Study finds low mortality, high complication rates after aortic endograft explantation

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The explantation of aortic endografts—associated with high postoperative morbidity, particularly in patients with infected grafts—can be carried out with a low mortality rate, a new single-center study reveals.

Mohammad Khasawneh

Mohammad Khasawneh, MD, a vascular surgery fellow at the Mayo Clinic in Rochester, Minnesota, and the team behind the findings set out to assess outcomes in patients who underwent late open conversion of endografts after either an infection or an endoleak. The investigators undertook a retrospective review in a single tertiary center study of outcomes in patients who had undergone explantation of aortic endografts.

Delivering the results at the Midwestern Vascular Surgical Society (MVSS) annual meeting (Sept. 9–12), Khasawneh observed that more than 75% of abdominal aortic aneurysms (AAAs) are repaired using endografts, further pointing out that the scientific literature shows an open late conversion incidence rate of “anywhere between 1.9–4.5%.”

The study drew data from across a 17-year period (2002–2019), comparing patients who had endografts explanted for either endoleaks or infections. A total of 108 patients—66 with endoleaks, 42 with infections—were included.

Over the breadth of the study period, the authors found that the number of explantations increased. Between 2010 and 2014, 41 patients had explants, with another 50 undergoing an explantation from 2015 until the end of the study. This compared to 17 patients between 2002 and 2009.

The researchers found no difference between the two groups in terms of the type of endograft explanted, while endoleak type 1a was the most common at around 40%, with type 2 following at 22%, while 20% had a mixed endoleak presence. The endoleak patients had a higher rate of aneurysm sac size increase at 97%, compared to 31% in the infection group. The research team reported that 10% in each grouping presented with a ruptured aneurysm.

The extent of the aneurysms was significantly different between the two groups, Khasawneh told the MVSS audience. Those with an infection were more likely to have an infrarenal aneurysm, he said. For those with endoleaks, a juxtarenal or pararenal aneurysm was more likely. Furthermore, four patients in the endoleak group had an extent IV thoracoabdominal aortic aneurysm (TAAA).

Most operations were performed using either suprarenal or a supramesenteric clamp. Clamp time was found to be significantly longer among patients who had infections, with a mean of 29 minutes compared with 22 minutes for the endoleak group.

Those with endoleaks were more likely to undergo a partial excision of the endograft compared to those with infections, which the research team found to be statistically significant.

In terms of outcomes, the 30-day mortality was significantly different between the two groups. Four patients from the endoleak group died but there were zero deaths among those with an infection.

Meanwhile, those who had an infection were more likely to have a postoperative complication (71% vs. 48%, p <0.01). There was no difference between the two groups in terms of major complications—classified as a return to the operating room, major cardiac event, or thrombosis of a graft. One stroke occurred among the endoleak patients, with one myocardial infarction discovered in the infection group.

Summarizing the results, Khasawneh said: “Explantation of endografts can be performed with a low mortality rate. These procedures are difficult and associated with high postoperative morbidity, especially in patients who have infected endovascular grafts. Finally, in situ reconstruction is often feasible in those cases.”

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