The durability of endovascular repair of para-anastomotic aneurysms after previous open aortic reconstruction

Introduction: Anastomotic pseudoaneurysms and true para-anastomotic aneurysms after initial open abdominal aortic prosthetic reconstruction often need reintervention because they are at risk for rupture. However, open surgical reinterventions are technically challenging procedures with high mortality and morbidity rates. In the present multicenter study, we describe the long-term clinical course in an expanded number of patients who underwent endovascular repair of para-anastomotic aneurysms after previous open reconstruction.

Methods: The study included all patients who were treated with an endovascular stent graft between July 1999 and July 2009 for an aortoiliac anastomotic pseudoaneurysm or a true para-anastomotic aneurysm after previous aortic prosthetic reconstruction for aneurysmal or occlusive disease in one of the four participating centers. Main outcomes were long-term complications, reinterventions and conversion rate, mortality, and hospital length of stay.

Results: An endovascular stent graft was used to treat 58 patients (53 men; mean age, 71 ± 9 years), with 80 aortic or iliac pseudoaneurysms or true para-anastomotic aneurysm, or both. Bifurcated stent grafts were used in 32 patients, endovascular tube grafts in eight, aortouniiliac stent grafts in seven, and iliac extension grafts in 11. Stent graft deployment was successful in 55 patients, for a technical success rate of 95%. Median hospital admission was 3 days (range, 1-122 days). The 30-day and in-hospital mortality rates were 3.4% (n = 2) and 6.9% (n = 4), respectively. The 30-day clinical success rate was 91% (n = 53). Median follow-up was 41 months (range, 0-106 months). The cumulative and procedural-related mortality during follow-up was 19% (n = 11) and 10% (n = 6), respectively. Follow-up computed tomography angiography revealed nine endoleaks (three type I; six type II) in eight patients and endotension in two patients. The overall reintervention and conversion rate during follow-up was 26.9% (n = 15) and 6.9% (n = 4), respectively. Life-table analysis showed reduced freedom from reintervention for aortouniiliac and tube stent grafts. Type I endoleaks were observed in 25% of patients with endovascular aortic tube grafts for proximal anastomotic aneurysms.

Conclusions: The present study demonstrates that endovascular repair of para-anastomotic aortic and iliac aneurysms after initial prosthetic aortic surgery is safe and durable in patients with an appropriate anatomy. The long-term follow-up showed fewer complications occurred after procedures with bifurcated stent grafts compared with procedures with tube grafts, aortouniiliac, or iliac extension stent grafts.