Late open conversion after thoracic endovascular aortic repair

Objective: With the increasing use of endovascular aortic repair, open repair after aortic stent grafting is of increasing interest. We retrospectively reviewed cases of late open conversion for complications after thoracic endovascular aortic repair (TEVAR). Methods: TEVAR due to aortic aneurysm and dissection was performed in 538 patients between 1994 and 2017. A total of 33 patients, including 4 patients referred from other centers, required late conversion to open repair; 14 (42.4%) patients required circulatory arrest for aortic arch involvement. The mean interval to open conversion after TEVAR was 33.9 months (range, 1-123 months). Demographics of the patients, reason for conversion, surgical techniques, surgical outcomes, and survival were reviewed. Results: Indications for late open conversion included type I endoleak (14), stent graft-induced new entry intimal tear (6), retrograde type A dissection (4), stent migration and fracture (3), stent graft infection (3), sac enlargement without endoleak (1), aortopulmonary fistula (1), and stent implantation failure (1). Hospital mortality was 9.1% (3/33). All occurred in the patients with arch involvement. The patients had several major morbidities; six patients (18.1%) had pulmonary complications, two (6.1%) suffered a stroke, one (3.0%) experienced paraplegia, and one (3.0%) had renal failure. Overall survival rates at 1 year, 5 years, and 10 years were 84.5% +/- 6.4%, 74.5% +/- 8.7%, and 67.1% +/- 10.1%, respectively. The arch involvement group (48.1% +/- 15.7%) had significantly worse 10-year survival than the no arch involvement group (86.1% +/- 9.4%; P = .048). Conclusions: Despite the complexity of TEVAR, open conversion due to late complications can be performed successfully with acceptable results. However, cases involving the aortic arch have relatively worse outcomes. Lifelong surveillance is mandatory, and early decision-making about open conversion before the development of a complicated aortic arch lesion is suggested to achieve better outcomes.