Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
J Vasc Surg. 2011 Jul;54(1):42-6. doi: 10.1016/j.jvs.2010.12.042. Epub 2011 Feb 18.
To evaluate indications for, operative strategy during, and outcomes following late open surgical conversion following endovascular aneurysm repair (EVAR).
Between 2002 and 2009, patients undergoing open abdominal aortic aneurysm repair at a university hospital were entered prospectively into a database which was examined to identify patients undergoing open conversion >30 days after EVAR.
Over 7 years, 21 patients required late open conversion of EVAR. The average patient age was 75 years (range, 59-88), and there were 16 male (76%) patients. The mean interval to conversion was 33.4 months (range, 2-73). Eight patients (38%) presented with proximal type I endoleak; 4 patients (19%) presented with type II endoleak and aneurysm expansion; 5 patients (24%) presented with graft migration and aneurysm expansion; and 5 patients (24%) presented with de novo visceral aneurysms. Rupture (1) and infection (1) were also observed. There were five (24%) emergent cases. Most patients (12/21, 57%) had more than one reason for conversion. There were no perioperative deaths; three patients (14%) had major complications. Grafts requiring conversion were AneuRx (6; Medtronic AVE, Santa Rosa, Calif), Zenith (6; Cook Inc, Bloomington, Ind), Talent (3; Medtronic), Excluder (2; W. L. Gore, Flagstaff, Ariz), Anaconda (1; TERUMO Corp, Ann Arbor, Mich), Ancure (1; Guidant, Menlo Park, Calif), Quantum LP (1; Cordis Corp, Miami Lakes, Fla), and Powerlink (1; Endologix, Irvine, Calif). The surgical approach was retroperitoneal in 16 (76%) and transperitoneal in four (19%) patients. Initial proximal aortic control was supraceliac (9/21), suprarenal (7/21), or infrarenal (5/21), with stepwise distal clamping to reduce ischemic time. Complete endograft removal was performed in 17/21 patients; in 4/21 the distal anastomosis was performed to the endograft after proximal segment explantation. Reconstruction was completed with tube (19/21) or aortoiliac (2/21) grafts; in one case, homograft was used. Mean intraoperative blood loss was 1.9 L (range, 0.4-6.5 L), mean intensive care unit (ICU) stay was 3 days (range, 2-6), and the mean hospital stay was 10 days (range, 4-39).
While technically challenging, delayed open conversion of EVAR can be accomplished with low morbidity and mortality in both the elective and emergent settings. These results reinforce the justification for long-term surveillance of endografts following EVAR.
评估血管内动脉瘤修复（EVAR）后晚期开放手术转换的适应证、手术策略和结果。
在 2002 年至 2009 年间，在一家大学医院接受开放式腹主动脉瘤修复的患者被前瞻性地纳入数据库，以确定在 EVAR 后 30 天以上接受开放转换的患者。
在 7 年期间，21 名患者需要对 EVAR 进行晚期开放转换。患者平均年龄为 75 岁（范围为 59-88 岁），有 16 名男性（76%）患者。平均转换时间为 33.4 个月（范围为 2-73）。8 名患者（38%）出现近端 I 型内漏；4 名患者（19%）出现 II 型内漏和动脉瘤扩张；5 名患者（24%）出现移植物迁移和动脉瘤扩张；5 名患者（24%）出现新的内脏动脉瘤。还观察到破裂（1 例）和感染（1 例）。有 5 例（24%）为紧急病例。大多数患者（21 例中的 12 例，57%）有不止一个转换原因。没有围手术期死亡；3 名患者（14%）出现重大并发症。需要转换的移植物有 AneuRx（6 例；Medtronic AVE，Santa Rosa，Calif）、Zenith（6 例；Cook Inc，Bloomington，Ind）、Talent（3 例；Medtronic）、Excluder（2 例；W. L. Gore，Flagstaff，Ariz）、Anaconda（1 例；TERUMO Corp，Ann Arbor，Mich）、Ancure（1 例；Guidant，Menlo Park，Calif）、Quantum LP（1 例；Cordis Corp，Miami Lakes，Fla）和 Powerlink（1 例；Endologix，Irvine，Calif）。16 名患者（76%）采用腹膜后入路，4 名患者（19%）采用经腹腔入路。初始近端主动脉控制采用超肾（9/21）、肾上（7/21）或肾下（5/21），逐步远端夹闭以减少缺血时间。21 名患者中有 17 名完成了完全的移植物取出；4 名患者在近端节段切除后将远端吻合口与移植物吻合。重建采用管状（19/21）或腹主动脉髂动脉（2/21）移植物；1 例采用同种异体移植物。术中平均失血量为 1.9 L（范围为 0.4-6.5 L），平均 ICU 住院时间为 3 天（范围为 2-6 天），平均住院时间为 10 天（范围为 4-39 天）。
尽管具有技术挑战性，但在择期和紧急情况下，EVAR 后晚期开放转换可实现低发病率和低死亡率。这些结果证实了对 EVAR 后长期监测内支架的合理性。
