O-202 - LATE OPEN CONVERSIONS AFTER EVAR IN A MULTICENTRE EXPERIENCE: A COMPARISON OF COMPLETE VS PARTIAL EXPLANTATIONS OVER A PERIOD OF 25 YEARS

TOPIC:
Abdominal Aortic Aneurysms
AUTHORS:
Perini P. (University Hospital of Parma ~ Parma ~ Italy) , Gargiulo M. (University of Bologna ~ Bologna ~ Italy) , Silingardi R. (University of Modena and Reggio Emilia ~ Modena ~ Italy) , Bonardelli S. (University of Brescia ~ Brescia ~ Italy) , Bellosta R. (Poliambulanza Foundation Hospital ~ Brescia ~ Italy) , Michelagnoli S. (S. Giovanni di Dio Hospital ~ Firenze ~ Italy) , Piffaretti G. (University of Insubria ~ Varese ~ Italy) , Ferrari M. (University of Pisa ~ Pisa ~ Italy) , Turicchia G.U. (AUSL Romagna ~ Forlì Cesena ~ Italy) , Migliari M. (University of Modena and Reggio Emilia ~ Modena ~ Italy) , Attisani L. (Poliambulanza Foundation Hospital ~ Brescia ~ Italy) , Chisci E. (S. Giovanni di Dio Hospital ~ Firenze ~ Italy) , Troisi N. (University of Pisa ~ Pisa ~ Italy) , Rivolta N. (University of Insubria ~ Varese ~ Italy) , Paciaroni E. (AUSL Romagna ~ Forlì Cesena ~ Italy) , Paro B. (University of Brescia ~ Brescia ~ Italy) , Faggioli G. (University of Bologna ~ Bologna ~ Italy) , Freyrie A. (University Hospital of Parma ~ Parma ~ Italy)
Introduction:
The great majority of endovascular abdominal aneurysm repair (EVAR) complications is managed by endovascular means. However, endograft explantation (EE) may be required sometimes. EE may be complete (CEE), or partial (PEE) if a portion of the endograft is left in place and the new surgical graft is sewed directly to the endograft remnants. To date, whether a CEE has an advantage over a PEE is still debated. The aim of this study is to report the technical aspects of a multicentre experience of EE, and to compare early and long-term outcomes of CEE vs. PEE.
Methods:
All-EE performed from 1996 to 2020 in 12 vascular centres were reviewed. Open or laparoscopic surgery for endoleak (EL) correction with complete endograft preservation (i.e. the so-called semiconversions) were excluded. Patients' demographics, time elapsing from EVAR, indication for conversion, operative data, 30-day and in-hospital mortality were analysed. The 2 groups were compared using univariable methods, then by stepwise multivariable logistic regression analysis (we included factors with P<.10). Long-term survival was evaluated by Kaplan-Meier method.
Results:
Three hundred and fifty-three patients were included: 214 (60.6%) underwent CEE, 139 (39.4%) PEE. The 2 groups were homogeneous in terms of age at conversion (74±8 vs. 75±7.1 years, p=.34), male sex (88.5% vs. 89.3%, P=.82), aneurysm diameter (72.9±18mm vs. 76.9±17.8mm, P=.12), ASA score (median: 3, P=.054), and time elapsing from EVAR (47.2±42.2 vs. 48.7±35.2 months, P=.74). The 2 groups were also homogeneous in terms of indications for EE: type I endoleak (P=.48), type II (P=.18), type III (P=.29), endotension (P=.39), endograft thrombosis (P=.11), rupture on presentation (22.9% vs. 18%, P=.27), and previous endovascular attempts to repair the failing EVAR (37.9% vs. 46%, P=.13). Among the 139 patients in the PEE group, 68 (49%) underwent proximal preservation of the endograft, 45 (32%) distal preservation, and 26 (19%) preservation of both the proximal and the distal part of the endograft. There were no statistical differences in terms of surgical time length between the 2 groups (271±111 vs. 268±98 minutes, P=.88), nor in terms of length of stay (17.3±17.2 vs. 14.8±12.7 days, P=.14). Patients in the CEE group underwent more frequently supracoeliac clamping (36.4% vs. 23.7%, P=.04). Overall 30-day mortality was 15.6% (55/353). Thirty-day mortality was 18.2% (39/214) in the CEE group vs. 11.5% (16/139) in the PEE group; however, this difference did not reach statistical significance (P=.09). Major renal or gastrointestinal complications occurred in the 27.5% of the patients, and were associated with suprarenal clamping (OR 1.90, 95%CI 1.06-3.42; P=.03), but not with CEE or PEE (OR 1.02, 95%CI 0.56-1.88; P=.94). On multivariable analysis, a suprarenal fixation of the endograft was independently associated with PEE (OR 3.59, 95%CI 1.37-9.44; P=.009). Mean follow-up length was 30.4±90.6 months. The estimated 1- and 5-year survival rates were 75.9% and 50.6% for CEE, and 77.9% and 56.2% for PEE (log-rank P=.51; Fig.1).
Conclusion:
In our experience, in case of an endograft with suprarenal fixation, a PEE was preferred. However, even though PEE may theoretically simplify the surgical technique, it does not lead to shorter surgical time, nor to better early or long-term outcomes. These data suggest that rather than PEE or CEE approach, the most important predictor of outcome is the level of aortic clamping.
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