Surgical strategy for conversion to open repair after endovascular treatment of abdominal aortic aneurysm

Aim. Conversion to open surgery after endovascular aneurysm repair (EVAR) still represents a challenging problem for vascular surgeons. The purpose of this study was to review our experience with open conversion following EVAR and to examine the indications, operative strategies, and technical maneuvers that may facilitate primary and secondary conversion. Methods. From April 1997 to December 2005, a total of 127 EVARs were successfully treated. Thirteen patients (10.2%) required conversion to open repair: 4 patients underwent primary conversion to surgical repair and 9 patients underwent secondary conversion at an average of 17 months (range, 6-28 months). Results. Suprarenal or supraceliac aortic control was performed in 8 cases (61%), infrarenal aortic control was performed in five patients. In 11 patients (84%) total explanation of the endograft was preferred; partial removal of the endograft was performed in one case and a transperitoneal sacotomy without explantation was performed in one case. There were no intraoperative deaths; two perioperative deaths were observed 15 days after operation, due to myocardial infarction after early conversion and to acute renal insufficiency after secondary conversion (mortality rate in secondary conversion: 11%). Postoperative complications included one case of paraplegia and one case of respiratory failure. Conclusion. Conversion to open surgery after EVAR requires an adequate preoperative planning, carefully considering the differences among endograft designs; surgical procedure eventualities include suprarenal cross-clamping, partial removal of endograft in selected cases, transperitoneal sacotomy without explantation of the graft in type II endoleak.