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Conversion to open procedure:
Decision making, treatment, tips & tricks
Vascupedia@LINC: Endoleaks–case-based solutions
Roberto ChiesaDirector, Dept. of Vascular Surgery
San Raffaele Scientific Institute – Milan, Italy
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Conflict of interest
Nothing to disclose
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EVAR vs Open
EVAR has no advantage on survival!
Salata K. et al. JAMA Net Open –Surgery - 2019
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EVAR vs Open
.. but higher need of secondary procedures!
Salata K. et al. JAMA Net Open –Surgery - 2019
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Endoleak
Durability
Migration
EVAR unsolved issues
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ACE (299 pts)
DREAM (351 pts)
EVAR1 (1,252 pts)
MEDICARE (45,560 pts)
OVER (881 pts)
SwedVasc (3,777 pts)
ENDO vs OR: long-term
Stather et al, Br J Surg 2013
reinterventions
(OR = 2)
AAA rupture
(OR = 6)
Meta-analysis (52,220 pts)
AAA rupture @ 4 yrs
Reinterventions @ 4 yrs
EVAR
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Late ruptured AAA after EVAR
Proximal type I EL with retroperitoneal hematoma
Chiesa R et al. European Vascular Course Text Book & Acta Chir Belg 2006
3 years after EVAR
AneuRX
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Trend of open conversion
2010-2015
Growing rate of EVAR
Moulakakis et al J Endovasc Ther 2010
Kouvelos et al J Vasc Surg 2015
Secondary procedures
Late open conversions
1.9%
4 %
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OSR personal experience
2005-2019
1487 EVAR procedures
23 Open conversion *
*1.5 %
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Tot. 84 pts
Open conversion after EVAR
23 pts
OSR
*27%
61 pts
other centers
*73%
OSR global experience
2005-2019
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Causes of open conversion
Endoleak I - III 45
Endoleak II 21
Occlusion 7
Graft failure 5
Infection 4
Migration 2
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..it’s time for surgical conversion!
When EVAR fails …
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Surgical approach after EVAR
Saccotomy
Laparoscopic ligation
Partial endograft removal
Complete endograft removal
Lumbar artery
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Saccotomy
Laparoscopic ligation
Partial endograft removal
Complete endograft removal
Surgical approach after EVAR
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Surgical approach after EVAR
Saccotomy
Laparoscopic ligation
Partial endograft removal
Complete endograft removal
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Surgical approach after EVAR
Saccotomy
Laparoscopic ligation
Partial endograft removal
Complete endograft removal
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Technique: surgical accesses
8%
44%
48%
Median laparotomy
Bilateral subcostal laparotomy
Thoraco-phreno-laparotomy
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Infrarenal: 47% Suprarenal: 42% Supraceliac:11%
Technique: clamping site
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62 y.o. male
2012: EVAR (Gore Excluder)
Type II endoleak
(IMA and lumbar)
2013-14: Previous embolizations
2015: Rapid sac enlargement
Case #1
Main body complete removal
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Case #1
Main body complete removal
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But… endograft configuration
30%
27%43%
No free-flow
Free-flow
Free-flow + barbs
57%
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Aortic dissection
Aortic endoarterectomy
Renal dissection
Renal ischemia
Renal embolization
Main body complete removal
may cause…
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Complete removal (stent+barbs)
LRA
RRA
Bilateral renal artery bypass Bilateral renal occlusion after conversion
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71 y.o. female
2013: EVAR (Trivascular Ovation)
Type II endoleak
2015: Embolization
2016: Rapid sac enlargement
Case #2
Main body partial removal
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Case #2
Main body partial removal
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Focus on the technique:
Proximal anastomosis(when stent-graft is partially removed)
“Triple-layer technique”
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Pruitt catheters limb occlusion
Focus on the technique:
Distal anastomosis(with iliac limbs preservation)
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Case#3
Nellix (EVAS) open conversion
78 y.o. male
2016: EVAS (Nellix)
2018: Graft migration
with sac reperfusion
and abdominal pain
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Case#3
Nellix (EVAS) open conversion
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Case#3
Nellix (EVAS) open conversion
Polymer disruption
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Open conversion: results
Total 84
Renal insufficiency 5 (5.9 %)
Respiratory failure 8 (9.5 %)
In-hospital mortality 2 (2.4 %)
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Open conversion: results
Complete removal
Partialremoval
Saccotomy
Patients 38 (45 %) 43(51 %) 3 (3.6 %)
Renal
Insufficiency4 (10 %) 1 (2.3 %) 0
In-hospital
Mortality1(2.6 %) 1 (2.3 %) 0
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Conclusions
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Open conversion after EVAR
• Technical challenging
• Mortality and morbidity rates acceptable in
high volume centres for open repair
• Partial removal of the stent-graft offers reduced
renal morbidity
• Careful patient selection and follow-up after
EVAR
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Conversion to open procedure:
Decision making, treatment, tips & tricks
Vascupedia@LINC: Endoleaks–case-based solutions
Roberto ChiesaDirector, Dept. of Vascular Surgery
San Raffaele Scientific Institute – Milan, Italy