Open conversion after endovascular aortic aneurysm repair with the Ovation Prime™ endograft

Advances in abdominal aortic aneurysm (AAA) endograft device technology have contributed to improved outcomes and durability of endovascular aortic aneurysm repair (EVAR), even in complex infrarenal aortic anatomies. However, stent graft failure secondary to endoleaks, migration, endotension and sac enlargement are persistent problems that can result in aneurysm rupture following EVAR. A symptomatic infrarenal AAA (4mm proximal neck) was treated initially with an Ovation Prime (TM) device (TriVascular, Inc., Santa Rosa, CA) in an off-label fashion, leading to type la endoleak moderately reduced by additional proximal neck ballooning. A failed Chimney technique to the single patent, but severely stenosed, right renal artery preceded the use of this device. A large type Ia endoleak was evident at 6-month follow-up, but following a failed supplementary endovascular intervention with coils to seal the endoleak, the patient presented with hemorrhagic shock from AAA rupture, requiring urgent open conversion. Intraoperatively it was impossible to explant this new type of endograft. Circumferential tying of the infrarenal aorta with a Teflon band was unable to stop the bleeding. However, after dividing the body of the stent-graft below the two proximal polymer rings, the endoleak was successfully treated by suturing the graft with the proximal aortic neck. The procedure was completed with extension of the stump to the common femoral arteries using a bifurcated Dacron prosthesis. The body of an Ovation Prime (TM) endograft may be impossible to explant in open conversion conditions. Large prospective studies with longer follow-up are required to adequately reflect the behavior of this particular device.