0 2016 EDIZIONI MINERVA MEDICA
`The onlinc version of this article is located at http://www.mincrvarncdica.it
`
`The Jou=I of Cardiovascular Surgety 2016 April;57 (2): 185-90
`
`20 YEARS EVC: MANAGEMENT OF ARTERIAL DISEASES
`THORACIC AND ABDOMINAL AORTA
`
`Indications for and outcome
`of open AAA repair in the endovascular era
`
`/
`
`Carola M. WIEKER, Max SPAZIER, Dittmar BOCKLER "'.. .
`/ ,- /: /
`
`✓,
`
`Department of Vascular and Endovascular Surgery, Ruprecht-Karls University, Heidelberg, Germany
`
`•corrcs~nding author: Diltrnar B?Ckl_er, Department for Vascular and Endovascular Surgery, University Hospital Hcideiberg, Im Ncucnheimer Feld I IO,
`69120 Heidelberg, Germany. E-mail: d11trnar.boeckler@med.uni-heidclberg.de
`
`''
`/
`ABSTRACT
`/ /
`·
`ented and inten'sive;;;eported in multiple ran(cid:173)
`The ~enefi!5, safety and efficacy of endovascular aortic aneurysm repair (EVAR) is well doc,
`domized tnals and meta-analysis. Therefore, EVAR became the first choice ofabdor'ninal a'ortic aneurysnis (AAA) treatment in almost 70-100%
`of patients. Consecutively, op~n repair (OR) is performed less frequently 'in morphologically preselected pa tients. Anatomical condition remains
`the most important factor for indication for QR_ Especially unfavorable intrarcnal landing zone based on difficult neck anatomy like very short
`neck or excessive neck angulation is still the most predictive factor. Furthermore patients presenting additional iliac aneurysms aortoiliac oc-
`clusive disease or variations of renal arteries are recommended for OR!
`'
`/
`'
`Randomized trials like EVAR I, DREAM and OVER from the year 2004/2005 and 2009 snowed lower 30-day mortality rates in EVAR com(cid:173)
`pared to OR- However, the late mortality rates after two years occ'ame equal'in both treatment options. Furthermore, reintervenlions after EVAR
`occur more frequently than after QR_ Analysis from our own data sho,ved a higher 30-clay mortality in the patients who underwent OR in the
`endovascular era (15% vs. 2.5%), however the number of eme rgency open AAA·rcpair because of ruptured aneurysms was much higher in the
`endovascular era (32.5% vs. 5%). In conclusion, treatme nt of AAA has changed in tl1e past decade. Nevertheless OR of AAA still remains as
`a safe and durable method in experienced surgeons, evc'n in the cndovascular era. High volume centres are needed to offer the best patients·
`treatment providing the best postoperative outcome. Therefore OR must remain a-part of fellowship training in the future. To decide the best
`treatment option many facts hke patients' ~•t s.and preference or ,!!~l(Y ti e·anato1uic suitability for endovascular repair have to be considered.
`(Cite this anicle as: Wicker CM, Spazier,M, B_ockler D. Indications for and outcome' of open AAA repair in the cndovascular era
`J Cardiovasc Surg 2016;57:185-90) /
`/ / ,. · ~ --.....
`Key words: Aortic Aneurysm, Abdominal - Surgical Procedurcs; Operative - Endovascular procedures.
`/ - - -
`!'
`'
`
`-
`/
`The evolution/ in the end6vascul, ~ex'£· has changed
`
`r,
`
`.
`
`the manag~ment of,KAA (abdq minal iiortic aneu(cid:173)
`rysm) repair. Since its introduction by-Pifrodi et al. in
`1991, EVAR (endovascular aneurysm repair) has re(cid:173)
`placed OR (open repair) as the treatment of choice for
`the majority of patients undergoing elective AAA re(cid:173)
`pair.I The advantage ofEVAR as a minimally invasive
`treatment option is the reduced perioperative morbidity
`and mortality rate compared to OR. Randomized trials
`showed significant reduction of perioperative mortal(cid:173)
`ity compared to open repair, shorter operating time,
`reduced inhospital stay and decreased blood loss. How-
`
`ever, EVAR can only be performed in patients with a
`specific aortic anatomy. For patients with an increased
`risk profile, high comorbidities and favorable anatomy,
`EVAR became the preferred treatment option with a
`considerably lower physiologic stress. Furthermore,
`with the appearance ofEVAR, it seems that the indica(cid:173)
`tions for OR have changed. In the era ofEVAR open an(cid:173)
`eurysm repair is less frequent, patients outcomes seem
`to worsen and complexity of OR increases significantly.
