Beyond Endovascular Solutions: Open Sac Revision with Graft Preservation for Persistent Aortic Sac Expansion Post-EVAR

Background: Aortic sac expansion after endovascular aortic aneurysm repair (EVAR) is associated with higher re-intervention rates, late rupture, and long-term all-cause mortality. Endovascular options have limitations, and guidelines recommend open surgical revision (OSR) if these fail. This study reviews the technique, indications, and outcomes for OSR following EVAR at Auckland City Hospital.

Methods: We identified all OSR cases with stent graft preservation for aortic sac expansion post-EVAR at Auckland City Hospital from January 2010 to October 2023. Techniques included sac closure, plication, or omental wrapping. Cases involving infected grafts were excluded.

Results: Seventeen patients (median age: 82 years, predominantly male) underwent OSR, with a median follow-up of 3 years. The primary indication was sac expansion with type 2 endoleak (T2EL) in 88.24% of patients, while two cases were type V endoleaks. Intraoperatively, endoleaks were found in 94.12% of patients, with 88.24% having T2EL and 17.65% having type 3 endoleaks. Omentoplasty was performed in 58.82% of cases. Although not statistically significant, there was a trend towards lower endoleak recurrence with omentoplasty compared to sac closure. Re-intervention for progressive sac expansion was required in 17.65% of patients (3/17), with two additional patients (11.76%) monitored for recurrent endoleak without further intervention. All patients were discharged, with 82.35% going home without needing rehabilitation. The median hospital stay was 7 days, and the 30-day mortality rate was 0%.

Conclusion: OSR with graft preservation is effective for sac expansion post-EVAR, facilitating endoleak identification and repair while avoiding aortic clamping. Ongoing surveillance is necessary.