Open Thoracic Surgical Procedures to Treat Early and Late Aortic Complications Post Endovascular Repair of the Thoracic Aorta: lessons learned.

O.K. Steinmetz, K. S. MacKenzie, M. M. Corriveau, C.Z. Abraham, D. Obrand
Division of Vascular Surgery, McGill University, Montreal, Quebec

Purpose:  Endovascular treatment of thoracic aortic pathology(TEVAR) has emerged as a viable alternative to open surgical repair.  Longterm follow-up of these patients with imaging studies is required to detect complications requiring secondary interventions. The aim of this study was to evaluate the need for open surgical intervention to treat early and late aortic complications post TEVAR. We evaluated the indications, preoperative work-up, intra-operative strategy, and outcomes of these procedures.

Methods and Patients:  All patient information was obtained by a retrospective review of an established clinical database for all endovascular thoracic stent graft cases. From October 1999 to March 2007, 100 patients were treated with TEVAR with a median follow-up 22 months (range 0-70).  We reviewed the cases of  7 patients (6 from our series, and 1 case who had TEVAR at another institution) who required open surgical intervention to treat early or late aortic complications post TEVAR.

Results:  Median time from TEVAR to intervention was 26 months(range 6 days-57 months). Indications for surgical intervention were retrograde dissection of proximal ascending aorta (1), endoleak (4), graft infection (5), aortoesophageal fistula (2), aortobronchial fistula (2). Overall mortality was 29% (2 cases) and was associated with uncontrolled sepsis in both. Circulatory arrest with deep hypothermia was used with success for explantation of proximal (zone 1 and 2) endografts. Left atriofemoral partial bypass was used during endograft explantation of more distal lesions. All cases are summarized in the table below.

Conclusions:   Aortic complications after TEVAR which require open surgical reintervention are seen infrequently. However, these complications can occur years after the initial procedure. This experience underscores the importance of ongoing clinical and radiologic followup of all patients undergoing TEVAR. Operative mortality is high for these open surgical interventions, but long-term survival and control of local sepsis can be achieved in the majority of patients.