`In the year 2008 Ballotta et al. reported in a study of OR
`in octogenarians after the adoption of EVAR that open
`surgery has become more complicated, including more
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`THE JOURNAL OF CARDIOVASCULAR SURGERY
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`WIEKER
`
`INDICATIONS FOR AND OlITCOME OF OPEN AAA REPAIR
`
`Indications
`
`frequent suprarenal aortic cross-clamping, left renal
`vein division and longer operating time.2 Furthermore
`there is a greater need to deal with the management of
`associated iliac aneurysmal and occlusive disease in the
`EVAR era,3 The rising ofEVAR is also associated with
`the risk oflate conversion thus vascular surgeons in the
`endovascular era have to face and deal with open con(cid:173)
`version after EVAR.
`The aim of this manuscript was to provide an over(cid:173)
`view and to clarify the indications for and outcome of
`open AAA repair in the endovascular era.
`
`my such as short neck or unfavorable landing zones have
`been observed to increase the risk for late device-related
`complications especially endoleak thus leading to more
`reinterventions and higher risk oflate mortality.7
`In our clinic EVAR is performed in all patients who
`are anatomically suitable for this technique. Patients
`with, for example, a difficult neck anatomy like very
`short neck or excessive neck angulation just as well pa(cid:173)
`tients presenting additional iliac aneurysms, aortoiliac
`occlusive disease or variations of renal arteries are rec-
`ommended for OR.
`(
`The histogram in Figure 1 sho0ws the development of
`elective AAA repair in our clink c6mparing OR versus
`EVAR from the year 2°002 io 201~. From year 2010 to
`To decide between the two treatment options, the sur-
`2011 there is a shift with m'ore'than half of the patients
`/ 0 ) / (.;
`geons need to consider an amount of parameters, such who are suitable for EVAR.a nd repaired with it.
`as the patients' fitness including patients life expectan-
`cy, the anatomic vascular suitability for EVAR or OR Shififrom{pen 10 endovascvular repair
`' , J
`< , ~,, /
`\
`and finally the patients' preference. Therefore success-
`ful endovascular repair depends on correct patients' se-
`Hifo'matsu et al. s compared the pefioperative outcome
`lection regarding the vascular anatomy, selection of the ofeiective ORbefor{ ana after adoption ofEVAR. The
`correct endoprosthesis and the surgeons familiarity with
`'authors ·illustrated the shift ' in" AAA treatment examin(cid:173)
`the chosen technique.4, 5 Particularly, the patients fitness
`ing 99 patients'with OR Before and 125 patients after
`is an important variable predicting the outcome afte r, advanf e of,EVAR.. The 'i:uthors found higher need for
`suprarenaI'clamping (i 1.2% vs. 3%), higher proportion
`AAA repair. Due to current common perception,oR is
`appropriate for young, healthy patients and EV{\R 'for {of elderly ~ati~ ts over 80 years (23.2% vs. 11 .1 %) and
`older, sicker patients if they are anatomically. suitable.6
`extensixe iliac~mvolvement (35.2% vs. 22.2%) in the
`Anatomical condition of the infrarenalaneruysm re- p6st-EVAR era. The morbidity rates were similar be(cid:173)
`tween the t\vo groups (22.3% vs. 24.8%), thus there was
`mains the most predictive factor that slwuld be ciu-efully(
`evaluated to offer the best treatment. Unfavorable anato-
`Jo difference in major morbidity, such as myocardial
`A/ / / I
`•
`
`<14
`
`12
`10
`
`(
`
`80
`
`60
`
`40
`
`20
`
`0
`
`2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
`■ OR (AAA) DEVAR (AAA)
`
`Figure !.-Development of elective AAA repair from 2002 to 2014 in Heidelberg.
`
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`INDICATIONS FOR ANO O\ITCOME OF OPEN AAA REPAIR
`
`WIEKER
`
`infarction or permanent renal failure. The perioperative number of emergency open AAA repair because ofrup(cid:173)
`mortality rate between the two groups was 0% in both
`lured aneurysms was much higher in 2014/15 (32.5%
`vs. 5%).
`pre- and post-EVAR eras.8
`In a retrospective study from Joels el al. 9 indications
`Inhospital complication rate (30-days) was higher in
`the 2014/15 group (27.5% vs. 6.2%). The late postop(cid:173)
`for OR in the endovascular era included age younger
`than 65 years with minimal comorbidities, unfavor-
`erative complication rate (60-days) was similar between
`the years 2004 and 2014/15 (5% vs. 5%).
