Late open conversion after TEVAR

The aim of this paper was to characterize indications, describe repair methods and report outcomes of patients undergoing late open conversion (LOC) after thoracic endovascular aortic repair (TEVAR).

From to 1999 to 2015, 65 patients underwent redo procedures after TEVAR at our Institution. Thirty patients underwent LOC. The average time from the index TEVAR to LOC was 57 months (range 2-98 months). Indication to LOC was progression of distal aortic disease in nine patients (30%), stent-graft infection/fistulization in 10 (33.3%), retrograde dissection in 6 (20%), endoleak in 3 (10%), device migration/failure in 2 (6.7%). Left heart bypass and cerebrospinal fluid drainage were used in 22 (73.3%) and 16 (53.3%) cases, respectively. In 17 patients (56.6%) thoracic stent-graft was only partially removed and the proximal anastomosis was performed including the native aorta, the stent-graft and the surgical graft. Biological flap coverage with intercostal muscle flap was used 6 six of infected cases.

Overall perioperative mortality rate was 16.6% (5 patients) - 20% in the subgroup of patients with stent-graft infection/fistulization (2 patients) and 33% in the subgroup with retrograde dissection (2 patients). Respiratory failure was the most common complication with seven cases (23.3%). Paraplegia was observed in 1 patient (3.3%). At a mean follow-up of 19 months (range, 5-63) there was 1 aortic-related death for aorto-esophageal fistula.

Open conversion after TEVAR was feasible leaving in site the proximal segment of the thoracic stent-graft in most of the cases. The risk of death and morbidity was higher in case of infection, fistula and retrograde dissection.