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Secondary Intervention After Endovascular Abdominal Aortic Aneurysm Repair

Conrad, Mark F. MD; Adams, Andrew B. MD; Guest, Julie M. BS; Paruchuri, Vikram MD; Brewster, David C. MD; LaMuraglia, Glenn M. MD; Cambria, Richard P. MD

doi: 10.1097/SLA.0b013e3181b365bd
Original Articles

Objective: Endovascular Abdominal Aortic Aneurysm Repair (EVAR) has been criticized because of the need for frequent secondary interventions (2ndINT) to maintain effective abdominal aortic aneurysm (AAA) exclusion. The study goal is to detail such interventions and determine their effect on clinical outcomes.

Methods: From January 1997 to December 2007, 832 patients underwent EVAR. Those requiring 2ndINT were stratified according to the indications and specific nature of 2ndINT and treatment. Study endpoints included freedom from 2ndINT, aneurysm-related and overall survival.

Results: There were 91 (11%) patients who underwent 131 2ndINT (mean follow-up 35 months). No demographic features (age, gender, etc) predicted the need for 2ndINT. Actuarial 5-year freedom from 2ndINT was 80%. Indications for 2ndINT included: sac rupture 5 (4%), graft migration/ type I endoleak 37 (28%), persistent type II endoleak 40 (38%), endotension with sac growth 5 (4%), and limb occlusion/kinking 24 (18%). The majority of 2ndINT were accomplished with an endovascular approach (76%) with a >80% initial success rate for all indications except type II endoleak in which the initial intervention was successful only 34% of the time. Initial 2ndINT were successful in 62% and 35 (38%) patients underwent more than one 2ndINT. Multivariate predictors of 2ndINT were AAA sac size >5.5cm (OR = 2.1, P = 0.004), and preprocedure coil embolization (hypogastric or inferior mesenteric artery) (OR = 2.1, P = 0.008). The actuarial survival was 70% at 5 years and the aneurysm-related survival was 97.5% with no difference in either parameter in patients who underwent 2ndINT compared with those who did not.

Conclusions: Although 2ndINT are common after EVAR, most were addressed through an endovascular approach; technical success thereof varies widely with the specific indication for 2ndINT. Secondary intervention did not adversely affect aneurysm-related or overall actuarial 5-year survival.

This study details the secondary interventions after endovascular abdominal aortic aneurysm repair to determine their effect on clinical outcomes. The study found that 11% of patients will require secondary interventions after endovascular abdominal aortic aneurysm repair but most can be accomplished through an endovascular approach with no effect on long-term survival.

From the Division of Vascular and Endovascular Surgery; Department of Surgery, Massachusetts General Hospital; Harvard Medical School, Boston, MA.

Reprints: Mark F. Conrad, MD, Massachusetts General Hospital, WACC 4, 15 Parkman Street, Boston, MA 02114. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.