Is EVAR a durable solution? Indications for reinterventions.

Introducion: Indications for reinterventions after endovascular aneurysm repair (EVAR), as well as their occurrence in number and time, are important to establish in order to optimize patient selection, postprocedure surveillance and also to guide improvements in endograft designs. The aim of this report was to present an overview of current data on reinterventions after elective EVAR.

Evidence Acquisition: Qualitative review of studies reporting on reinterventions after elective EVAR, identified by a systematic literature search in MEDLINE, EMBASE and the Cochrane Library for publications from 2010 to 13th of November 2017.

Evidence Synthesis: Twenty-three studies reporting on 83,307 patients met the inclusion criteria. Index procedures were performed between 1996-2014. There was wide heterogeneity in reporting standards. Type I endoleaks were reported in 0.6%-13% and type III endoleaks in 0.9-2.1% with a significant improvement for newer devices. Migration rates varied between 0-4%. Endoleak type II was the most common indication for re-intervention ranging from 14-25.3% although the majority resolved without intervention. Rupture rates ranged from 0-5.4% and carried a high mortality (60-67%). Ruptures occurred at any time after the index procedure. Limb ischemia rates were reported at 0.4-11.9% with re-intervention rates between 0.06-11.9%. Wound related complications and related re-interventions were the indication in 0.5-14% and 0.3-6.5%, respectively. Endograft infection carried a high risk of mortality and was described in 0.3-3.6%, often related to graft-enteric fistula and the majority had an open explantation of the endograft.

Conclusions: This review showed that the rates of complications and techniques for reintervention developed over time with a tendency towards better outcomes considering the aneurysm related indications. Significant factors that led to subsequent secondary interventions were migration, rupture, infections and type I and II endoleaks. Patients treated with earlier generation endografts are still alive and need continued surveillance to detect these severe complications before they lead to rupture.