Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy; Vascular Surgery, Department of Surgery, University Hospital of Parma, Parma, Italy.
Vascular Surgery, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Italy.
Eur J Vasc Endovasc Surg. 2020 May;59(5):757-765. doi: 10.1016/j.ejvs.2020.01.011. Epub 2020 Feb 5.
The aim was to report indications, technical aspects, and outcomes of a multicentre experience of late open conversions (LOCs) after endovascular abdominal aneurysm repair (EVAR), in order to identify risk factors which may influence early morbidity and mortality rates, and long term survival.
Ten vascular centres retrospectively reviewed all patients requiring LOC (≥30 days from initial EVAR, undergoing total or partial endograft explantation) from 1996 to 2017. Baseline characteristics, endograft data, indications, procedural details, post-operative outcomes, and follow up data were reviewed and analysed.
Included patients totalled 232 (90.1% males, mean age 74.3 ± 7.9 years). The number of LOC per year significantly increased during the study period, reaching 22 in 2017 (correlation r = 0.867, p < .0001). Reasons for LOC were 80.2% endoleak (186/232), 15.5% endograft infection (36/232), and 9.9% endograft thrombosis (23/232). Sixty-nine patients (29.7%) were operated on urgently; rupture was present in 18.5% (43/232). Eighty-nine patients (38.4%) underwent endovascular re-interventions prior to LOC. The proximal aortic cross clamp site was infrarenal in 40.5% (94/232), suprarenal in 25.4% (59/232), supracoeliac in 32.8% (76/232), and thoracic in 1.3% (3/232). Endograft explantation was total in 164/232 patients (70.7%), and partial in the remaining 68/232 (29.3%). The overall 30 day mortality was 11.2% (26/232). Early mortality was significantly higher for patients operated on urgently (26.1% vs. 4.9%, p < .001). Suprarenal clamping (odds ratio (OR) 2.34, 95% CI 1.12-4.88) and pre-existing renal insufficiency (OR 2.11, 95% CI 1.03-4.31) were independent risk factors for post-operative renal failure on multivariable analysis. Median follow up was 24.1 months (IQR 4.4-60.6). The estimated overall one and five year survival rates were 79.7% and 58.6%, respectively. Survival estimates were significantly lower for patients with endograft infection (83.8% vs. 59% at one year, 65.2% vs. 28.9% at five years; log rank p = .005), as well as for urgent patients (87.2% vs. 62.1% at one year, 65.1% vs. 43.7% at five years; log rank p < .0001).
The annual number of LOC increased over time. LOCs performed urgently or for endograft infection are associated with poor survival. Infrarenal aortic clamping has lower post-operative complication rates.
报告血管内腹主动脉瘤修复（EVAR）后晚期开放转换（LOC）的多中心经验的适应证、技术方面和结果，以确定可能影响早期发病率和死亡率以及长期生存率的风险因素。
10 个血管中心回顾性分析了 1996 年至 2017 年间所有需要 LOC（EVAR 后≥30 天，进行全或部分内移植物取出）的患者。回顾并分析了基线特征、内移植物数据、适应证、手术细节、术后结果和随访数据。
共纳入 232 例患者（90.1%为男性，平均年龄 74.3±7.9 岁）。在研究期间，LOC 的数量每年显著增加，2017 年达到 22 例（相关系数 r=0.867，p<0.0001）。LOC 的原因分别为 80.2%的内漏（186/232）、15.5%的内移植物感染（36/232）和 9.9%的内移植物血栓形成（23/232）。69 例（29.7%）患者紧急手术；232 例患者中破裂占 18.5%（43/232）。89 例（38.4%）患者在 LOC 前接受了血管内再介入治疗。近端主动脉夹的位置在肾下 40.5%（94/232）、肾上 25.4%（59/232）、腹腔上 32.8%（76/232）和胸上 1.3%（3/232）。232 例患者中 164 例（70.7%）进行了全移植物取出，其余 68 例（29.3%）进行了部分移植物取出。30 天总体死亡率为 11.2%（26/232）。紧急手术患者的早期死亡率显著更高（26.1%比 4.9%，p<0.001）。肾上夹（比值比（OR）2.34，95%可信区间 1.12-4.88）和术前肾功能不全（OR 2.11，95%可信区间 1.03-4.31）是多变量分析中术后肾衰竭的独立危险因素。中位随访时间为 24.1 个月（IQR 4.4-60.6）。估计的总 1 年和 5 年生存率分别为 79.7%和 58.6%。内移植物感染患者的生存估计值显著较低（1 年时为 83.8%比 59%，5 年时为 65.2%比 28.9%；对数秩检验 p=0.005），紧急手术患者的生存估计值也显著较低（1 年时为 87.2%比 62.1%，5 年时为 65.1%比 43.7%；对数秩检验 p<0.0001）。
LOC 的年数量随着时间的推移而增加。紧急或因内移植物感染而进行的 LOC 与较差的生存率相关。肾下主动脉夹的术后并发症发生率较低。
