Die späte offene Semikonversion mit Prothesenerhalt bei (Typ II­)Endoleckagen mit spätem Aneurysmasackwachstum nach EVAR - Indikationen, Methode und Ergebnisse im eigenen Patientenkollektiv

Zusammenfassung

Hintergrund

Die EVAR (englisch: Endovascular Aortic Repair) ist inzwischen die häufigste Methode zur Ausschaltung eines Bauchaortenaneurysmas, birgt jedoch prinzipiell und – nach neusten Erkenntnissen klinisch bestätigt – die Gefahr später auftretender Komplikationen. Diese können u. a. durch ein (spätes) Aneurysmasackwachstum entstehen. Sind konservative und interventionelle Therapiemaßnahmen diesbezüglich ausgeschöpft, so ist eine offene Konversion vonnöten, um einer Aneurysmaruptur vorzubeugen. Hierzu stehen mehrere Verfahren zur Verfügung, bei denen die EVAR-Prothese komplett erhalten werden kann oder (partiell) entfernt wird. Die späte offene Semikonversion mit In-situ-Erhalt der EVAR-Prothese und Raffung des Aneurysmasacks kann für den Patienten im Vergleich zur vollständigen Konversion eine weniger belastende Operationsmethode darstellen. Ziel der vorliegenden Arbeit ist die Darstellung der Operationsmethode samt Indikationen und technischen Hinweisen sowie die Präsentation der Ergebnisse im rezenten klinikeigenen Patientenkollektiv.

Patienten und Methoden

Alle Patienten, die in unserer Klinik für Gefäßchirurgie und Phlebologie aufgrund einer (Typ-II-)Endoleckage semikonvertiert wurden, wurden eingeschlossen. Alle Daten werden als n (%) bzw. Median (Spannweite) angegeben.

Ergebnisse

Zwischen 6/2019 und 3/2023 wurde bei 13 Patienten eine Semikonversion durchgeführt. Diese fand 6 (2–12) Jahre (Median, Spannweite) nach der initialen EVAR statt, der Aneurysmasackdurchmesser lag zum Zeitpunkt der Semikonversion bei 69 mm (58–95 mm). Die Operationszeit lag bei 114 min (97–147 min), der Blutverlust bei 100 ml (100–1500 ml). Fünf (38%) Patienten erhielten intraoperativ, 2 (15%) postoperativ Bluttransfusionen. Der Aufenthalt auf der Intensivstation dauerte 1 (1–5) Tage, die Hospitalisationszeit betrug 8 (6–11) Tage. Postoperative Komplikationen waren Darmatonie (3 [23%], 1 [8%] mit Nausea/Emesis und Magensondeneinlage), Anämie (2 [15%]), Hyponatriämie (2 [15%]), Delir (1 [8%]), COVID-19-Infektion (1 [8%]) sowie 1 [8%] intraabdominelle Nachblutung mit der Indikation zur operativen Revision und der Transfusion von 8 EKs.

Schlussfolgerung

Die Semikonversion ist eine sicher durchführbare und mit weniger schweren Komplikationen behaftete Operationsmethode für ein ausgewähltes Patientenkollektiv und sollte als Alternative zu invasiveren Methoden mit (partieller) Prothesenentfernung in Betracht gezogen werden. Weitere Untersuchungen zum Vergleich der Semikonversion mit der vollen Konversion sind im Langzeitverlauf notwendig um ihre Vorteile zu belegen.

Abstract

Background

EVAR (endovascular aortic repair) is the most common method for treating an abdominal aortic aneurysm, but according to the latest findings it carries the risk of subsequent complications. These can be caused by (late) aneurysm sac growth. If conservative and surgical therapies fail to treat the aneurysm sac growth, open conversion is necessary to prevent aneurysm rupture. There are several options for open conversion, in which the EVAR prosthesis can be completely preserved or is (partially) removed. Late open semi-conversion with complete in-situ preservation of the EVAR-prosthesis and gathering of the aneurysm sac are a less invasive method than complete conversion and may be performed instead for selected patients. The aim of the present work is to present the surgical method, including indications and technical information, as well as the presentation of the results in our recent patient collective.

