The Single-centre Experience of the Supra-arch Chimney Technique in Endovascular Repair of Type B Aortic Dissections

Differences in In-Hospital and Follow-Up Outcomes Between Non-A Non-B Aortic Dissection and Type B Aortic Dissection Treated by Endovascular Based Treatment

OBJECTIVES

Non-A non-B aortic dissection (AD) is a rare and life-threatening medical emergency, and it has been controversial whether it should be managed as type B aortic dissection (TBAD). The study aims to compare in-hospital and follow-up outcomes between patients with non-A non-B AD and those with TBAD treated by endovascular based treatment (EBT).

METHODS

From January 2017 to December 2021, 96 consecutive patients with non-A non-B AD met the inclusion criteria and underwent EBT. Patients with TBAD were matched to patients with non-A non-B AD at a 1:1 ratio using propensity score matching analysis to correct for baseline confounding factors. The primary endpoint was all-cause mortality. Aortic-related events were defined as dissection-related death, aortic rupture, retrograde type A aortic dissection, reintervention, and type Ia endoleak.

RESULTS

Patients with non-A non-B AD required more TEVAR-related adjunctive procedures compared to TBAD patients during EBT and they required a longer ICU length of stay (36.0 vs 24.0 hours, P < .05) as well as a longer hospitalization (8.0 vs 7.0 days, P < .05) after EBT. There was no statistical difference in overall survival after EBT for patients with TBAD and non-A non-B AD. However, compared to patients with TBAD, non-A non-B AD patients had a higher rate of reintervention and experienced more aortic-related late events during follow-up.

CONCLUSION

Patients with non-A non-B acute AD who are treated with EBT do not have higher in-hospital or follow-up mortality rates compared to patients with type B AD. However, there is an increased risk of reintervention and aortic-related late events after the intervention during follow-up.

Treatment for Stanford type B aortic dissection with insufficient anchoring region using castor integrated branched aortic stent graft

Background

To investigate the clinical efficacy of Castor integrated branched aortic stent graft for the treatment of Stanford type B aortic dissection with insufficient anchoring area.

Methods

Retrospective analysis of clinical data of 26 patients with Stanford type B aortic dissection with insufficient anchoring region (<15 mm) treated by Castor branched aortic stent graft from September 2018 to June 2022 at Ganzhou People's Hospital, including 23 acute cases and 3 chronic cases.

Results

Surgical procedures were successfully performed in all 26 patients, and during the perioperative period no complications occurred, such as cerebrovascular accident, stenosis or occlusion of left subclavian artery, progression of reverse avulsion of aortic dissection, and paraplegia. During the operation 2 patients had a small amount of type I endoleak, which disappeared during the postoperative follow-up. The other patients had good postoperative follow-up results. Review of the aortic CTA indicated good stent morphology with patency of the left subclavian artery.

Conclusions

The Castor integrated branched aortic stent graft expanded the indications for endoluminal treatment for Stanford type B aortic dissection, which can avoid open surgery and has good clinical outcomes.

A meta-analysis on the effect of proximal landing zone location on stroke and mortality in thoracic endovascular aortic repair

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) involving the aortic arch may increase the opportunity for stroke owing to disruption of cerebral circulation and embolization. In this study, a systematic meta-analysis was performed to examine the impact of proximal landing zone location on stroke and 30-day mortality after TEVAR.

METHODS

MEDLINE and Cochrane Library were searched for all original studies of TEVAR reporting outcomes of stroke or 30-day mortality for at least two adjacent proximal landing zones, based on the Ishimaru classification scheme. Forest plots were created using relative risks (RR) with 95% confidence intervals (CI). An I2 of <40% was regarded as minimal heterogeneity. A P value of <.05 was considered significant.

