Increasing Technical Complexity of EVAR Conversion over Time Is Not Associated with Worse Outcomes at a High-Volume...

Open conversion after endovascular aneurysm repair (EVAR-c) remains a treatment strategy for EVAR failure. However, little is known regarding the evolution of EVAR-c practice. Advancements in surveillance and endovascular salvage may influence failure phenotypes, referral timing, and reconstructive complexity. We hypothesized that patients undergoing EVAR-c at aortic referral centers present increasingly later and with greater complexity.

EVAR-c procedures (n = 294) from a single center were stratified into equivalent eras by volume (Era-1:10/2002-7/2015; Era-2:8/2015-5/2020; Era-3:6/2020-1/2025; N = 98 each). The primary outcome was temporal change in operative complexity variables across eras. Secondary outcomes included 30-day mortality, interval to conversion, failure phenotype, length of stay, and complications.

Age was similar across eras (median 73[interquartile range (IQR) 67-80] vs. 76[68-80] vs. 72[67-77] years); however, contemporary cohorts had more total comorbidities (median 3[IQR 2-5] vs. 4[3-5] vs. 4[3-5]; P = 0.046). Time from EVAR to conversion increased (34[9-63] vs. 58[34-89] vs. 75[31-120] months; P < 0.001). Operative complexity increased over time, with greater use of retroperitoneal exposure (67% vs. 77% vs. 87%; P = 0.006) and renal/visceral bypass (7% vs. 21% vs. 46%; P < 0.001). Multivariable modeling confirmed increasing complexity over time (≥2 features: OR 1.11/year, 95% confidence interval [CI] 1.05-1.17; ≥3 features: OR 1.19/year, 95% CI 1.12-1.28; both P < 0.001). Elective 30-day mortality declined numerically (8% vs. 3% vs. 3%; P = 0.5), while nonelective mortality remained unchanged (21% vs. 21% vs. 15%; P = 0.8). Major complications, length of stay, and mid-term survival were similar.

EVAR-c has evolved toward later referral and greater operative complexity, reflecting progressive endograft failure in the contemporary EVAR population. Despite increasing complexity, perioperative outcomes remained stable. These findings support the role of specialized aortic centers in managing EVAR-c.