Open Aortic Repair After Thoracic Endovascular Aortic Repair: Strategic Insights From a Single Centre Surgical Experience

• Published in: EJVES vascular forum 2024-12
• Main Authors: Iba, Yutaka, Nakajima, Tomohiro, Nakazawa, Junji, Shibata, Tsuyoshi, Miura, Shuhei, Kawaharada, Nobuyoshi
• Format: Article
• Language: English
• Subjects: Aortic Aneurysm; Aortic Dissection; Complication; Thoracic Endovascular Aneurysm Repair
• ISSN: 2666-688X; 2666-688X
• DOI: 10.1016/j.ejvsvf.2024.12.001

Thoracic endovascular aortic repair (TEVAR) is widely used in thoracic aortic surgery. However, some patients require secondary open aortic repair for various reasons. Herein, the surgical outcomes and problems of such open conversion surgery after TEVAR are investigated. This was a retrospective and observational study. From January 2010 to June 2022, 20 patients who underwent open aortic repair after TEVAR were included. The indications for open conversion surgery were as follows: aortic enlargement due to endoleak (EL) in seven patients (type Ia: n = 4, type II: n = 1, type V: n = 2; 35%), stent graft infection including aorto-oesophageal fistula (AEF) in six (30%), retrograde type A aortic dissection (RTAD) in three (15%), and dilatation of adjacent distal aorta or false lumen in four (20%). Seven patients with type Ia EL or RTAD required open aortic arch repair. Four underwent thoracoabdominal aortic repair for distal aortic enlargement. Descending thoracic aortic replacement was performed in all six infection cases and two patients with type V EL. Furthermore, three patients with AEF received concomitant oesophagectomy. One patient with persistent type II EL underwent intercostal artery ligation and aneurysmorrhaphy via thoracotomy. There were two in hospital deaths (10%), all with AEF. Thus, the rates of in hospital death were 0% in non-infected cases, 33% in graft infections, with 66% in those with AEF. Stroke and paraplegia were observed in two patients (10%). When open conversion surgery is required after TEVAR, the indications are complex, often associated with infectious pathology, and are necessarily high risk particularly in patients with AEF. Surgical strategy has to be individualised based on the nature/cause of the complication and extent of aortic involvement.