Partial and Complete Explantation of Aortic Endografts in the Modern Era.
Publication Title
Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Document Type
Article
Publication Date
7-19-2022
Keywords
washington; everett; prmc
Abstract
OBJECTIVES: Despite the progressive advancement of devices for endovascular aortic repair (EVAR), endografts continue to fail, requiring explant. We present a single-institutional experience of EVAR explants, characterizing modern failure modes, presentation, and outcomes for partial and complete EVAR explantation.
METHODS: A retrospective analysis was performed of all EVARs explanted at an urban quaternary center from 2001-2020, with one infected endograft excluded. Patient and graft characteristics, indications, and perioperative and long-term outcomes were analyzed. Partial versus complete explants were performed per surgeon discretion without predefined protocol. This was informed by patient risk factors; asymptomatic, symptomatic, or ruptured aneurysm presentation; and anatomical or intraoperative factors including endoleak type.
RESULTS: From 2001-2020, 52 explants met inclusion and exclusion criteria. Over half (57.7%) were explants of EVAR devices placed at outside institutions, designated non-index explants. Most were male (86.5%), median age was 74 years (IQR 70-78). Over half (61.5%) were performed in the second decade of the study period. The most commonly explanted grafts were Gore Excluder (9 grafts), Cook Zenith (8), Endologix AFX (7), Medtronic Endurant (5), and Medtronic Talent (5). Most (78.8%) were explanted for neck degeneration or sac expansion. Five were explanted for initial seal failure, five for symptomatic expansion, and seven for rupture. Median implant duration was 4.2 years, although ranging widely (IQR 2.6-5.1 years), but similar between index and non-index explants (4.2 versus 4.1 years). Partial explantation was performed in 61.5%, with implant duration slightly lower, 3.2 years versus 4.4 years for complete explants. Partial explantation was more frequent in index explants (68.2% versus 56.7%). Median length of stay (LOS) was 8 days. Median ICU LOS was 3 days, without significant differences in non-index explants (4 versus 3) and partial explants (4 versus 3). 30-day mortality occurred in two non-index explants (one partial and one complete explant). 30-day readmission was similar between partial and complete explants (9.7% versus 5%), without accounting for non-index readmissions. Long-term survival was comparable between partial and complete explants in Cox regression (hazard ratio 2.45, 95% CI [0.79 - 7.56], p=0.12).
CONCLUSION: Explants of EVAR devices have increased over time at our institution. Partial explant was performed in over half of cases, per operating surgeon discretion, demonstrating higher blood loss, more frequent AKI, and longer ICU stays, however with comparable short-term mortality and long-term survival.
Area of Special Interest
Cardiovascular (Heart)
Specialty/Research Institute
Cardiology
Specialty/Research Institute
Surgery
Specialty/Research Institute
Critical Care Medicine
