Secondary Intervention after Endovascular Abdominal Aortic Aneurysm Repair (EVAR)
*Andrew B Adams, *Mark F Conrad, *Julie M Guest, David C Brewster, *Glenn M LaMuraglia, Richard P Cambria
Massachusetts General Hospital, Boston, MA
OBJECTIVE: EVAR has been criticized because of the need for frequent secondary interventions (2ndINT) to maintain effective AAA exclusion. The study goal is to detail such interventions and determine their effect on clinical outcomes. METHODS: From 1/1997-12/2007, 832 patients underwent EVAR. Those requiring 2ndINT were stratified according to indication for 2ndINT and treatment. Study endpoints included freedom from 2ndINT, aneurysm related and overall survival. RESULTS: There were 91(11%) patients who required 2ndINT (mean follow-up 30 months). No demographic features(age, gender, etc) predicted the need for 2ndINT. 5-year freedom from 2ndINT was 82%. Indications for 2ndINT included: sac rupture(5.5%), graft migration (type I/type III) endoleak(30.7%), persistent type II endoleak(28.6%), endotension(2.2%) and limb occlusion/kinking(27%). Management and outcomes are summarized in Table I. The majority(75.6%) of 2ndINT were accomplished using an endovascular approach and open conversion was rare(4%). Initial 2ndINT were successful in 73% and 34(37.4%) patients underwent more than one 2ndINT. Multivariate predictors of 2ndINT were AAA sac size >5.5cm(OR=2.1,p=0.036) and pre-procedure coil embolization (hypogastric or inferior mesenteric artery)(OR=2.1, p=0.008). 5-year actuarial survival was 70% and the aneurysm related survival was 96% with no difference in either parameter in patients who underwent 2ndINT. CONCLUSIONS: 2ndINT are common after EVAR; most were accomplished through an endovascular approach with a 73% success rate and did not adversely affect aneurysm related or overall actuarial 5-year survival.
|Indication for 2ndINT||% Endo repair||% Open repair||% Hybrid repair||%success w/ 1st 2ndINT||#PatientDeaths|
|Type II endoleak (n=26)||96.1||3.9||0||26.9||0|
|Type I, III, & IV endoleak (n=30)||76.6||0||23.3||96.7||0|
|Limb occlusion/ kinking (n=25)||64||28||8||96||0|