Endovascular Management of Juxtarenal and Pararenal Abdominal Aortic Aneurysms: Role of Chimney Technique (original) (raw)
Related papers
Journal of Vascular Surgery, 2012
Objective: Patients with juxtarenal, pararenal, or thoracoabdominal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. The "chimney graft" or "snorkel" technique has evolved as a potential alternative to fenestrated and side-branched endografts. The purpose of this study is to review all published reports on chimney graft (CG) technique involving visceral vessels and investigate the safety and efficacy of the technique.
Endovascular Treatment of a Juxtarenal Aortic Aneurysm with the Chimney Technique
2017
Endovascular treatment of juxtarenal aortic aneurysms is a complex challenge to the vascular surgeon. We present a case of an 83 year old man with a large juxtarenal aneurysm treated with an endovascular approach with chimneys to the left renal artery and superior mesenteric artery. Fenestrated aortic endovascular repair has been considered the preferred endovascular approach in juxtarenal aneurysms, however when the risk of rupture is considered high to wait for a manufactured device and/or when the anatomy is not suitable for a fenestrated repair, chimney endovascular repair is a viable and promptly available option. This case report is an example of the applicability of this treatment with a positive short-term outcome as shown here.
Journal of Vascular Surgery, 2011
A 79-year-old woman presented with a ruptured saccular thoracoabdominal aortic aneurysm involving the celiac and mesenteric artery. The patient was unfit for open surgical repair. A "chimney" procedure was performed, which involved placement of stents in the aortic side branches alongside the endograft. The patient underwent another chimney procedure 2 weeks later for a type I endoleak. Computed tomography angiography (CTA) at 1 and 6 months showed a good result with no endoleaks or graft migration. The chimney procedure provides an alternative for emergency patients unfit for open repair and has the advantage that stents can be used that are already available in most institutions. ( J Vasc Surg 2011;53:1386-90.)
European Journal of Vascular and Endovascular Surgery, 2020
In contrast to prior reports regarding the chimney technique for complex abdominal aortic aneurysms, this large national series provides concerning early results with this technique. Performing unplanned intra-operative procedures was identified as the only independent predictor of post-operative death. Based on these results, future research should focus on improvements in pre-operative planning and intra-operative technical aspects. Objective: The chimney technique (ChEVAR) allows for proximal landing zone extension for endovascular repair of complex aortic aneurysms. The aim of the present study was to assess ChEVAR national outcomes in French university hospital centres. Methods: All centres were contacted and entered data into a computerised online database on a voluntary basis. Clinical and radiological data were collected on all consecutive ChEVAR patients operated on in 14 centres between 2008 and 2016. Patients were deemed unfit for open repair. Factors associated with early (30 day or in hospital) mortality and type 1 endoleak (Type I EL) were calculated using multivariable analysis. Results: In total, 201 patients with 343 target vessels were treated. There were 94 juxtarenal (46.8%), 67 pararenal (33.3%), 10 Crawford type IV thoraco-abdominal (5%) aneurysms, and 30 (15.1%) proximal failures of prior repairs. The pre-operative diameter was 66.8 AE 16.7 mm and 28 (13.9%) ChEVAR were performed as an emergency, including six (2.9%) ruptures. There were 23 (11.7%) unplanned intra-operative procedures, mainly related to access issues. The rate of early deaths was 11.4% (n ¼ 23). The elective mortality rate was 9.8% (n ¼ 17). Nine patients (4.5%) presented with a stroke. The rate of early proximal Type I EL was 11.9%. Survival was 84.6%, 79.4%, 73.9%, 71.1% at 6, 12, 18, and 24 months, respectively. The primary patency of chimney stents was 97.4%, 96.7%, 95.2%, and 93.3% at 6, 12, 18, and 24 months, respectively. Performing unplanned intra-operative procedures (OR 3.7, 95% CI 1.3e10.9) was identified as the only independent predictor of post-operative death. A ChEVAR for juxtarenal aneurysm was independently associated with fewer post-operative Type I ELs (OR 0.17, 95% CI 0.05e0.58). Conclusion: In this large national ChEVAR series, early results were concerning. The reasons may lie in heterogeneous practices between centres and ChEVAR use outside of current recommendations regarding oversizing rates, endograft types, and sealing zones. Future research should focus on improvements in preoperative planning and intra-operative technical aspects.
Endovascular Repair for Abdominal Aortic Aneurysms: Initial Experience of an Endograft Programme
Asian Journal of Surgery, 2003
aneurysm repair has provided a less invasive therapeutic alternative to conventional open surgery. 5 With improvements in endovascular devices and greater experience, favourable early and mid-term results were reported for various commercially available devices. 6-8 As with all new procedures, there is a definite learning curve, 9 and there is always concern over their safety and efficacy, especially during the initial phase of an aortic endograft programme. The aim of this study was to evaluate the early clinical results of elective endovascular repair for abdominal aortic aneurysms during the initial phase of an aortic endograft programme and to compare them with that of conventional open surgery.
