Late failure of endovascular aortic repair: Indications for and outcomes of endograft explantation.

Abstract

As endovascular aortic repair (EAR) has become more frequent over the past 3 decades, so has the need for endograft explantation followed by open aortic reconstruction (OAR). We retrospectively examined our experience and outcomes with these procedures. Between 1996 and 2025, 181 patients (median age 65 years [interquartile range, 53-72 years]; 70.2% male) underwent endograft explantation (33.7% partial and 66.3% complete) with OAR at our center. Previous EAR were primarily thoracic (48.1%) and abdominal (41.4%). We analyzed trends in practice, preoperative characteristics, operative details, early outcomes, and factors associated with operative mortality (death within 30 days of repair or before final hospital discharge). Survival was estimated with Kaplan-Meier and competing risk analyses. Median time from index EAR to explant was 2.7 years [interquartile range, 0.6-5.8 years] overall and was shorter (1.4 years [interquartile range, 0.2-3.4 years]) in patients with hereditary aortopathies. Endograft explantation increased from <1% of OAR cases (11/2150) in 1996-2005 to 6% (78/1214) in 2006-2015 to 20% (92/469) in 2016-2025. Thirty-eight patients (21.0%) were ≤50 years old, 34 (18.8%) had Marfan or Loeys-Dietz syndrome, and 74 (40.9%) had aortic dissection. Operative complexity was high: 20.4% (n = 37) had infection, 18.8% (n = 34) had a redo incision, and 61.3% (n = 111) underwent thoracoabdominal aortic repair. Operative mortality was 13.8% (n = 25). Survival was 53% at 5 years. Endograft explantation with OAR is technically demanding and high-risk, especially when the endograft is infected. These findings highlight the importance of long-term surveillance and careful patient selection for EAR, especially when patients are young or have aortic dissection.