Nabi David, Murphy Erin H, Pak Jimmy, Zarins Christopher K
Division of Vascular and Endovascular Surgery, Stanford University Medical Center, Stanford, CA 94305-5431, USA.
J Vasc Surg. 2009 Oct;50(4):714-21. doi: 10.1016/j.jvs.2009.05.024.
Open surgical repair after failed endovascular aneurysm repair (EVAR) usually involves complete endograft removal and replacement with a prosthetic surgical graft. This is associated with significant morbidity and mortality. We have used an alternative strategy focused on limiting the magnitude of surgical repair by preserving the functioning portion of the endograft and avoiding aortic cross-clamping, when possible.
Between January 2000 and 2008, patients requiring delayed conversion after EVAR at our institution were managed with (1) complete endograft preservation and external wrap of the aortic neck to secure a proximal seal, or (2) partial endograft removal with interposition grafting from the infrarenal aortic neck to the remaining endograft. Records of all patients were retrospectively reviewed for demographics, operative details, and outcomes.
During this time, 12 patients were treated with delayed open surgical conversion. The indication for conversion in all patients was a type I endoleak with aneurysm enlargement not amendable to percutaneous intervention. Mean age was 81 +/- 6.2 years (range, 61-90 years). Average time to conversion was 44.7 months (range, 7-80 months). Complete endograft preservation was attempted in eight patients and was successful in six (75%). The two patients that failed this approach, as well as four additional patients who were not candidates for this approach, underwent partial endograft excision and replacement with an interposition graft sutured to the remaining portion of the stent graft. Complete endograft removal was not required in any patients. There was one post-operative mortality (8.3%) and one significant post-operative morbidity (8.3%). Mean intensive care unit and hospital stays were 2.8 +/- 3.9 days (range, 1-15 days) and 8.4 +/- 5.8 days (range, 3-26 days), respectively.
Open surgical repair of failed EVAR can be accomplished with preservation of all or a significant portion of the endograft in most patients. This may limit the magnitude of the repair procedure and may reduce morbidity and mortality.
血管内动脉瘤修复术（EVAR）失败后进行的开放性手术修复通常需要完全移除腔内移植物并用人工手术移植物进行置换。这会带来较高的发病率和死亡率。我们采用了一种替代策略，重点是通过保留腔内移植物的功能部分并尽可能避免主动脉交叉钳夹来限制手术修复的范围。
2000年1月至2008年期间，在我们机构需要在EVAR后进行延迟转换的患者采用以下方法进行处理：（1）完全保留腔内移植物并对主动脉颈部进行外部包裹以确保近端密封，或（2）部分移除腔内移植物并从肾下腹主动脉颈部至剩余腔内移植物进行间置移植。对所有患者的记录进行回顾性审查，以了解人口统计学、手术细节和结果。
在此期间，12例患者接受了延迟开放性手术转换。所有患者转换的指征均为I型内漏且动脉瘤增大，无法通过经皮介入治疗。平均年龄为81±6.2岁（范围61 - 90岁）。平均转换时间为44.7个月（范围7 - 80个月）。8例患者尝试完全保留腔内移植物，6例成功（75%）。该方法失败的2例患者以及另外4例不适合该方法的患者接受了部分腔内移植物切除并用缝合至支架移植物剩余部分的间置移植物进行置换。所有患者均无需完全移除腔内移植物。有1例术后死亡（8.3%）和1例严重术后并发症（8.3%）。平均重症监护病房和住院时间分别为2.8±3.9天（范围1 - 15天）和8.4±5.8天（范围3 - 26天）。
对于大多数患者，EVAR失败后的开放性手术修复可以在保留全部或大部分腔内移植物的情况下完成。这可能会限制修复手术的范围，并可能降低发病率和死亡率。