`able anatomy for endovascular repair and aortoiliac oc-
`elusive disease. The authors reported that 30-day and We also focused on the~J1alysis of decision making
`5-year mortalities were affected by indications and that parameters between the two treatment options. Anatom(cid:173)
`complication rates were significant lower in the pre-
`ical condition remains the most important factor for in(cid:173)
`EVAR era (23.7% vs. 43.5%). Summing up the authors dieation for OR. Especially unfavorable infrarenal land(cid:173)
`concluded that patients undergoing open AAA repair
`ing zone based on short neck is still the most predictive
`factor (29.6% in 2004 vf.' 22:5% i/ 2014/15). Aortic or
`in the EVAR era have more comorbidities, longer op-
`iliac kinking decreased tis predictive factor (6.2% vs.
`crating times and more complications, therefore there
`should be a preference for OR in younger patients with 15%). Third importan ' factor, for primary OR became
`minimal comorbidities.9
`additional iliac,nneurysn1s(8.6% vs. 12.5%). Variation
`A study by Costin el al. 3 reviewed 606 patients un-
`ofrcnal arteries isanotl,c{prcdictive factor for choosing
`dergoing elective open AAA repair before and after OR as prefcrecl trea'tm~nt option (6.2'yo vs. 12.5%), this
`adoption of an endovascular stent grafting program.
`factord6ubled'fr'om'the ye'ar'200416'2014/2015.
`The authors found similar morbidity and mortality rates
`Pafien s' fitness, including yoiiiig"'age and cardiac fit(cid:173)
`(2% vs. 3.8%) in patients operated before and after the ness~also' i~creased as a p redicting factor for OR (7.4%
`'vs. 12:5%) / Other,p redicting'factors are iliac stenosis
`initiation of the program.3 Close to the results of Jo-
`els el al. 9in 2009 the authors concluded that surgeons
`(0% vs. 5%), tight iliac bifurcation (1.2% vs. 5%), renal
`performing open repair of AAA in the era of EVAR'a?e....__artery/ stenosis with indication for aorto-rcnal bypass
`operating on patients who require more compleivc- , (2:5% vs. 12.5%), co1"11cal infrarenal neck (3.7 vs. 5%),
`pairs, ~eluding a ~at~r. ~quency of supra_;ena~ t !l)~S {co?nec(i~e\ t~~_$,d1sease (0% ~s. ?¾), emergency re(cid:173)
`elampmg, renal vem d1V1s1on, and management of'as/ pair un'aer carcl1ovascular resuscitation (0% vs. 5%) and
`patient'h~si((3.7% vs. 0%).
`sociated iliac aneurysmal and occlusive disea's~J.9_..)
`W: analyzed patients from our cliJii{. wh~)_Ve~ treat-(\ 0 /
`ed With OR before and after endovascular, ns~g. In the .. Open ~ pair versus EVAR
`year 2004 in our clinic OR was _p( rfc(rfue'd in 81 pati; nts -.._,_
`(75 male, 92.6%). 82.7% (67/81) o f the patients ~nder,-
`vTrials like EVAR I, DREAM and OVER from the
`went operation due to an,asymptoiriadc AAA'; I Y 3% year 2004/2005 and 2009 showed lower 30-day mortal(cid:173)
`( 10/81) were symptomatic'and 5%(4i81) underwent OR
`ity rates in EVAR compared to OR. However, these re(cid:173)
`because of ruptured X~ . Sympto matic t as ~ lin'ec!' as
`suits were not maintained beyond the long term follow(cid:173)
`back pain. The seco~d grotip was analyzed betwee'n Oc-
`.. , \ . ,,,...,, , ; \ - . . .
`up. The late mortality after two years became equal in
`tober 2014 and Sept~mb~r,2015. 4Q pa!1:Pts underwent patients undergomg EVAR or OR.10-14 The authors from
`OR (35 male, 87:5%). 65% (26/40)-had an1asymptom- EVAR I trial reported that there were no differences
`atic AAA, one patien was symptom'atic'(i/40, 2.5%)
`seen in total mortality or aneurysm-related mortality in
`the long term.15 Furthermore the authors observed that
`and 32.5% of the patients (13/40) had a ruptured AAA.
`The 30-day mortality was higher in the patients group EVAR was associated with increased rates of graft-relat(cid:173)
`analyzed from 2014/15 (15% vs. 2.5%), however the ed complications and reinterventions and was more cost-
`
`TABLE !.-Rea.sons for open conversion ajier EVAR.
