Secondary endovascular and conversion procedures for failed endovascular abdominal aortic aneurysm repair: can we still be optimistic?

The purpose of this study was to evaluate the incidence, etiology, and outcome of secondary endovascular and "open" conversion procedures after failed endovascular abdominal aortic aneurysm repair (EVAR). From January 1997 until December 2005, 625 patients with an infrarenal abdominal aortic aneurysm were treated by elective EVAR, with 98.7% (n = 617) primary EVAR success. The mean follow-up of the 617 patients was 46.7 +/- 11.2 months. One hundred of these patients (16.2%) required secondary endovascular or peripheral procedures, and 39 (6.3%) patients underwent a secondary abdominal conversion. There were 5 acute conversions (0.8%) and 34 elective conversions (5.5%). The pre-EVAR anatomic suitability data, the main cause of the secondary procedure, and stent graft type were compared between patients with primary EVAR success, patients in need of a secondary endovascular or peripheral procedure, and patients with abdominal conversion. The overall main causes for reinterventions were proximal migration (n = 60; 9.7%), progressive kinking of the stent graft (n = 59; 9.6%), and late type III endoleak (n = 12; 1.9%). Multivariate logistic regression analysis showed that factors significantly correlated with secondary procedures were the abdominal aortic aneurysm's maximum diameter, the proximal neck's width and length, and particularly the commercial withdrawal of the stent graft (p < .001). The morbidity and mortality rates of secondary endovascular or peripheral interventions were 0%. The mortality rate of acute secondary conversions was 20% (n = 1) and of elective secondary conversions was 8.8% (n = 3). The morbidity rates for acute and elective conversions were 0% and 65%, respectively. The aneurysm-related mortality rate in our series was below 1%. Abdominal conversion surgery still carries a high mortality rate, but the overall EVAR-related mortality rate remains low. Early pitfall detection and proper reintervention are crucial to long-term EVAR success.