Midterm results of aneurysmorrhaphy for enlargement after endovascular aneurysm repair.

Abstract

Although endovascular aneurysm repair (EVAR) is a standard treatment for abdominal aortic aneurysms, postprocedural aneurysm expansion caused by types II and V endoleaks (ELs) remains challenging. Aortic graft replacement is a definitive solution, but is associated with high morbidity and mortality, especially in elderly patients. Aneurysmorrhaphy has emerged as a less invasive alternative. This study evaluated the midterm outcomes of aneurysmorrhaphy after EVAR and identified factors associated with aneurysm re-expansion. This retrospective study included 50 patients who underwent aneurysmorrhaphy after EVAR from 2016 to 2021. Indications included aneurysm expansion owing to type II or V ELs. Surgery was performed using a transperitoneal approach with aneurysm sac opening, thrombus removal, and plication without graft replacement. Intraoperative EL diagnosis and preoperative computed tomography findings were compared. Survival, reintervention, and risk factors for re-expansion were assessed by Kaplan-Meier analysis and logistic regression. The intraoperative morbidity rate was 6%, the perioperative mortality rate was 0%, and the postoperative morbidity rate was 12%. Compared with preoperative computed tomography findings, the diagnosis was changed in 13 cases (26%). Among the cases initially diagnosed as type II EL alone, two cases had concomitant type Ib EL, and seven cases were type IIIb EL. The mean follow-up period was 4.5 years. The 5-year survival and reintervention-free rates were 90% and 92%, respectively. Notably, the 5-year freedom from aneurysm re-expansion rate was only 84%. Residual ELs and dead space areas were notable predictors of re-expansion. Receiver operating characteristic analysis identified a dead space threshold of 70%, above which re-expansion risk was significantly greater. Aneurysmorrhaphy is a viable alternative to graft replacement for post-EVAR aneurysm expansion, especially in high-risk patients. However, the risk of re-expansion remains critical, particularly when dead space reduction is inadequate. Careful patient selection and further research can optimize long-term outcomes.