`
`Reason for con,·cnion
`
`rAAA
`
`Infection
`2 (28 6%)
`
`1)'p I cndoleak
`4 (57.1%)
`J (42.9%)
`
`Other
`I (14.3%)
`
`VoL57 -No. l
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`TIIE JOURNAL OF CARDIOVASCULAR SURGERY
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`WIEKER
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`INDICATIONS FOR AND OlITCOME OF OPEN AAA REPAIR
`
`ly than OR. However, there are Iimitiations in this trial branched stent grafts (BEVAR) versus OR for complex
`who ~ay ~ead to some wrong conclusions. For example, aortic aneurysms (WINDOW registry). A number of268
`comphcatJOns were not well defined in this trial with all cases ofFEVARand BEVAR and a control group of\678
`endoleaks including Typ II considered as major comp Ii-
`patients were included. Equally to Rao et al. there was no
`cations. At the maximum follow-up the early aneurysm-
`significant difference in thirty day mortality between the
`related mortality benefit due to EVAR was lost as a re-
`two groups (6.7% vs. 5.4%), but costs were significant
`suit ofa significant number of late ruptures in the EVAR higher with FEVAR and BEVAR compared to OR The
`group. Late ruptures reasons are considered to depend authors concluded that FEVAR and BEVAR do not ap(cid:173)
`on endograft-migration, cndoleak and sac expansion.16
`pear justified for patients with para/juxtarenal AAA and
`The EVAR2 trial from 2010 investigates the outcome
`infradiaphragmatic TAAA (thoracoabdominal aortic an(cid:173)
`ofEVAR compared to conservative treatment in AAA pa-
`eurysm fit for OR). In the autl1ors opinion endovascular
`tients who were physically ineligible for OR In this trial
`repair may be an attractive option for patients with para/
`the thirty day mortality was 7.3% in the EVAR group.
`juxtarenal AAA who are'not eligible for surgery and pa(cid:173)
`EVAR was associated with a significantly lower rate of
`tients with supradiaphcigmatlc TAAA..20
`aneurysm-related mortality than no repair. The overall
`Besides developing BEVAR"and FEVAR the rising of
`rate of aneurysm rupture in the no-intervention group
`technical advances in EVAR has changed existing ther(cid:173)
`was 12.4%. The authors concluded that the advantage apy modalitie's, thus mbre endografis arc implanted out(cid:173)
`oflower aneurysm-related mortality in the EVAR group
`side the instructions fo'r use. Furthermore there has to be a
`did not result in any benefit in terms of total mortality. consistc"nt SurvCi°Ua~ce aft~r"EVAR. d elccting devices re(cid:173)
`Forty-eight per cent of patients who survived EVAR had
`latedcomplicati6ns and the iieed for furthersecondary in(cid:173)
`graft-related complications, and 27% required rcinter-
`terve'ntions.'Follow-Gp 6fEVAR is associated with costs
`vent ion within the first 6 years thus leading in more costs and in~reas'ed rislc of radiation due to CT-scan follow-up
`compared to the no-intervention group.17
`/':-.. or reintc:Nentions. lmaging surveillance exposes compli-
`Reinterventions after EVAR occur more frequently ~cations sucli as endoleaks, limb thrombosis, graft migra(cid:173)
`than after OR. Advanced stent-grafts such as fenes trated , tion, aneucysi'n' sac enlargement or late rupture.5, 7, 21·23
`(FEVAR) and branched devices for juxtarenal_ an.cu-,.
`' _.,,
`rysms require secondary procedures mo!"e ~~en Iha~ a Open repair in ruptured abdominal aortic aneurysm
`standard stent-graft for infrarenal end~vasc,ular r!:pair.18
`·•.
`/."
`.
`.
`.
`1
`Current data from Rao et al, published in2015; compared'
`Ruptured abdommal aortic aneurysm (rAAA) 1s one
`1
`'th
`d 1·
`OR versus FEVAR (fenestrated endova.scular aneurysm of. the greatest vascular emergencies ea mg w,
`a
`'
`'
`/
`,,-
`•
`'
`repair) ofjuxtarenal aneurysll),Sin-:~ e pe~od froyi•~947 - ~bserved overall m~rtali_ty from 70 to 90%.24
`25 Best
`•
`to 2013 including 23~6 pa~ents.J>ri11z~ outCOII}C~ W<;!e
`treatment strategy w~th either EVAR or OR depends_ on
`perioperative mortahty ,.~ d, po~~J?,_Crat1vy renal 1~uJ- man)'. factors, e.g. ~u,table ~natomy ~r centers ex~crt,se.
