Delayed complications following EVAR.

More than a decade after the first clinical attempts, two large randomized studies have proven that endovascular aortic aneurysm repair (EVAR) provides immediate advantages over open repair. In the long run, however, a relatively high number of reinterventions is necessary to improve the long-term efficacy of EVAR, which may outweigh the early benefits. Since EVAR is gaining popularity in the medical community and in patients with abdominal aortic aneurysm (AAA), it is expected that a growing number of patients will present with delayed complications requiring some kind of reinterventions. For the patient's safety, vascular surgeons and interventional radiologists involved in EVAR must be well aware of these complications and the ways to overcome them. We began our endovascular program for AAA in 1994 and currently follow 485 patients with a variety of manufactured grafts. In this article we describe the delayed complications observed with EVAR, their mechanisms, favoring factors, and ways to treat them.

Outcomes of secondary interventions after abdominal aortic aneurysm endovascular repair.

PURPOSE: We assessed the distribution of secondary interventions after aortic stent grafting (EVAR) performed to treat infrarenal abdominal aortic aneurysm (AAA), and evaluated clinical success and survival in patients who underwent a secondary procedure (group 2) compared with patients who did not undergo a secondary procedure (group 1). METHODS: Two hundred fifty patients (mean age, 71.3 years) with asymptomatic AAAs (mean aneurysm diameter, 54.5 mm) underwent treatment with commercially available stent grafts. Mean follow-up was 28 months (median, 25 months). Secondary procedures were defined as any additional procedures performed after initial graft placement to treat endoleak, migration, kinking, stenosis, or occlusion. Overall clinical success was defined according to reporting standards of the Society for Vascular Surgery/American Association for Vascular Surgery. RESULTS: Sixty-eight patients (27%) required 112 secondary procedures, with a mean time from initial graft placement of 18.2 months. Patients who received grafts since removed from the market required more secondary procedures (59%, procedure:patient ratio) compared with patients who received devices still on the market (21%; P =.001). Thirty-six patients (53%) required a single secondary procedure, 24 patients (35%) required two procedures, 5 patients (10%) required three procedures, 2 patients (3%) required four procedures, and 1 patient required five secondary procedures. Ninety-eight procedures (87%) were performed with endovascular methods, including placement of 42 additional covered stent grafts (36 iliac, 6 aortic), with a success rate of 85%; 35 embolization procedures (21 lumbar, 9 internal iliac artery, 5 mesenteric), with only 23 (65%) successful; 14 angioplasty procedures, with 85% successful; 4 thrombolysis procedures, 2 of them successful (50%); and 3 successfully placed new endografts within a previous endovascular graft. Surgical secondary operations included nine femorofemoral bypass procedures and three femoral thromboendarterectomies, all of which remain patent; one cerclage of an external iliac limb; and one laparoscopic repair of a type II endoleak, which was successful. Overall clinical success rate for EVAR was 84% (211 of 250) in this series. Clinical success rate in groups 1 and 2 was 91% (166 of 182) versus 66% (45 of 68; P =.001) if all endoleaks on the most recent computed tomography scans are taken into account, and 94% (171 of 182) versus 76% (52 of 68; P =.001) if type II endoleak without aneurysm growth is not considered failure. The survival rate and rupture-free survival in groups 1 and 2 were, respectively, 97.7% +/- 1.0% and 98.5% +/- 1.4% at 1 month, 95.9% +/- 1.5% and 96.9% +/- 2.1% at 6 months, 94.4% +/- 2.0% and 93.2% +/- 3.4% at 1 year, and 80.8% +/- 5.2% and 88.5% +/- 5.0% at 3 years (P =.273, log-rank test). CONCLUSION: With close follow-up and a significant number of secondary operations, this 8-year experience has not included any aneurysm ruptures to date. Secondary operations did not lead to increased mortality, but were associated with more surgical conversions and with a higher clinical failure rate.

Endograft fabric disintegration simulating a type II endoleak.

PURPOSE: To report a case of endograft disintegration misinterpreted as a type II endoleak. CASE REPORT: An 86-year-old man underwent successful Vanguard stent-graft implantation for a 49-mm abdominal aortic aneurysm. At 1 month, a distal type I endoleak was repaired, but another endoleak thought to arise from the lumbar or inferior mesenteric arteries remained. Multiple interventions to embolize the feeding arteries were unsuccessful, and the endoleak persisted. At 1 year, the leak was still present, and the aneurysm had increased to 69 mm. After failing to demonstrate the source of the leak radiographically, surgery was performed. At operation, the endoleak was traced to small holes in the graft fabric. The endograft was removed without difficulty, and the flow was re-established with an aortobi-iliac woven graft. CONCLUSIONS: Chronically implanted stent-grafts can show signs of failure that are confusing or misleading. Correct diagnosis of endoleaks may be difficult, but every effort must be made to identify their source. It is vital that no enlarging aneurysm be left untreated.