Endovascular Treatment of Abdominal Aortic Aneurysms: Lessons Learned
Journal of Endovascular Surgery, 1997
We evaluated the influence of placement of the bifurcated Powerlink endograft (Endologix Inc, Irvine, Calif) on the aortic bifurcation, with the addition of a proximal extension, in the endovascular treatment (EVAR) of selected patients with atherosclerotic abdominal aortic aneurysms (AAAs). Methods: From September 1999 to June 2007, 205 patients were treated with the bifurcated Powerlink endograft for atherosclerotic AAA at two Italian centers with shared protocols. Patients were retrospectively divided in two groups according to treatment with the bifurcated graft only (n ؍ 126), or its placement on the bifurcation with the addition of a proximal extension (n ؍ 79) at the initial procedure. Study end points included postoperative complications, secondary procedures, immediate and late conversion, migration, endoleak, death, and aneurysmal sac behavior. Results: Overall technical success was 98.5%. Additional procedures were performed in 18%, and postoperative complications occurred in 11.2% (systemic, 8.3%; local, 2.9%). Median follow-up was 42.4 months (range, 6-94 months). Secondary procedures were recorded in 11.2%, migration in 3.9%, type I proximal endoleak in 7.8%, and late conversions in 2.4%. Placement on the bifurcation and the addition of an extension were associated with a higher incidence of postoperative complications (7.1% vs 17.7%, P ؍ .020). A reduced incidence of endoleak (19% vs 8.9%, P ؍ .048), secondary procedures (14.3% vs 6.3%, P ؍ .04), and migration (6.3% vs 0%, P ؍ .024) were observed in the group with a proximal extension. Analysis of single variables reveals that migration was significantly influenced by placement of the graft on the bifurcation (47% vs 0%, P < .001). Both placement on the bifurcation and the addition of an extension positively influenced the type I proximal endoleak rate (3.8% vs 35.3% P < .001) and the need for a secondary intervention (6.3% vs 35.3% P < .001) Two aneurysm ruptures and five cases of late conversion occurred in the group treated with a bifurcated graft only (4%, P ؍ .52, P ؍ .159). Analysis of aneurysm sac behavior was not statistically significant: enlargement, 4.1% vs 1.3% (P ؍ .158); reduction, 34.1% vs 40.5% (P ؍ .542). Conclusion: The placement of the bifurcated Powerlink endograft on the aortic bifurcation with a proximal extension for complete sealing seems to improve late outcomes, particularly secondary procedures, migration, and endoleak development. Larger prospective studies with longer follow-up are necessary to confirm these promising results. ( J Vasc Surg 2008;48:795-801.)
Journal of Cardiovascular Surgery, 2019
landing zone below the renal arteries precludes standard eVar, requiring the patient to undergo or with suprarenal aortic cross clamping. according to the reporting standard for vascular surgery, AAAs were classified as juxta-renal (j-AAA) when extending to renal arteries without involving them. 3 d ata from randomized and controlled trials have proved that endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) is associated with lower early morbidity and mortality in comparison with open repair (OR). 1, 2 The feasibility and effectiveness of this technique depend from anatomical aortic-iliac features. An inadequate proximal
European Journal of Vascular and Endovascular Surgery, 2000
Objectives: to prospectively evaluate the mid-term results of endovascular and open repair in patients with abdominal aortic aneurysm (AAA) anatomically suitable for endovascular repair. Material and methods: between January 1995 and March 1999, among 438 patients treated for AAA, 180 (41%) were suitable for endovascular repair as assessed by computed tomography (CT) scan and angiogram. Seventy-three were treated by various commercially available endovascular grafts (EV) and 107 by open repair (OR). Postoperatively, patients were followed every 6 months with clinical examination, duplex scan and in the EV group, CT scans. Patients' demographic data, intra-and postoperative events were recorded prospectively in a computerised database and compared for each group. Results: median age, sex ratio, preoperative risk factors and aneurysm diameters were not statistically different between the two groups. Respectively in the EV and OR, the average duration of operation was 149±73 mn, and 133±44 mn (NS), blood loss 96 ml±28 and 985 ml±113 (p<0.01), duration of hospitalisation 7 days±2 and 13 days±7 (p<0.01). The one-month mortality was 2.7% (n=2) for EV and 2.8% (n=3) for OR. The rate of cardiac and pulmonary complications was significantly higher in the OR group (6.9% versus 19.6%, p=0.017). At a mean follow-up of 1 year, the cumulative survival rate was 82.2%±7.5 for EV and 96%±2.12 for OR (log-rank test p=0.043). No patients died of rupture, but three patients had to be converted to open surgery. Twenty-two percent (n=16) patients in the EV and 7.5% (n=8) in the OR were submitted to a subsequent minor or major reintervention (p=0.007). At 1 year, the cumulative rates free of any reintervention were respectively 78.8%±6.7% and 92.9%±2.7% (p=0.001). In the EV there were 17 early endoleaks (23.3%). At the end of patient's follow-up seven endoleaks (9.6%) persisted. The primary success rate defined by the absence of endoleak and the absence of reintervention was 54 (74%) with EV and 101 (94%) with OR (p=0.001). Conclusion: EV is a promising technique. However, with current devices and indications the immediate benefits, mainly less blood loss, fewer cardiac and pulmonary complications, and shorter hospitalisation time, are outweighed by a higher rate of reinterventions to treat endoleak, or to maintain patency of the graft.