RESULTS

Of the 57 studies examined, a total of 22,244 patients (male 73.1%, aged 71.9 ± 11.5 years) were included in the meta-analysis, with 1693 undergoing TEVAR with proximal landing zone 0, 1931 with zone 1, 5839 with zone 2, and 3089 with zone 3 and beyond. The overall risk of clinically evident stroke was 2.7% for zones ≥3, 6.6% for zone 2, 7.7% for zone 1, and 14.2% for zone 0. More proximal landing zones were associated with higher risks of stroke compared with distal (zone 2 vs ≥3: RR, 2.14; 95% CI, 1.43-3.20; P = .0002; I2 = 56%; zone 1 vs 2: RR, 1.48; 95% CI, 1.20-1.82; P = .0002; I2 = 0%; zone 0 vs 1: RR, 1.85; 95% CI, 1.52-2.24; P < .00001; I2 = 0%). Mortality at 30 days was 2.9% for zones ≥3, 2.4% for zone 2, 3.7% for zone 1, and 9.3% for zone 0. Zone 0 was associated with higher mortality compared with zone 1 (RR, 2.30; 95% CI, 1.75-3.03; P < .00001; I2 = 0%). No significant differences were found in 30-day mortality between zones 1 and 2 (P = .13) and between zone 2 and zones ≥3 (P = .87).

CONCLUSIONS

The risk of stroke from TEVAR is lowest in zone 3 and beyond, increasing significantly as the landing zone is moved proximally. Furthermore, perioperative mortality is increased with zone 0 compared with zone 1. Therefore, risk of stent grafting in the proximal arch should be weighed against alternative surgical or nonoperative options. It is anticipated that the risk of stroke will improve with further development of stent graft technology and implantation technique.

Comparison of Chimney and Fenestrated Techniques for Supra-Aortic Branch Revascularization During Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis

PURPOSE

To compare the technical and clinical outcomes of fenestrated thoracic endovascular aortic repair (F-TEVAR) and chimney thoracic endovascular aortic repair (CH-EVAR) of aortic disease.

METHODS

PubMed, Embase and Cochrane databases were systematically searched to identify studies on the management of thoracic aortic pathologies using chimney or fenestrated techniques published between 2000 and 2022. Individual studies provided at least one of the following essential outcomes: technical success, immediate and follow-up type I endoleak, 30-day and aorta-related mortality, cerebral events and supra-aortic branch patency.

RESULTS

24 chimney (1106 patients) and 21 fenestrated technique studies (1040 patients) were included. The scope of the study encompassed various thoracic aortic conditions, such as thoracic aortic dissection, thoracic aortic aneurysm, thoracic aortic ulcer, and other thoracic aortic diseases. Technical success was defined as the handling of the principal ailment affecting the aorta, devoid of any instances of complications. The technical success rates were higher in fenestrated group compared with chimney group (98.0% vs. 95.8% p < 0.001), and the rate of type I endoleak either immediately or during follow-up was higher in the chimney technique group (9.3% vs. 1.3% p < 0.001, 4.0% vs. 0.0% p < 0.001). The chimney technique group had higher 30-day mortality and aorta-related mortality than those in the fenestrated technique group (2.1% vs. 0.3% p < 0.001, 0.4% vs. 0.0% p < 0.001). Morbidity rates of cerebral events and supra-aortic branch patency were same in both groups (2.2% vs. 1.1% p = 0.116, 98.2% vs. 99.4% p = 0.094). The chimney technique group had longer operative time (110.0 min vs. 90.8 min p < 0.001). Two groups had same fluoroscopy time (34.0 min vs. 33.4 min p = 0.614).

CONCLUSIONS

The finding suggest that both the chimney and fenestrated techniques are efficacious in supra-aortic branch reconstruction. However, the fenestrated technique exhibits potential superiority as an interventional strategy, as it demonstrates a lower incidence of type 1 Endoleak, 30-day mortality, and aorta-related death following TEVAR.

