Cases of Late Open Conversion After Failed Endovascular Aneurysm Repair is Increasing and its 30-Day Mortality Remains High

Endovascular aneurysm repair (EVAR) is the preferred treatment of abdominal aortic aneurysms (AAAs). The use of EVAR has been pushed to its limits since its inception and has evolved to include the treatment of patients beyond the recommendations in the guidelines from the Society for Vascular Surgery and instructions for use for endovascular devices. Recently, cases of failure and subsequent open conversion have increased. We evaluated the national trend of yearly cases and assessed the 30-day outcomes of nonurgent secondary open repair after failed EVAR compared with primary open repair. In the National Surgical Quality Improvement Program database, we used the relevant Current Procedural Terminology and International Classification of Diseases, 9th and 10th revision, codes to identify patients who had undergone primary and secondary open repair of nonruptured AAAs from 2009 to 2018. We assessed the trend of yearly cases and compared the perioperative outcomes after both procedures. We used a multivariable logistic regression analysis to identify the independent perioperative factors associated with mortality. A total of 9635 patients were identified and analyzed (primary, n = 9250; secondary, n = 385). During the 10-year period, the yearly cases of secondary repair steadily increased and the use of primary repair decreased. The incidence of postoperative complications was similar between both groups, except for cardiac arrest, which occurred more frequently in the secondary group (Table). The 30-day mortality was higher in the secondary group compared with the primary group (9.6% vs 3.9%; P < .0001). Secondary repair was also independently associated with higher odds of death (adjusted odds ratio [OR], 2.1; 95% confidence interval [CI], 1.8-2.4; P < .0001). When the average mortality in both groups were compared between the first and last 5 years, no difference was found (secondary, 9.8% vs 9.5%; P = 1.00; and primary, 3.6% vs 4.2%; P = .19). On multivariable analysis, the other perioperative factors that were independently associated with mortality included increased age (OR, 1.8; 95% CI, 1.5-2.1; P < .0001), American Society of Anesthesiologists class ≥3 (OR, 2.7; 95% CI, 1.1-6.6; P = .029), diabetes requiring insulin (OR, 2.0; 95% CI, 1.2-3.3; P = .005), chronic obstructive pulmonary disease (OR, 1.4; 95% CI, 1.1-1.8; P = .006), the presence of dyspnea at rest (OR, 3.3; 95% CI, 1.8-6.1; P < .0001), and high preoperative hematocrit (OR, 0.94; 95% CI, 0.93-0.97; P < .0001). Secondary open repair after failed EVAR was independently associated with higher mortality. Its yearly cases have also continued to increase without significant improvements in postoperative mortality. Therefore, we recommend a more careful selection of patients for EVAR.TablePostoperative outcomes (n = 9635)VariablePrimary repair (n = 9250)Secondary repair (n = 385)P valueTotal operation time, minutes217 (168-287)244 (175-320)