Conversion to Open Surgical Treatment After Failed Endovascular Aortic Aneurysm Repair

Endovascular aneurysm repair (EVAR) has proved to be safe and effective for the primary treatment of aortic aneurysms. However, endoleaks, endotension, migration, and stent fracture can lead to aneurysm growth and rupture if not treated in a timely fashion. Although transition to newer-generation material and technology has improved the durability of EVAR, complications still occur. Despite the success rate of secondary interventions, patients who are not candidates for an endovascular repair or have unsuccessful interventions require conversion and explant of their endograft. As the length of follow-up increases, studies have also shown that all devices remain susceptible to the risk of removal.

The overall conversion rate is 0% to 9% based on published literature within various EVAR series. The true risk of conversion is difficult to ascertain because many patients are lost to follow-up or report to a different institution for removal. Devices that are placed outside of the instructions for use have been found to carry a higher risk of endograft failure and subsequent removal.

Differences exist between early and late conversions, which are defined as occurring before and after 30 days, respectively. A systematic literature review found that the incidence of early conversion is 0.3% to 5.9%, with a decrease in recent years. For late conversions they found that the incidence averaged 0.4% to 6.3%. In either situation, conversion to open surgery and endograft explant requires careful planning and technical skill.