Endovascular surgery for failed open aortic aneurysm repair

Determine the usefulness of endovascular surgery for repair of aortic lesions late after open surgical repair.

A retrospective analysis of our databank (Patient Analysis and Tracking System, Dendrite, UK) for 2000-2002 showed 286 descending thoracic and/or abdominal aortic aneurysms: 60/286 (21%) descending thoracic, and 255/286 abdominal (89%). Endovascular surgery was planned in 98 patients (17/60 (28%) for thoracic lesions, and 81/255 (32%) for abdominal lesions). 13/98 patients (13%) underwent endovascular surgery late after failed open aortic repair: 4/13 at the level of distal aortic arch (3/4 for false aneurysms post-coarctation repair), 4/13 at the level of the descending thoracic aorta (3/4 for false aneurysms proximal to the previous graft), and 5/13 at the level of the infrarenal abdominal aorta (4/5 for false aneurysms proximal to the previous graft). Endovascular surgery included per procedural target site identification (previous graft) with intravascular ultrasound (IVUS) under fluoroscopic control (no angiographies), controlled hypotension (partial inflow occlusion with a right atrial balloon introduced through a femoral vein) for unloading of covered endoprostheses in the thoracic aorta, as well as in situ introducer sheath dilatation in case of complex access to the aorta.

There were no hospital deaths and no parapareses or paraplegias in this small series of patients who underwent endovascular surgery for aneurismal lesions occurring late after open repair. An endoleak type I was documented in 2/13 patients (15%) requiring a proximal extension in 1 patient. For the second patient with a minor endoleak, a control examination is planned at 6 months of follow-up.

Endovascular surgery is an elegant approach for repair of recurring aortic lesions late after open aortic surgery. IVUS is a precious instrument for per procedural identification of the previous implants. However, long-term follow-up is mandatory after endovascular surgery.