Thoracic or thoracoabdominal approaches to endovascular device removal and open aortic repair

Background: Endovascular aortic repair is becoming increasingly common and diverse in its application despite ongoing uncertainty about long-term durability. Recent reports detail late conversion to open surgical repair to treat disease progression and repair failure. We describe our experience with using thoracic or thoracoabdominal approaches to endovascular device removal and open aortic repair after previous endovascular procedures.

Methods: Thirty-five patients underwent open aortic repair through thoracotomy (n=7) or thoracoabdominal incision (n=28) 0.5 to 48 months after undergoing endovascular thoracic (n=27) or abdominal (n=8) aortic procedures. Indications for open repair included expanding aneurysm (n=23), device infection (n=8), fistula (n=5), pseudoaneurysm (n=2), aneurysm rupture (n=2), and restenosis (n=1). Endovascular devices were completely removed in 26 patients and partially removed in 9. Descending thoracic aortic repair was performed in 10 patients, thoracoabdominal aortic repair in 24, and juxtarenal abdominal aortic repair in 1.

Results: There were 2 in-hospital deaths (6%), both in patients who presented with endovascular device infection. There were 8 late deaths. Overall 1-year survival was 83%±7%. Among the patients who presented with infected devices, 3 experienced major late complications, including persistent infection, pseudoaneurysm, and recurrent fistula; 2 of these patients succumbed to late deaths.

Conclusions: Open surgical repair after previous endovascular aortic procedures is successful in the majority of patients, particularly in those without device infections. Achieving definitive aortic repair in patients with infected endovascular devices is particularly challenging.