Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.
Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass.
J Vasc Surg. 2019 Jan;69(1):80-85. doi: 10.1016/j.jvs.2018.03.426. Epub 2018 Jun 15.
Failure of endovascular aneurysm repairs (EVARs) requiring open conversion remains a major challenge. We analyzed indications for repair, operative strategies, and outcomes with a focus on iliac artery degeneration after endograft removal.
A prospective, institutional database was reviewed to identify patients who underwent explantation of a failed EVAR device. Demographics, reason for failure, operative details including extent of endograft removal, and complications/survival were examined. Postexplantation computed tomography imaging was evaluated for iliac artery degeneration.
There were 32 patients who underwent explantation from 2002 to 2017. Six patients were treated emergently for rupture. The majority were elderly (average age, 76 ± 8.5 years), white (100%) men (91%) who had their EVAR graft inserted 45.5 months (range, 0.3-86 months) before open conversion, usually at an outside institution (75%). Explanted endografts included nine AneuRx (Medtronic, Minneapolis, Minn), nine Excluder (W. L. Gore & Associates, Flagstaff, Ariz), four Endurant (Medtronic), three Zenith (Cook Medical, Bloomington, Ind), three Powerlink/AFX (Endologix, Irvine, Calif), one Aorfix (Lombard Medical, Oxfordshire, United Kingdom), one Talent (Medtronic), and two unknown. Failure was due to endoleak in 91% (type I, 38%; type II, 28%; type III, 13%; type V, 13%), infection in 6%, and occlusion/kinking in 3%. A previous attempt at endovascular salvage of EVAR occurred in 12 (37.5%) patients. Operative approach was transabdominal in 69% and retroperitoneal in 31%. Initial aortic clamp position was supraceliac in 31%, suprarenal in 31%, and infrarenal in 38%. Most patients had complete removal of their endograft (n = 19 [59%]), with 22 (69%) having at least the iliac limbs removed. Grafts with suprarenal fixation were more likely to have the upper main body left in situ (67% vs 17%; P = .029). The 30-day mortality was 6.3% (3.8% elective, 16.7% ruptured), and 31% had a major complication. Of the 23 patients who had follow-up imaging, there was a trend for more iliac degeneration (>5 mm in growth) in those who had the iliac limbs removed (29.4% vs 0%; P = .184). Three patients with iliac limb removal required subsequent iliac endovascular intervention (two for rupture). Patients who presented with a rupture had a decreased 5-year overall survival (33%) compared with those who were converted electively (59%).
Both complete and partial endograft explantation, although morbid procedures, can be performed safely. Postoperative imaging surveillance is important, especially if the endograft has been removed from the iliac arteries, as degeneration can occur.
需要开放转换的血管内动脉瘤修复（EVAR）失败仍然是一个主要挑战。我们分析了修复的指征、手术策略和结果，重点关注血管内移植物取出后髂动脉的退化。
对 2002 年至 2017 年间接受失败 EVAR 装置取出的患者进行前瞻性、机构数据库回顾。检查人口统计学、失败原因、手术细节，包括移植物取出的范围，以及并发症/生存率。对取出后血管内成像进行髂动脉退化评估。
共有 32 例患者因破裂接受紧急治疗。其余 26 例患者为择期手术。大多数患者为老年人（平均年龄 76±8.5 岁），白人（100%）男性（91%），其 EVAR 移植物在开放转换前 45.5 个月（0.3-86 个月）插入，通常在外部机构（75%）。取出的血管内移植物包括 9 个 AneuRx（美敦力，明尼苏达州明尼阿波利斯）、9 个 Excluder（戈尔公司，亚利桑那州弗拉格斯塔夫）、4 个 Endurant（美敦力）、3 个 Zenith（库克医疗，印第安纳州布鲁明顿）、3 个 Powerlink/AFX（Endologix，加利福尼亚州欧文）、1 个 Aorfix（伦巴第医疗，牛津郡，英国）、1 个 Talent（美敦力）和 2 个未知。失败的原因是内漏 91%（1 型，38%；2 型，28%；3 型，13%；5 型，13%）、感染 6%和阻塞/扭曲 3%。12 例（37.5%）患者曾尝试过血管内 EVAR 修复。手术入路经腹 69%，经腹膜后 31%。初始主动脉夹的位置在肾上 31%、肾下 31%和肾下 38%。大多数患者完全取出了他们的血管内移植物（n=19 [59%]），22 例（69%）至少取出了髂支。带肾上固定的移植物更有可能将上主身体留在原位（67%比 17%；P=0.029）。30 天死亡率为 6.3%（3.8%择期，16.7%破裂），31%有主要并发症。在有随访影像学的 23 例患者中，髂支取出的患者有更多的髂动脉退化（生长超过 5 毫米）（29.4%比 0%；P=0.184）。3 例髂支取出患者需要随后进行髂内血管内介入治疗（2 例为破裂）。破裂患者的 5 年总生存率（33%）较择期患者（59%）降低。
虽然完全和部分血管内移植物取出都是很严重的手术，但都可以安全进行。术后影像学监测很重要，特别是如果髂动脉内的移植物已被取出，因为可能会发生退化。
