Explantation versus Graft Preserving Strategy Following Primary Endovascular Aneurysm Repair: Two Decades of EVAR and Lessons Learned

Objectives: Continuous sac expansion could result in rupture, requiring aggressive management with re-intervention to abolish the risk of rupture. Re-intervention could be achieved through salvage of the primary endograft through graft preserving strategy or explantation as necessary. We aim to scrutinize our 20 years of EVAR practice, strategies indications for management and re-interventions following primary EVAR.

Methods: We identified 136 (14.95%) ELs (15 type I, 98 type II, 18 type III, and 5 type IV ELs). Factors like the rate of sac expansion, EL types, and the patients’ general condition were considered for re-intervention ([Fig. 1]). Type I ELs were managed with proximal aortic cuff and/or distal extension or chimney EVAR (ChEVAR). Amongst type II ELs, 12 (12.24%) were associated with persistent sac expansion despite initial trial of embolization. Seven out of these 12 underwent double breasting for aortic sac hygromas. The remaining five had explantations due to chronic fabric fatigue (CFF) with type IIIB EL within three years of re-intervention. Our isolated type II ELs had spontaneous resolution rate of 41.84% (n = 41) and none ruptured. For aortic sac hygromas, aortic sacotomy, hygroma evacuation and aneurysmorrhaphy by double breasting and plication of the aneurysm sac over EVAR graft were performed. In contrast, our type III ELs were managed initially with explantation; however, when our experience matured, we employed EVAR GORE SalvAge Fabric Technique (ARAFAT) in high-risk patients. ARAFAT involved the deployment of an oversized EXCLUDER® aortic cuff into previously implanted stent graft, with the simultaneous deployment of EXCLUDER® iliac extensions as necessary in double-barrel configuration from the main cuff.¹

Results: In total, 44 patients underwent re-intervention post-primary EVAR: 18 EVAR GORE SalvAge Fabric Technique (ARAFAT), 12 double breasting, and 14 explantations. Mean EL detection duration following primary EVAR was 53.3 ± 6.82 months, while re-intervention time was 70.2 ± 6.98 months. Before the primary EVAR and re-intervention, the mean sac size was 6.00 and 7.51 cm. Polyester (61.40%) was the most commonly employed stent-graft material. Factors associated with the need for reintervention and the likelihood of CFF failure included using more than three modular stent-graft components (3.42 ± 1.31); with the proximal stent-graft diameter of 31.6 ± 3.80 cm and the use of iliac limbs more than 18 mm. We had one peri-operative mortality following explantation due to sepsis-induced multiorgan failure.

Conclusion: Increasing complications post-EVAR necessitates developing and studying re-intervention strategies to salvage existing endograft and/or address graft-related complications.

Re-intervention strategies Fig. 1 Flowchart depicting the adoption of the re-intervention strategies (EVAR GORE SalvAge FAbric Technique (ARAFAT), Double Breasting, and Explantation) following Prone ContrASt EnHanced Computed Tomography Angiography (PASHA).

Reference

1. Sultan S, Acharya Y, Atteia E, Hynes N. Management of Concealed Type IV Endoleak and Aortic Sac Hygroma by Prone ContrASt EnHancement Computed Tomography Angiography. Ann Vasc Surg 2021;72:647–661 PubMed

Publication History

Article published online:
10 June 2022