Surgical conversion after thoracic endovascular aortic repair

Objective: Improved early and late outcomes of thoracic endovascular aortic repair compared with open repair have changed the therapeutic paradigm of thoracic aortic lesions. However, rare but serious complications due to device failure or adverse events may occur, requiring conversion to open repair. Methods: In our experience, 186 patients underwent thoracic endovascular aortic repair. Seven of these patients (3.7%) required open repair because of 3 retrograde type A dissections, 1 thoracic stent-graft collapse, 1 aneurysm enlargement without endoleak, 1 aortoesophageal fistula, and 1 stent-graft infection. All patients but 1 underwent surgical repair using cardiopulmonary bypass. Four stent-grafts were totally removed, and 3 endografts were left in situ. Three patients underwent supracoronary ascending aorta replacement via a sternotomy. Three patients underwent a descending aortic replacement via a left thoracotomy. One patient was treated by ligation of the aortic arch, ascending to supraceliac abdominal aorta bypass, and stent-graft explantation. Results: Thirty-day mortality was 28%. Four patients had an uneventful postoperative course. One patient was treated for postoperative sternitis. Two patients with stent-graft infections died of multiorgan failure in the early postoperative course. No stroke, paraplegia, or renal failure occurred. With a mean follow-up of 21.4 months (range, 2-60 months), 5 patients had no adverse events. Conclusions: Complications due to device failure or adverse events may occur after thoracic endovascular aortic repair, requiring conversion to open repair. Our experience suggests that in some clinical or anatomic situations, caution should be recommended when offering endovascular procedures to patients with thoracic aortic diseases. Open conversion can be performed with encouraging results by a team experienced in the management of thoracic aortic diseases. With the increasing use of thoracic endovascular aortic repair, more patients will present with indications of surgical conversion. (J Thorac Cardiovasc Surg 2011;142:1027-31)