`ficiency. Secondary 9utcomes ,~ere s~condary, reinter-
`J?esp1te advances m operative t_echmque and penop~ra(cid:173)
`ventions and patients Jon~-te~ s~ 1~a!. The 1 ~uthors
`llve management ~AAA. re~ams fraught w1~ a h!g~
`concluded that FEVAR ano OR have similar short-term
`rate of death and comphcatJons. Advantages m m1m(cid:173)
`outcomcs with the same pe'rioperative' mortality rate of mally invasive surgical techniques such as EVAR may
`4. I% and no significant'1differences in postoperative re-
`improve the outcom~ in rAAA p~tien~.
`.
`nal insufficiency as second primary endpoint was noted.
`The I~PROYE Ina!, ~rst p~bhsh~d m 2014, 1~clude_d
`Furthermore FEVAR patients had higher rates of sec-
`613 patients with a chmcal diagnosis ofrAAA mvestJ(cid:173)
`ondary reintervention, renal impairment during follow-
`gating the 30-day out~ome ofEVAR vs. OR: Co~pared
`up and a lower Jong-term survival compared with OR
`torcsultsfromtrialsw1thnon-ruptur~dAAAmth1sstudy
`ts Thus the authors summed up that FEVAR is a EVAR did not reduce 30-day mortahty compared to OR
`tJ.
`·r,
`pa en .
`37 401) H
`ti
`.
`t'
`t
`favorable option in high-risk patients, who are not fit for
`(35.4% vs.
`. 10 . oweve~ s1gn1 1can _Y more pa 1en s
`OR but that OR remains viable as the gold standard.19
`treated with EVAR ~ere d1sch
`arged directly to home
`0
`Similar data were published by Michel et al. investi-
`c?~pared to OR (941/o vs. 771/o). Overall costs were
`gating thirty day outcomes and costs of fenestrated and
`s1m1lar between the two groups. The one-year all-cause
`
`\
`
`'\
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`INDICATIONS FOR AND OUTCOME OF OPEN AAA REPAIR
`
`WI EKER
`
`0
`
`mortality was 41 .1 % for EVAR and 45.1 % for patients and cross-over-bypass occlusion after aortomonoiliac
`assigned for OR with similar reintervention rates in each EVAR. The further 4 patients had to be converted be(cid:173)
`group. The average hospital stay were significantly lower cause of Typ Ia endoleaks after EVAS ( endovascular
`in the EVARgroup compared to the OR group (17 vs. 26
`aneurysm sealing). Three out of the seven patients pre(cid:173)
`days). The authors concluded that the EVAR first strategy
`sented with ruptured aneurysms. In all ruptured patients
`for management ofrAAA does not offer a survival ben-
`the cause of rupture was a Type I endolcak after EVAS.
`efit over I year but offers patients faster discharge with Complete graft removal was achieved in I 00%. During
`better quality-of-life (QoL) and cost-effectiveness.26
`the maximum follow-up of3 months the overall mortal-
`Similar data were published by Reimerink et al. in
`ity rate was 14.3% (1/7). One patient with a conversion
`2013. In this randomized study EVAR and OR were com-
`due to an infected endograft died IO days afteroperation.
`pared in 116 patients with rAAA. Primary endpoints of
`Data from 2004/2005 show's a late open conversion
`thestudywerethecompositeofdeathandseverecompli-
`rate after EVAR in 2/81 (2.5%) , one.patient had to be
`cations at 30 days. The combined primary endpoint rate converted directly intra6perat ive from endovascular to
`for EVAR was 42% and for OR 47%. The 30-day mortal-
`open repair because ·of a ' strbng' iliac kinking with the
`ity was 21 % in patients assigned for EVAR versus 25%
`impossibility to place the endo'graft correctly.
`In a published study by Kelson et al. from the year
`in those assigned for OR. In the nonrandomized cohort
`including patients with unfavorable anatomy for EVAR 2009 the autliors h:P,orted'a overall hospital mortality rate
`who were treated by OR the 30-day mortality was 26%. of 19% (8/4 J) aftef conversi cin operation with a 30-day
`The combined endpoint (death and severe complications) mortality of 17% (7/41 );1This
`retrospettive study includ(cid:173)
`at 6 months was 46% for EVAR versus 4 7% for OR.
