required more blood units than patients with endoleak (6.40 vs. 1.86, p = 0.045; 6.76 vs. 1.86, p = 0.0036, respectively). Compared with endoleak, the duration of conversions in the setting of infection (274 vs. 316 minutes, p = 0.42) and recurrent sAEF (274 vs. 396 minutes, p = 0.021) was longer. All patients with recurrent sAEF died at a mean 3.0 ± 2.5 days after LOC from proximal anastomosis disruption and hemorrhagic shock (n = 2), myocardial infarction (n = 2), acute stroke (n = 1), or persistent sepsis (n = 1). Perioperative mortality was significantly higher in patients with endograft infection (6/12, p = 0.002) and in cases of supraceliac cross-clamping (4/6, p = 0.003). The association of infection with supraceliac cross-clamping was a strong predictor for perioperative mortality (p < 0.001).
  
  
  CONCLUSIONS
  In our experience, endograft infection led to greater perioperative mortality after LOC. Recurrent aortoenteric fistula in association with supraceliac cross-clamping is a strong predictor of poor outcome. Patients surviving the perioperative period may have good chances of long-term survival.
authors.affiliation: Sapienza University of Rome, Italy dmenna@hotmail.it.
authors.forename: Danilo
authors.initials: D
authors.lastname: Menna
authors.affiliation: Sapienza University of Rome, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Capoccia
authors.affiliation: Sapienza University of Rome, Italy.
authors.forename: Pasqualino
authors.initials: P
authors.lastname: Sirignano
authors.affiliation: Sapienza University of Rome, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Esposito
authors.affiliation: Sapienza University of Rome, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Rossi
authors.affiliation: Sapienza University of Rome, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Speziale
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture; D001807:Blood Vessel Prosthesis / Q000009:adverse effects; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D061887:Conversion to Open Surgery / Q000379:methods / Q000401:mortality; D020878:Device Removal; D057867:Endoleak / Q000209:etiology; D057510:Endovascular Procedures / Q000009:adverse effects*; D004937:Esophageal Fistula / Q000209:etiology / Q000382:microbiology* / Q000401:mortality / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents / Q000009:adverse effects*; D016019:Survival Analysis; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000209:etiology / Q000382:microbiology* / Q000401:mortality / Q000628:therapy
chemical_list: D000900:Anti-Bacterial Agents
keywords: abdominal aortic aneurysm; endovascular repair; infection; mortality; open conversion; secondary aortoesophageal fistula; stent-graft; stent-graft explant