Tratamiento endovascular con técnica de chimenea para patologías del arco aórtico

Introducción. La patología del arco aórtico se ha tratado principalmente con cirugía por vía abierta, pero con una alta morbimortalidad. Las técnicas endovasculares híbridas y las reconstrucciones en “chimenea” son una técnica válida y segura para disminuir el riesgo y la mortalidad. Métodos. Se presentan dos pacientes con patología del arco aórtico y contraindicación de manejo quirúrgico abierto, atendidos en el Servicio de Cirugía Vascular, Hospital Universitario Clínica de San Rafael, Bogotá, D.C., Colombia. Resultados. Se realizaron dos procedimientos endovasculares del arco aórtico para tratar un aneurisma torácico roto y una úlcera aórtica sintomática, con cubrimiento de los troncos supra aórticos con una endoprótesis y canalización de los vasos supra aórticos con prótesis cubiertas y uso de la “técnica de chimenea”, de manera exitosa. Discusión. La patología del arco aórtico es de alta complejidad y se asocia con una morbimortalidad elevada por lo que, en los últimos 20 años se han desarrollado diferentes técnicas utilizando procedimientos percutáneos. Conclusión. La “técnica de chimenea” se puede realizar de una manera mínimamente invasiva en pacientes con patología del arco aórtico, no candidatos para cirugía abierta, con resultados exitosos.

Chimney Graft Technique Combined With Embolization for Treating Ruptured Aortic Arch Lesions

Background: This study aimed to share the experience in applying the chimney graft technique combined with embolization for treating aortic arch rupture under emergency conditions and evaluating early-term results in these patients. Methods: This study retrospectively included patients with ruptured aortic arch lesions who received the chimney graft technique combined with embolization between March 2016 and March 2021. The primary endpoint was a technical success, deemed as successful stent graft deployment to the planned location, patency of the target branch vessel, and absence of significant type I endoleak. The secondary endpoint was clinical success defined with the size of false lumen in follow-up remaining unchanged or decreasing over time, 30-day mortality, complication, and primary patency of chimney graft. Results: This study included 12 patients (age, 61 ± 12 years; male, 83%). Five patients (42%) received single chimney, one patient (8%) received double chimney, and six patients (50%) received triple chimney. Intraoperative type I endoleak occurred in six patients (50%) who underwent endovascular embolization in the primary operation. Post-operative type I endoleak, evaluated by computed tomography angiography examination following the primary operation, occurred in seven patients (58%), including one patient who received endovascular embolization two times. All patients with post-operative type I endoleak were successfully re-treated using coil and Onyx glue within 1 week, and the median length of stay was 22 ± 11 days (range: 7-44 days). Overall technical success was 100%. Eleven patients had completed their follow-up (median, 12 months, range: 1-34 months), and one patient was out of contact. The 30-day mortality was 9% (1/11, post-operative death of a patient with cerebral hemorrhage). No major complications and no chimney compression, migration, occlusion, or stenosis were recorded during follow-up. Seven patients (58%) have ≥6 months of clinical follow-up time with appropriate imaging. In four (57%) of these patients, diameter stabilization was detected, whereas three (43%) experienced significant reduction (≥5 mm). Conclusion: The patients in this study had satisfactory early-term outcomes. The chimney graft technique combined with coil and Onyx glue embolization may be a safe and effective treatment for ruptured aortic arch lesions under emergency conditions.

Aortic Dissection: Branched, Fenestrated, and Parallel Aortic Stent Grafts in the Ascending Aorta and Arch

Open surgical repair of dissections and post-dissection degenerative aneurysms involving the ascending thoracic aorta and aortic arch, whether in the acute or post-repair state, is associated with high rates of morbidity and mortality. Recent advancements in minimally invasive endovascular techniques have expanded the role of thoracic endovascular aortic repair (TEVAR) for dissections and dissection-related arch pathologies. Image-guided endovascular techniques, such as in situ fenestrated grafts, chimney and/or periscope grafts, along with newly developed commercially available branched aortic devices, have allowed for an increasing number of high-risk operative candidates to undergo definitive repair of aortic arch pathology who otherwise would have been destined for non-operative management. This paper reviews the data, pre-procedural planning, and technical considerations for complex TEVAR techniques for ascending and aortic arch dissections and dissection-related aneurysms.