`ed I 606 patients ~ ho were treated with EV AR in the years
`Interestingly 14% of patients who were initially as-
`1999-2007) the corivci'sion rate was 2.5% (41/1606).
`signed for EVAR were converted to OR because of iliac A<:_ute rupture was the presenfing indication for explant
`access failure or persisting endoleak. A further 4 pa-
`in 14.6% (6/41). All patients that presented with rupture
`tients needed additional laparotomy without endogra~ ha.? type I/6r(type •Ill_,eildoleak or graft migration. The
`removal due to persisting bleeding because of-type ~ -1 mortalityrateforelectiveconversionforAAA-relatedis(cid:173)
`endoleak and abdominal compartment syndrodle. ih,o/ sues in this' study,was 3.3%. The authors concluded that
`authors concluded that the present study do~ not sh'ow electiv"'i: conversion in skilled hands can be done with ac(cid:173)
`a significant difference in patients outc6me 2ompafing( c'eptable results and recommend early removal for failing
`EVAR and OR in rAAA. The compa~ tively low mor- EVAR before emergency or urgent repair is necessary.28
`tality-rate for OR both in randomiied'and non-randoih-' ·
`\ In' a-'recently published systematic research by Kou(cid:173)
`ized cohort could be explained in' the authors opinionby~ velos et al. the overall 30-day mortality was 9.1 % and
`optimization of logistics, pre6Jl1:rativ~ CT imaging and d'i°lfered between elective (3.2%) and emergency con(cid:173)
`centralization of care in cinters of expf rtise.27 ~
`/
`versions (29.2%). Indications for late open conversion
`Within the study by.Reim'erink "'eta!. th/re was a need were similar to our data and included endoleak in 62.4%,
`for conversion of EVAR, reporte"d iiy-20%.'Ndwadays
`infection in 9.5%, migration in 5.5% and thrombosis in
`vascular surgeonsar'e fac~ with an increasing £umber 6.7%. The authors concluded that endoleak remains the
`of endovascular' treated P,_atients whb nbed a) ate conver- most important weakness of EVAR as the leading cause
`sion.27 We analyzed data from our cli1 ic in the era before of late open conversion. When performed electively
`EVARadoptionandafteritandcomparedtheconversion particularly in a center with high expertise open con(cid:173)
`rates and analyzed reasons for it. The overall conversion version after EVAR has relatively low mortality rates.
`rate was higher in the 2014/15 group: 17.5% (7/40) vs. Open repair as first treatment option after failed EVAR
`2.5% (2/81) in 2004. Reasons for conversion were simi-
`represents a valuable solution.29
`lar in the two groups, in the 2004 group it was rupture
`and endoleak after EVAR. In the 2014/15 group reasons
`for conversions were besides rupture and endoleak af-
`Nowadays endovascular repair is the first line thera(cid:173)
`ter EVAR in nearly 30% the suspicion of infected endo-
`graft (2/7, 28.6%). One patient had a limb thrombosis py in patients with abdominal aneurysms with suitable
`
`Conclusions
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`Vol.57. No. 2
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`m e JOURNAL OF CARDIOVASCULAR SURGERY
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`WIEKER
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`INDICATIONS FOR AND OlITCOME OF OPEN AAA REPAIR
`
`anatomy. Nevertheless, with experienced surgeons open
`repair remains a safe and durable method even in the en(cid:173)
`dovascular era. Particulary in this era surgeons are faced
`with the need of a higher amount of open repair because
`of conversion. Therefore the knowledge of handling
`and practicing open repair must be a part of fellowship
`training in the future. Besides the improved evidence,
`decision making still depends on many facts including
`the balance of risks and benefits, patients· fitness and
`preference and finally the anatomic suitability for endo(cid:173)
`vascular repair.
`
`References
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`13. Blonkcnstcijn JD, de Jong SE, Prinsscn M, van dcr Ham AC, Buth J,
`vnn Slcrlccnburg SM, et al. Two-year outcomes ancr conventional or
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`2005;352:2398-405.
`14. Lcdcrlc FA, Frcischlag JA, Kyriakidcs TC, Padberg FT Jr, Mat(cid:173)
`sumura JS, Kohler TR, et al. Outcomes following cndovascular VJ',
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`Conflicts of inlt rest.-Thc authors certify thal there is no conflict orinlcrcst with any financial organization regarding lhc material discussed in the manuscnpt.
`Aniclc first published online: January 28. 2016.
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`TIIE JOURNAL OF CARDIOVASCULAR SURGERY
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`April 2016
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