Contemporary outcomes of open conversion after failed endovascular aortic aneurysm repair from a high-volume aortic center.

Abstract

Open conversion after failed endovascular aneurysm repair (EVAR-c) is associated with higher morbidity and mortality relative to native open aneurysm repair, particularly in non-elective settings. These concerns drive enthusiasm for endovascular salvage strategies; however, high-volume aortic centers can achieve excellent open abdominal aortic aneurysm (AAA) outcomes, potentially influencing EVAR-c results. Although worse outcomes are expected after non-elective presentations, comparing elective and non-elective EVAR-c highlights distinct patient phenotypes, technical demands, and outcome profiles that can guide management. We reviewed our single-center experience to characterize operative strategies, complications, and survival after EVAR-c. A retrospective review of all EVAR-c performed at our high-volume aortic center (2002-2025) was performed. Patients were stratified as elective or non-elective (rupture, intraoperative conversion, infection, and/or aorto-enteric fistula). The primary outcome was 30-day mortality. Secondary outcomes included postoperative complications, 90-day mortality, discharge disposition, and long-term survival. Among 294 EVAR-c procedures, 193 (66%) were elective and 101 (34%) were non-elective. The median age was 73 years, and 84% were male, with comparable comorbidity profiles between groups. Non-elective indications included rupture (54%), mycotic aneurysm (32%), aorto-enteric fistula (10%), and intraoperative conversion (4%). Elective conversions were predominantly for endoleak (85%; type 1a/1b in 70%). Elective EVAR-c occurred later after the index endovascular aneurysm repair (EVAR) (60 months; interquartile range [IQR], 31-105 months) vs non-elective (34 months; IQR, 6-73 months; P < .001). Non-elective procedures involved more complex reconstructions, including higher rates of supra-mesenteric cross-clamping (67% vs 50%; P = .006), total graft explant (59% vs 21%; P < .001), and adjunctive intraoperative procedures (49% vs 30%; P = .002). They were also associated with greater blood loss (3.0 vs 2.0 L; P < .001), higher transfusion requirements (5 units [IQR, 3-8 units] vs 2 units [IQR, 0-3 units]; P < .001), and longer operative times (4.4 hours [IQR, 3.0-5.4 hours] vs 3.2 hours [IQR, 2.5-4.5 hours]; P < .001). Overall 30-day mortality was 10% (non-elective, 19% vs elective, 5%; P < .001). Ninety-day mortality was 25% vs 10% (P = .001). Median length of stay was 11 days [IQR, 8-17 days] (non-elective 14 vs elective 10 days; P < .001). Major complications occurred in 63% of patients, more frequently after non-elective EVAR-c (79% vs 55%; P < .001), including bowel or limb ischemia (9% vs 2%; P = .004) and new hemodialysis requirement (15% vs 6%; P = .02). Five-year survival was 66% ± 5% for non-elective and 80% ± 3% for elective procedures, with similar trajectories beyond 90 days (log-rank P = .007). EVAR-c is resource-intensive and associated with high complication rates and prolonged hospitalization, particularly after non-elective presentations. Elective EVAR-c, however, can be performed with low mortality and acceptable morbidity at experienced centers. Although elective and non-elective procedures represent distinct clinical phenotypes with different technical challenges and resource requirements, these data underscore the importance of early detection of failing EVAR, timely referral for elective conversion, and centralization of care in specialized aortic centers to optimize outcomes.