Mid-term Results of Aneurysmorrhaphy for Enlargement After EVAR.

Abstract

Objective: Although endovascular aneurysm repair (EVAR) is a standard treatment for abdominal aortic aneurysms, postprocedural aneurysm expansion caused by types II and V endoleaks remains challenging. Aortic graft replacement is a definitive solution but is associated with high morbidity and mortality-especially in elderly patients. Aneurysmorrhaphy has emerged as a less invasive alternative. This study evaluated the mid-term outcomes of aneurysmorrhaphy after EVAR and identified factors associated with aneurysm re-expansion.

Methods: This retrospective study included 50 patients who underwent aneurysmorrhaphy after EVAR in 2016-2021. Indications included aneurysm expansion due to type II or V endoleaks. Surgery was performed using the transperitoneal approach with aneurysm sac opening, thrombus removal, and plication without graft replacement. Intraoperative endoleak diagnosis and preoperative computed tomography (CT) findings were compared. Survival, reintervention, and risk factors for re-expansion were assessed by Kaplan-Meier analysis and logistic regression.

Results: The intraoperative morbidity rate was 6%, the perioperative mortality rate was 0%, and the postoperative morbidity rate was 12%. Compared with preoperative CT findings, the diagnosis was changed in 13 cases (26%). Among the cases initially diagnosed as Type II EL alone, 2 cases had concomitant Type Ib EL, and 7 cases were Type 3b EL. The mean follow-up period was 4.5 years. The 5-year survival and reintervention-free rates were 90% and 92%, respectively. Notably, the 5-year freedom from aneurysm re-expansion rate was only 84%. Residual endoleaks and dead-space areas were notable predictors of re-expansion. Receiver operating characteristic analysis identified a dead-space threshold of 70%, above which re-expansion risk was significantly higher.

Conclusions: Aneurysmorrhaphy is a viable alternative to graft replacement for post-EVAR aneurysm expansion, especially in high-risk patients. However, the risk of re-expansion remains critical, particularly when dead-space reduction is inadequate. Careful patient selection and further research can optimize long-term outcomes.