Surgical “New Aortic Carrefour Technique" for late open conversion after Endovascular Aortic Repair

Abstract Objectives The aim of the study is to report the early and mid-term outcomes of late open conversion (LOC) after endovascular aortic repair (EVAR) using the “New Aortic Carrefour Technique” (NACT) for preservation of the stent-graft iliac limbs. Late conversions were defined as explants >6 months after previous EVAR. Methods Patients treated for elective or urgent LOC after EVAR with the “New Aortic Carrefour Technique” at a single centre (2009-2019), and with ≥6 months of follow-up, were included. Briefly, after completing the proximal aortic anastomosis, the endograft iliac limbs were truncated and sutured together in order to create a “new aortic-carrefour” (Veraldi’s technique). A Dacron knitted straight graft was therefore sutured to the newly created aortic bifurcation. Outcomes of interest were: immediate technical success, intraoperative characteristics and reinterventions. Results are reported as number (and percentages) or median (and interquartile range, IQR). Results During the study preiod, 433 patients underwent standard EVAR for abdominal aortic aneurysm (AAA) and 20 underwent LOC. Of these, 9 consecutive patients were deemed suitable and treated with NACT. The indication for conversion was endoleak in 6 (type IA n=1, type II n=4, type III n=1), complete graft thrombosis (n=2), and one case of sac enlargement without any clear signs of endoleak at computed tomography angiogram (CTA). Of these cases, six were treated electively while three were treated in urgent setting including one case of rupture. Median procedure, aortic cross-clamping and distal anastomosis times were 280 minutes (IQR 225-290), 24 minutes (IQR 22-29) and 15 minutes (IQR 14-18), respectively. Median blood loss was 1600 mL (IQR 700-1900) and median hospital stay was 8 days (IQR 7-12). None of the patients died, neither required unplanned re-intervention within 30 days. At a median imaging follow-up of 13 months (IQR 8-43), there were no reinterventions due to residual leaks or technical defects. One patient died during follow-up and recorded cause of deaths was heart failure. Conclusion Use of the NACT with preservation of the original endograft iliac limbs for LOC after EVAR is a safe and feasible technique, which results in low peri-operative morbidity and mortality rate in selected patients. The technique is effective during mid-term follow-up and might represent a valuable tool to expand the armamentarium of vascular surgeons for surgical regrafting after EVAR.