Patients and Methods

All patients semi-converted in our department of vascular surgery and phlebology due to (type II) endoleak were included. All data are presented as n (%) or median (range).

Results

Between 6/2019 and 3/2023, 13 patients underwent semi-conversion 6 (2–12) years (median, range) after the initial EVAR. The aneurysm sac diameter at the time of semi-conversion was 69 mm (58–95 mm), the operating time was 114 min (97–147 min), the blood loss was 100 ml (100–1500 ml). Five (38%) patients received blood transfusion intraoperatively and 2 (15%) postoperatively. The stay in the intensive care unit lasted 1 (1–5) days, the hospitalisation time was 8 (6–11) days. Postoperative complications were intestinal atony (3 [23%], 1 [8%] with nausea/emesis and gastric tube insertion), anaemia (2 [15%]), hyponatraemia (2 [15%]), delirium (1 [8%]), COVID-19 infection (1 [8%]) and 1 [8%] intra-abdominal postoperative bleeding with the indication for surgical revision and the transfusion of 8 erythrocyte concentrates.

Conclusion

Semi-conversion is a safe and practicable surgical method with few severe complications for a selected group of patients, which should be considered as an alternative to more invasive methods with (partial) removal of the EVAR-prosthesis. Further long-term studies comparing semi-conversion to full conversion are needed to demonstrate its benefits.

Schlüsselwörter

späte offene Konversion nach EVAR - Semikonversion - Prothesenerhalt - spätes Aneurysmasackwachstum

Keywords

late open conversion after EVAR - semi-conversion - endograft preservation - late aneurysm sac growth

