Late open conversion after thoracic and abdominal endovascular aortic repair: challenging cases


Alptekin G. S. , Erkul S., Parlar A. İ. , Çekirdekçi A.

Charing Cross Aortic Vienna 2021, London, England, 5 - 07 October 2021, pp.1-2

  • Publication Type: Conference Paper / Summary Text
  • City: London
  • Country: England
  • Page Numbers: pp.1-2

Abstract

Aims: A series of patients who required late open conversion  for rare complications which are observed after thoracic and abdominal endovascular aortic repair (EVAR) are presented in this study.

Methods:

Case 1 is a 78-year old male patient who presented with acute aortic thrombosis after EVAR for infrarenal abdominal aortic aneurysm. He was diagnosed with acute ischemia at lower limbs. We first performed an axillobifemoral bypass surgery for limb salvage. Due to recurrent thromboses of the left limb of the graft during longterm follow-up, we applied aortobifemoral bypass procedure to provide adequate lower limb flow. Case 2 is  a 56 year-old male patient who had undergone thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection 6-months before and was admitted to our clinic with uncontrolled hypertension for the last twelve hours and history of a syncopal attack three days before. Retrograde ascending aortic dissection (rAAD) was detected in computed tomography angiography. Ascending aorta and hemiarch replacement with a Dacron graft was safely performed via hypothermic circulatory arrest and antegrade cerebral perfusion for the treatment of rAAD after TEVAR. Case 3 was a 67- year old male patient who was admitted with a syncopal attack. He had a history of endovascular aneurysm repair five years before. He was diagnosed as  type 3 endoleak with rupture. An urgent aorto-bifemoral bypass was performed by removing the endograft completely.

Results: At 24 months of follow-up after the aortobifemoral bypass, the physical examination of Case 1 revealed palpable pulses of the lower limb arteries and no graft failure was observed The third month and subsequent CTA images of Case 2 revealed that the graft was intact with no dissection, haematoma or pseudo-aneurysm in aortic root, arcus aorta or the branches. He is in a good condition at 18th month. Case 3 was discharged at twentieth day and had ordinary findings at one year follow-up.

Conclusions:

Unfavourable aortic anatomy is an important limitation for EVAR treatment. Extra-anatomic bypass procedures should be kept in mind in urgent conditions for limb salvage as for our Case 1. However the long-term patency rates of extra-anatomic bypass procedures are not excellent, whereas aortobifemoral bypass surgery is a conventional gold-standard treatment modality which yields excellent long-term patency rates. Time to intervention is an important issue for acute Type B aortic dissection. Ascending aorta and hemiarch replacement was safely performed via hypothermic circulatory arrest and antegrade cerebral perfusion for the treatment of rAAD after TEVAR in our Case 2. The extension of the retrograde dissection and the involvement of the branches may vary among the different patients and the surgery should be modified according to the pathology. The ruptured aneurysm due to type 3 endoleak as in our Case 3 is a rare and catastrophic complication.  It is evident that a close surveillence for life time both after EVAR and TEVAR is crucial. Also it should be noted here that open surgery and endovascular treatment for aortic pathologies are not substitutional but complementary therapies currently.