Infective etiology affects outcomes of late open conversion after failed endovascular aneurysm repair

PURPOSE: To retrospectively review all patients undergoing late open conversion (LOC) after endovascular aneurysm repair (EVAR) in order to identify any clinical or technical predictors of poor outcome. METHODS: Twenty-six consecutive patients (24 men; mean age 74.7 ± 8.3 years) underwent LOC between June 2006 and April 2013 at our institution. The mean interval from index EVAR to LOC was 40.4 ± 29.2 months (range 5-93 months). The indication for LOC was endoleak in 14 (54%) patients and infection in 12 (46%): 2 (8%) patients with endoleak had a ruptured aneurysm and 6 (23%) patients with infection had a recurrent secondary aortoesophageal fistula (sAEF). RESULTS: In all 12 cases of infection and in 12 of 14 endoleaks, the entire endograft was explanted. A rifampin-soaked Dacron silver graft was implanted in all patients with infection. Patients with any infection and with recurrent AEF required more blood units than patients with endoleak (6.40 vs. 1.86, p = 0.045; 6.76 vs. 1.86, p = 0.0036, respectively). Compared with endoleak, the duration of conversions in the setting of infection (274 vs. 316 minutes, p = 0.42) and recurrent sAEF (274 vs. 396 minutes, p = 0.021) was longer. All patients with recurrent sAEF died at a mean 3.0 ± 2.5 days after LOC from proximal anastomosis disruption and hemorrhagic shock (n = 2), myocardial infarction (n = 2), acute stroke (n = 1), or persistent sepsis (n = 1). Perioperative mortality was significantly higher in patients with endograft infection (6/12, p = 0.002) and in cases of supraceliac cross-clamping (4/6, p = 0.003). The association of infection with supraceliac cross-clamping was a strong predictor for perioperative mortality (p < 0.001). CONCLUSION: In our experience, endograft infection led to greater perioperative mortality after LOC. Recurrent aortoenteric fistula in association with supraceliac cross-clamping is a strong predictor of poor outcome. Patients surviving the perioperative period may have good chances of long-term survival.