Publication History

Received: 28 June 2023

Accepted after revision: 09 September 2023

Article published online:
16 October 2023

• Literatur

• 1 Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991; 5: 491-499 DOI: 10.1007/BF02015271. (PMID: 1837729)
• 2 Chaar CI, Eid R, Park T. et al. Delayed open conversions after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2012; 55: 1562-1569.e1 DOI: 10.1016/j.jvs.2011.12.007. (PMID: 22503183)
• 3 Mohapatra A, Robinson D, Malak O. et al. Increasing use of open conversion for late complications after endovascular aortic aneurysm repair. J Vasc Surg 2019; 69: 1766-1775 DOI: 10.1016/j.jvs.2018.09.049. (PMID: 30583895)
• 4 Haidar H, Kapahnke S, Frese JP. et al. Risk factors for elective and urgent open conversion after EVAR-a retrospective observational study. Vascular 2022; DOI: 10.1177/17085381221141118. (PMID: 36413465)
• 5 Onitsuka S, Ito H. Surgical Treatment of Sac Enlargement Due to Type II Endoleaks Following Endovascular Aneurysm Repair. Ann Vasc Dis 2023; 16: 1-7 DOI: 10.3400/avd.ra.22-00115. (PMID: 37006865)
• 6 Greenhalgh RM, Brown LC, Kwong GP. et al. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004; 364: 843-848 DOI: 10.1016/S0140-6736(04)16979-1. (PMID: 15351191)
• 7 Patel R, Sweeting MJ, Powell JT. et al. Endovascular versus open repair of abdominal aortic aneurysm in 15-years’ follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet 2016; 388: 2366-2374 DOI: 10.1016/S0140-6736(16)31135-7. (PMID: 27743617)
• 8 Silverberg D, Baril DT, Ellozy SH. et al. An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach. J Vasc Surg 2006; 44: 453-459 DOI: 10.1016/j.jvs.2006.04.058. (PMID: 16950415)
• 9 Walker J, Tucker LY, Goodney P. et al. Type II endoleak with or without intervention after endovascular aortic aneurysm repair does not change aneurysm-related outcomes despite sac growth. J Vasc Surg 2015; 62: 551-561 DOI: 10.1016/j.jvs.2015.04.389. (PMID: 33568258)
• 10 Eden CL, Long GW, Major M. et al. Type II endoleak with an enlarging aortic sac after endovascular aneurysm repair predisposes to the development of a type IA endoleak. J Vasc Surg 2020; 72: 1354-1359 DOI: 10.1016/j.jvs.2020.01.038. (PMID: 32417014)
• 11 Sirignano P, Mangialardi N, Nespola M. et al. Incidence and Fate of Refractory Type II Endoleak after EVAR: A Retrospective Experience of Two High-Volume Italian Centers. J Pers Med 2022; 12: 339 DOI: 10.3390/jpm12030339. (PMID: 35330339)
• 12 Mangialardi N, Ronchey S, Orrico M. et al. Surgical conversion with graft salvage as a definitive treatment for persistent type II endoleak causing sac enlargement. J Vasc Surg 2015; 62: 1437-1441 DOI: 10.1016/j.jvs.2015.07.075. (PMID: 26386510)
• 13 Lal BK, Zhou W, Li Z. et al. Predictors and outcomes of endoleaks in the Veterans Affairs Open Versus Endovascular Repair (OVER) Trial of Abdominal Aortic Aneurysms. J Vasc Surg 2015; 62: 1394-1404 DOI: 10.1016/j.jvs.2015.02.003. (PMID: 26598115)
• 14 Hwang D, Kim HK, Huh S. Incidence and Risk Factors for Sac Expansion after Endovascular Aneurysm Repair of Abdominal Aortic Aneurysms. Vasc Specialist Int 2021; 37: 34 DOI: 10.5758/vsi.210035. (PMID: 34753833)
• 15 Madigan MC, Singh MJ, Chaer RA. et al. Occult type I or III endoleaks are a common cause of failure of type II endoleak treatment after endovascular aortic repair. J Vasc Surg 2019; 69: 432-439 DOI: 10.1016/j.jvs.2018.04.054. (PMID: 30686338)
• 16 Perini P, Gargiulo M, Silingardi R. et al. Late open conversions after endovascular abdominal aneurysm repair in an urgent setting. J Vasc Surg 2019; 69: 423-431 DOI: 10.1016/j.jvs.2018.04.055. (PMID: 30126779)
• 17 Turney EJ, Steenberge SP, Lyden SP. et al. Late graft explants in endovascular aneurysm repair. J Vasc Surg 2014; 59: 886-893 DOI: 10.1016/j.jvs.2013.10.079. (PMID: 24377945)
• 18 Lipsitz EC, Ohki T, Veith FJ. et al. Delayed open conversion following endovascular aortoiliac aneurysm repair: partial (or complete) endograft preservation as a useful adjunct. J Vasc Surg 2003; 38: 1191-1198 DOI: 10.1016/j.jvs.2003.09.012. (PMID: 14681610)
• 19 Wanhainen A, Verzini F, Van Herzeele I. et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57: 8-93 DOI: 10.1016/j.ejvs.2018.09.020. (PMID: 30528142)
