Is EVAR a durable solution: indications for re-interventions

Indications for re-interventions after endovascular aneurysm repair (EVAR), as well as their occurrence in number and time, are important to establish in order to optimize patient selection, post-procedure surveillance and also to guide improvements in endograft designs. The aim of this report was to present an overview of current data on re-interventions after elective EVAR. Qualitative review of studies reporting on re-interventions 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. 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. This review showed that the rates of complications and techniques for re-intervention 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