Tag Archives: AAA

Endograft Explant and Open AAA Repair

It was a day I saved since two week prior, and I am sure my seniors did the same. It was a big case, an endograft explant and open AAA repair for a type 1a endoleak due to caudad migration of AneuRx graft. It was a day to look forward. In addition, the patient was a pleasant gentleman, which added more warmth to our excitement.

Intra-operatively, we made a midline laparotomy,  dissected down to the peritoneum, moved the omentum and transverse colon up, small bowel to the right in a bowel bag, set up the Omni retractor set up. For the AAA dissection, retroperitoneum was dissected  towards the L renal vein while staying to the right of SMA, and distally the iliac arteries/limbs of graft were vessel looped. We then gave a small amount of heparin and went to work.  Initially, clamp was placed below the left renal artery and above the right renal due to severe downward and left angulation of the aneurysm. Conveniently, his right kidney was small and likely diminished in function.  Aorta was then transected with bevel at posterior wall and the AneuRx endograft was taken out along with struts. We moved the clamp infra-renal, and completed the proximal anastomosis. Afterwards, we moved the clamp to the graft and finished the anastomoses to both distal endograft iliac limbs. Hemostasis took sometime, but we eventually closed the retroperitoneum, put the bowels back and closed the abdomen.

The preparation for surgery and post-op care were just as important as the intra-operative techniques. Bowel prep, medical adjustment and consultation, and patient instructions before the surgery day were extensive. Post-op, he was intimately followed by the SICU team as well as the vascular surgery team, and each aspect of his organ system management were analyzed and communicated thoroughly. To our amazement, despite having multiple co-morbidities such as COPD, CAD, DM, etc he made a complete recovery and was transferred to floor on POD#4 and discharged home soon after.

One paper states removal of endograft using a proctoscope, as it’s easy to resheath

Some of the takeaways and learning points are listed below:

– During explantation of prior endograft, don’t pull out graft too hard, as this can tear the neck and makes it fragile to sew. There is tissue ingrowth and retroperitoneal inflammation.
– After clamping with Fogarty hydrogrip (with padding), check the sac for pulsatility. If there is then it’s not adequately controlled and will bleed.
– Endoleak remains the most common reason for elective explant.
– Late AAA endograft explant: indication and outcomes (Northwestern) – Indications included 9 device failures, 6 endograft infections, and a single type II endoleak with sac enlargement. 75% requiring supraceliac control. Reconstructions depended on clinical manifestations and included 10 in situ prosthetic repairs, 4 extra-anatomic bypasses, and 2 in situ cryopreserved human allograft repairs. 13% mortality rate. Mean hospitalization for survivors was 18 days (range, 6-78 days), and 7 (50%) of the patients were discharged directly home.
– If removal is due to infection, then should attempt to remove all barbs and not leave anything in situ. Proctoscope might help resheath.
– Partial explant (Cleveland Clinic) – 22 patients had a partial late EVAR explantation. Of these 22 patients, there were four patients with proximal components remaining, 17 patients with distal components remaining, and one patient with both proximal and distal components left. Nine of the 22 (41%) had postoperative and follow-up CT imaging, of which none of these patients had migration of their remaining graft components. The average length of follow-up in these nine patients was 25.9 months. Four of the 22 patients (18%) died secondary to postoperative infection, shock, and organ failure after explant.

Patient was extubated POD1, off of all pressors POD2, transferred to floor POD5 and discharged soon after. This has been one of those stories that makes you want to go into a particular specialty, and it was a pleasure caring for this patient, seeing him from pre-op all the way to stablization and discharge.

Comment on “Incidence of Myocardial Infarction After High-Risk Vascular Operations in Adults” by Yen-Yi Juo et al. JAMA Surg. 2017

Question raised by the paper – MI incidence in high risk vascular surgery didn’t decrease despite advanced cardiac care pre-op (2.7% 30 day MI in 2009; 3.1% in 2014).
My comment on this paper – This study only analyzed high risk procedure includes open AAA and infrainguinal bypass. Endovascular intervention was not included so SHOULD NOT BE MENTIONED ANYWHERE IN THE ARTICLE.
This study has poor generalizability. It is retrospective study on a very unspecific database. NSQIP database lacks specifics on location of cross-clamping in aortic cases and detailed perioperative medical management. Study population is predominantly white, and criteria for MI was not specified and only included up to 30 days.
With the advancement of endovascular intervention, more AAA and TAAA are treated with simple or complex EVAR (branched or fenestrated). The more emergency procedure in open AAA cohort reflects the makeup of open procedure for AAAs, as more and more elective cases of AAA are done endovascular. Open aortic procedure are also becoming increasingly complex, as the simple AAAs with adequate infrarenal aneurysm neck size, length, morphology are treated predominantly by EVAR. The leftover ones with aneurysm neck angulation and large diameter, juxtarenal/pararenal AAA, etc comprise the open AAA intervention. Thus, one can extrapolate that the open AAA procedures are becoming higher risk with expected poorer outcomes. It is no surprise that there is significantly higher actual incidence of post-op MI in open AAA repair [3.0%] vs [1.9%] in infrainguinal bypass, which is more of an elective procedure with subacute patient presentation. Therefore, pre-op cardiac workup and optimization are paramount. However, one cannot associate endovascular intervention with poorer outcome. EVAR, if anything, has made repair of AAA and TAAA into a low risk procedure, without the need for general anesthesia or cross clamp, and made even the rupture of AAA a controllable incident. It has made the cases of AAA/TAAA that require open approach more morbid procedure, but broad perspective that include all AAA/TAAA treated open and endovascularly would likely reflect an improvement in long term outcome of these patients.