• 20 Aho PS, Roth WD, Keto P. et al. Early elective conversion for failing EVAR. Scand J Surg 2005; 94: 221-226 DOI: 10.1177/145749690509400309. (PMID: 16259172)
• 21 De Bruin JL, Baas AF, Buth J. et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010; 362: 1881-1889 DOI: 10.1056/NEJMoa0909499. (PMID: 20484396)
• 22 Goudeketting SR, Fung Kon Jin PHP, Ünlü Ç. et al. Systematic review and meta-analysis of elective and urgent late open conversion after failed endovascular aneurysm repair. J Vasc Surg 2019; 70: 615-628.e7 DOI: 10.1016/j.jvs.2018.11.022. (PMID: 30956006)
• 23 Ascoli Marchetti A, Oddi FM, Tonidandel L. et al. Successful conversion strategy in patient submitted to EVAR demanding open surgery: comparative analysis 1997–2011 vs 2012–2020. Rev Cardiovasc Med 2021; 22: 1641-1647 DOI: 10.31083/j.rcm2204171. (PMID: 34957806)
• 24 Lopez-Espada C, Linares-Palomino J, Guerra Requena M. et al. Multicenter Comparative Analysis of Late Open Conversion in Patients With Adherence and Nonadherence to Instructions for Use Endovascular Aneurysm Repair. J Endovasc Ther 2022; DOI: 10.1177/15266028221102658. (PMID: 35735201)
• 25 Kansal V, Nagpal S, Jetty P. Editor’s Choice – Late Open Surgical Conversion after Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2018; 55: 163-169 DOI: 10.1016/j.ejvs.2017.10.011. (PMID: 29223353)
• 26 Perini P, Gargiulo M, Silingardi R. et al. Twenty-two Year Multicentre Experience of Late Open Conversions after Endovascular Abdominal Aneurysm Repair. Eur J Vasc Endovasc Surg 2020; 59: 757-765 DOI: 10.1016/j.ejvs.2020.01.011. (PMID: 32033872)
• 27 Jacobs CR, Scali ST, Khan T. et al. Endovascular aneurysm repair conversion is an increasingly common indication for open abdominal aortic aneurysm repair. J Vasc Surg 2022; 75: 144-152.e1 DOI: 10.1016/j.jvs.2021.07.121. (PMID: 34314833)
• 28 Kouvelos G, Koutsoumpelis A, Lazaris A. et al. Late open conversion after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2015; 61: 1350-1356 DOI: 10.1016/j.jvs.2015.02.019. (PMID: 25817560)
• 29 Nabi D, Murphy EH, Pak J. et al. Open surgical repair after failed endovascular aneurysm repair: is endograft removal necessary?. J Vasc Surg 2009; 50: 714-721 DOI: 10.1016/j.jvs.2009.05.024. (PMID: 19786235)
• 30 Scali ST, Runge SJ, Feezor RJ. et al. Outcomes after endovascular aneurysm repair conversion and primary aortic repair for urgent and emergency indications in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2016; 64: 338-347 DOI: 10.1016/j.jvs.2016.02.028. (PMID: 27288102)
• 31 Bellamkonda K, Ochoa Chaar CI. Open repair of type III endoleak with preservation of the endograft for a ruptured abdominal aortic aneurysm after endovascular aneurysm repair. J Vasc Surg Cases Innov Tech 2020; 7: 117-119 DOI: 10.1016/j.jvscit.2020.12.004. (PMID: 33718680)
• 32 Perini P, Gargiulo M, Silingardi R. et al. Multicenter comparison between open conversions and semi-conversions for late endoleaks after endovascular aneurysm repair. J Vasc Surg 2022; 76: 104-112 DOI: 10.1016/j.jvs.2022.01.023. (PMID: 35085746)
• 33 Xodo A, D’Oria M, Squizzato F. et al. Early and midterm outcomes following open surgical conversion after failed endovascular aneurysm repair from the “Italian North-easT RegIstry of surgical Conversion AfTer Evar” (INTRICATE). J Vasc Surg 2022; 75: 153-161.e2 DOI: 10.1016/j.jvs.2021.05.053. (PMID: 34182022)
• 34 Gambardella I, Antoniou GA, Gaudino M. et al. State of the art and meta-analysis of secondary open aortic procedure after abdominal endovascular aortic repair. J Vasc Surg 2019; 70: 1341-1350.e4 DOI: 10.1016/j.jvs.2019.01.092. (PMID: 31147115)
• 35 Phillips AR, Andraska EA, Reitz KM. et al. Any Postoperative Surveillance Improves Survival after Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2022; 80: 50-59 DOI: 10.1016/j.avsg.2021.09.047. (PMID: 34775012)
• 36 Torikai H, Inoue M, Nakatsuka S. et al. Imaging Findings of Atypical Type II Endoleak Through Vasa Vasorum After Abdominal Endovascular Aneurysm Repair. Cardiovasc Intervent Radiol 2018; 41: 186-190 DOI: 10.1007/s00270-017-1778-y. (PMID: 28861600)