Early Results of a Novel Gutter-Free Chimney Stent-Graft System to Treat Aortic Arch Dissection: Single-Center Data from a Prospective Clinical Trial

AIMS

Discuss the clinical value, technique characteristics, and early follow-up results of a newly designed gutter-free chimney stent-graft system for aortic arch pathology.

METHODS AND RESULTS

About 13 patients with aortic arch dissection were enrolled in a clinical trial testing a novel gutter-free stent-graft between February 2019 and December 2020. All 13 patients were male, age 52.6±10.4 years. The implantation time was 14.0±6.9 minutes; total procedure time was 89.5±19.8 minutes. The volume of contrast was 79.6±7.2 ml. And 15 aortic stent-grafts were implanted, and all 13 patients had chimney branch stent-grafts implanted into the left subclavian artery (LSA). There were 3 (23.1%) cases of immediate type Ιa endoleak after thoracic endovascular aortic repair (TEVAR), and 7.7% type Ιa endoleaks occurred in delayed fashion. Survival at 2 years was 100%, and the 2-year patency of chimney stent-grafts was 100%.

CONCLUSIONS

This study reports early success with good freedom from endoleak using a novel stent-graft designed for chimney TEVAR to treat aortic arch dissection. Postoperative survival and patency of the branch stent-grafts were excellent. Additional data from this multicenter clinical trial will be forthcoming.

Early Efficacy of In Situ Fenestration with a Triple Chimney Technique for High-Risk Stanford Type A Aortic Dissection: A Single-Center Retrospective Study

Purpose

The objective of this investigation was to study the early efficacy of in situ fenestration with triple chimney technique for high-risk type A aortic dissection patients.

Methods

This study included 24 patients who were treated by in situ fenestration with TCT for high-risk TAAD between January 2018 and December 2019. Multiple comorbidities or preoperative critical conditions rendered patients ineligible for open surgery, but all patients that were evaluated and considered had to undergo operation. By analyzing the regular follow-up data, the early postoperative efficacy of the patients was evaluated.

Results

The average age of the 24 patients was 65.4 ± 9.3 years. The success rate of the operation was 100%, as all the patients were discharged successfully. There were no serious neurological complications or persistent endoleakage. The mean follow-up time was 21.4 ± 6.9 months. The patency rate of all branching stents was 100%, with no stent displacement, stenosis, or blockage observed. While none presented with type I endoleakage, one patient (4.2%) presented asymptomatic type II endoleakage around the left subclavian artery stent. Currently, 23 of the 24 patients remain alive.

Conclusion

Initial results are encouraging with TCT for high-risk TAAD. However, due to its high selectivity and potential complexity related to surgical risks, the mid- and long-term efficacy of this technique remains unknown. For patients who are eligible for open heart surgery, we still recommend it be performed.

Non-A non-B aortic dissection: A literature review

Non-A non-B aortic dissections are an infrequent occurrence and represent a small proportion of aortic dissections. Treating this life-threatening medical emergency often requires surgeons to undertake some one of the most challenging surgical or endovascular cases in medicine. This literature review aims to define and classify non-A non-B dissections, describe their epidemiology as well as their pathology. This review also aims to discuss the range of surgical techniques employed in their treatment and management and to investigate the patient outcomes associated with each technique.

Outcomes of single physician-modified fenestrated stent grafts for endovascular repair of thoracic aortic lesions involving the distal aortic arch

OBJECTIVES

Our goal was to evaluate the outcomes of fenestrated thoracic endovascular aortic repair of thoracic aortic lesions involving the distal aortic arch using single physician-modified stent grafts.

METHODS

This single-centre, retrospective study included 58 consecutive patients (mean age, 57 ± 14 years; 11 women) who underwent fenestrated thoracic endovascular aortic repair for thoracic aortic pathologies involving the distal aortic arch using single physician-modified stent grafts between November 2015 and December 2018. