Long-term outcomes of secondary procedures after endovascular aneurysm repair

Purpose: This study evaluated the outcomes of secondary procedures after endovascular aneurysm repair (EVAR). Methods: From 2002 to 2009, 1768 patients underwent EVAR for treatment of 1662 elective (94%) and 106 emergent (6%) infrarenal abdominal aortic aneurysm (AAA) with a variety of Food and Drug Administration-approved and commercially available stent grafts. Postoperative follow-up included clinical examination, pulse volume recording, duplex ultrasound imaging, and computed tomography and magnetic resonance angiography at 1, 6, and 12 months, and yearly thereafter. Patients with type I and III endoleaks, unexplained endotension, limb occlusion, stent graft migration, with and without type I endoleak, and aneurysm rupture underwent secondary interventions. Type II endoleak at >6 months without a decrease in the aneurysm sac underwent translumbar embolization. Data were prospectively collected. Results: EVAR was performed in 1768 patients. During a mean follow-up of 34 (SD, 30.03) months, 339 patients (19.2%) required additional secondary procedures for aneurysm-related complications, including type I (n = 51, 15.0%), type II (n = 136,40.1%), and type III (n = 5, 1.5%) endoleaks; endotension (n = 8, 2.4%), stent graft migration proximal fixation site (n = 46, 13.6%), stent graft iliac limb thrombosis or stenosis (n = 25, 7.4%), subsequent iliac aneurysm formation (n = 39, 11.5%), or aneurysm rupture after EVAR (n = 29, 8.6%). The mean age was 74 (SD, 9.15) years. Mean AAA size was 5.7 (SD 3.24) cm. Compared with secondary procedures for AAA rupture, the nonrupture patients had a significantly lower mortality (1.6% vs 17.2%, P < .05) and a higher likelihood of being managed by endovascular means (98.8% vs 44.8%, P < .05). When nonruptured EVAR patients required urgent secondary procedures for type I endoleaks and stent graft migration or limb thrombosis, the mortality was 6.0% vs 0.5% for elective procedures (P < .05). Conclusions: Our long-term EVAR experience indicates that 18% of patients require additional secondary procedures, and most of these patients can be managed by endovascular means with an acceptable overall mortality of 2.9%. Most type I and II endoleaks can be successfully treated by transluminal embolization, and most patients with delayed aneurysm rupture after EVAR can be successfully managed by endovascular or open surgical repair. (J Vase Surg 2010;52:1442-8.)