A comparison of reinterventional options following endovascular aneurysm sealing for abdominal aortic aneurysm

Background: Despite initial positive outcomes endovascular aneurysm sealing (EVAS) with the Nellix device has been associated with mid-term therapeutic failure. Reinterventions are complex, with no consensus on the optimal treatment of therapeutic failure. Methods: A retrospective cohort study including all cases whereby reintervention was undertaken following EVAS at a single centre. Outcomes of reintervention were compared by indication and treatment modality undertaken. Results: 69 patients underwent 96 reinterventions, with the initial intervention at a median of 1.98 years. This represented 23.4% (69/295) of EVAS cases undertaken from 2013 onwards. Indications for re-intervention were variable, and often presented as a combination. When analysing for therapeutic failure (migration, sac expansion, type1a endoleak, type1b endoleak and rupture) treatment success was defined by resolution with no need for further intervention. Explantation had the highest success rate (12/13, 92%) followed by Nellix-in-Nellix application (16/24, 66%), proximal and/or distal graft extension (9/12, 64%) and embolization (9/27, 33%). Intervention for early signs of therapeutic failure i.e. migration alone was associated with increased treatment success. Conclusions: Complications following EVAS are challenging to detect and difficult to treat, often associated with multiple reinterventions. Early signs of therapeutic failure were associated with improved treatment outcomes, advocating early intervention. Where patient morbidity allowed, explantation appeared to offer the most durable form of treatment, conversely embolization offered the lowest chances of resolution.