Infrarenal clamping in late open conversions after endovascular abdominal aneurysm repair: a 28-year single-centre experience

Background: The present study aimed to report the technical aspects and outcomes of late open conversion (LOC) after endovascular aneurysm repair (EVAR) performed in a single-centre exclusively with infrarenal clamping. Methods: This prospective single-center study analysed the cases of LOC (>30 days) performed in our center from January 1996 to August 2024. The primary endpoints were technical success, 30-day mortality and morbidity. Results: During the analysis period, 37 patients underwent LOC with infrarenal clamping. The mean age at conversion was 75.59±6.28 years. The endografts were explanted after a mean of 45.39±30.27 months. The indication for LOC were: endoleak in 32 cases (17 type I, 4 type II, 4 type III, 4 endotension and 3 cases with multiple endoleaks), 2 distal migrations of the endograft, 2 graft infection and 1 endograft thrombosis. Partial conversion was performed in 72.9% (27/37) of cases. A partial proximal explant was performed in 63% of cases (17/27). The technical success was 100% (37/37). Overall 30-day mortality was 10.8%. The 30-day mortality was 7.41% (2/27) in elective patients and 20% (2/10) in the urgent setting (P =0.29). Post-operative Acute Kidney Damage (AKD) requiring transient hemodialysis rate was 9.1%. Mean follow-up was 42.35±50.47 months. The estimated 5-year survival rate was 69%. No aneurysm-related death occurred during follow-up. Conclusions: Infrarenal clamping during LOC is feasible. This technique, associated with partial endograft explantation, may allow the surgical procedure in selected cases, and may potentially reduce post-operative renal complications related to suprarenal clamping.