Department of Surgery, Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
J Vasc Surg. 2012 Jun;55(6):1562-9.e1. doi: 10.1016/j.jvs.2011.12.007. Epub 2012 Apr 11.
Secondary interventions after endovascular aneurysm repair (EVAR) remain a concern. Most are simple catheter-based procedures, but in some instances, open conversions (OCs) are required and carry a worse outcome. We reviewed our experience to characterize these OCs.
A retrospective review was conducted of all patients who underwent an OC after a previous EVAR for an aneurysm-related indication from 2001 to 2010. Clinical outcomes are reported.
Data were reviewed for 44 patients (77% men) with a mean age of 74 years (range, 55-90 years). The average time from EVAR to the first OC was 45 months (range, 2-190 months). In six patients (14%), the initial EVAR was at another institution. The endografts used were Ancure in 16, Excluder in 13, AneuRx in eight, Zenith in three, Lifepath in one, Renu in one, and undetermined in two. Twenty-two patients had previously undergone a total of 32 endovascular reinterventions before their index OC. Indications for OC were aneurysm expansion in 28 (64%), rupture in 12 (27%), and infection in four (9%). The endograft was preserved in situ in 10 patients (23%). Explantation was partial in 18 (41%) or complete in 16 (36%). Endograft preservation was used for type II endoleak in all but one patient by selective ligation of the culprit arteries (lumbar in four, inferior mesenteric artery in five, and middle sacral in one). Proximal neck banding was performed in one type Ia endoleak. Overall morbidity was 55%, and mortality was 18%. No deaths occurred in a subgroup of patients who underwent endograft preservation with selective ligation of culprit vessels for type II endoleak. Intraoperative complications included bowel injury in two, bleeding in two, splenectomy in one, and ureteral injury in one. At a mean follow-up of 20 months, two patients underwent additional procedures after the index OC: one after endograft preservation and one after partial explantation. None of the patients who underwent elective OC with endograft preservation required subsequent endograft explantation.
Most OCs after EVAR are associated with significant morbidity and mortality, except when electively treating an isolated type II endoleak with ligation of branches and preservation of the endograft.
血管内动脉瘤修复术（EVAR）后的二次干预仍然令人关注。大多数是简单的基于导管的手术，但在某些情况下，需要进行开放转换（OC），且其结果更差。我们回顾了我们的经验，以描述这些 OC。
对 2001 年至 2010 年间因动脉瘤相关原因在前一次 EVAR 后行 OC 的所有患者进行回顾性分析。报告临床结果。
共 44 例（77%为男性）患者的数据被纳入研究，平均年龄为 74 岁（55-90 岁）。从 EVAR 到首次 OC 的平均时间为 45 个月（2-190 个月）。在 6 例患者（14%）中，初始 EVAR 是在另一家机构进行的。使用的覆膜支架分别为 Ancure 16 个，Excluder 13 个，AneuRx 8 个，Zenith 3 个，Lifepath 1 个，Renu 1 个，以及不确定的 2 个。22 例患者此前共行 32 次血管内再介入治疗。OC 的指征包括动脉瘤扩张 28 例（64%），破裂 12 例（27%）和感染 4 例（9%）。10 例患者（23%）的覆膜支架原位保留。18 例（41%）为部分取出，16 例（36%）为完全取出。除 1 例外，所有患者均通过选择性结扎致病动脉（4 例为腰椎，5 例为肠系膜下动脉，1 例为中骶动脉）保留覆膜支架以治疗 II 型内漏。对 1 例 I 型 Ia 内漏行近端颈部带环术。总体发病率为 55%，死亡率为 18%。对于因 II 型内漏选择性结扎致病血管而行覆膜支架保留的患者亚组，无死亡病例。术中并发症包括 2 例肠损伤，2 例出血，1 例脾切除术和 1 例输尿管损伤。在平均 20 个月的随访中，2 例患者在索引 OC 后行进一步治疗：1 例在保留覆膜支架和 1 例在部分取出后。选择性 OC 并保留覆膜支架治疗孤立性 II 型内漏的患者中，无后续需要行覆膜支架取出的病例。
EVAR 后的大多数 OC 都与显著的发病率和死亡率相关，除非是选择性治疗孤立性 II 型内漏，通过结扎分支并保留覆膜支架。
