Open surgical repair after failed endovascular aneurysm repair: Is endograft removal necessary?

Aortic neck plication. A, A band of Dacron graft is placed circumferentially around the infrarenal aortic neck and (B) secured to itself with 4-0 polypropylene suture. C, The band is then serially tightened and secured with additional sutures until a tight band is formed around the exterior of the aorta, compressing it against the endograft.

Partial endograft preservation. A, The aneurysm is exposed, and a band of Teflon felt fabric is wrapped around the aortic neck. The aorta is then clamped and opened. B, The proximal attachments of the endograft are removed from the aorta, (C) and the proximal stent is resected. D, A bifurcated Dacron graft is anastomosed to the remaining portion of the stent graft. The aneurysm sac is then closed over the repair.

The endograft main body or iliac limbs may be collapsed and inserted into the main body or iliac limbs of the Dacron surgical graft, respectively. A, The self-expanding nitinol stents (yellow arrow) of the endograft create an anastomotic seal. B, Several tacking sutures (blue arrow) are placed incorporating both the Dacron graft and distal endograft to ensure that there is no slippage of the junction.

A, Preoperative image of the patient from Fig 1 shows a proximal type I endoleak (blue arrow) unamenable to endovascular intervention. The patient underwent conversion with creation of a proximal aortic wrap allowing complete endograft preservation. B, The postoperative image demonstrates recreation of the proximal endograft seal by the aortic wrap (yellow arrow) and elimination of endoleak.

Computed tomography (CT) scans of the same patient (A) before initial endovascular aneurysm repair (EVAR) and (B) after initial EVAR. Note on image (B) that while iliac fixation is maintained, there is a persistent type 1 endoleak associated with an angulated, reverse-funnel neck. On the CT scan image to the far right (C), completed after time of delayed conversion to open repair, note the absence of endoleak and preservation of the distal endograft.