Causes and outcomes of open conversion and aneurysm rupture after endovascular abdominal aortic aneurysm repair: can type ii endoleaks be dangerous?

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Abstract
The feasibility of endovascular abdominal aortic aneurysm repair (EVAR) and the short-term advantages compared with conventional open surgery are no longer in doubt. In patients with suitable aortoiliac anatomy the primary success rate, represented by successful access and endograft deployment, is almost 98%. In studies in which EVAR and open aneurysm repair were compared, there were no unfavorable results for the endovascular method. But late complications have plagued the stent-graft approach, with rupture of the aneurysm being the most dramatic evidence of treatment failure. Conversion to open surgery is either performed for manifest rupture of the aneurysm or for impending rupture, indicated by radiologic or ultrasonographic studies. In almost any current overview of EVAR the need for intensive surveillance to identify indicators for an increased risk of rupture is emphasized. Nevertheless, comprehensive surveillance is time consuming and expensive for the health care system, and it requires rigorous patient compliance—conditions that often are not met in everyday practice. In addition, there is uncertainty which signs and findings at regular imaging are accurate indicators for an increased risk of conversion to open surgery or aneurysm rupture. For instance, the role of endoleaks, in particular, type II or side branch perfusion endoleaks, is controversial. These aspects were analyzed in detail in this overview of the EUROSTAR series.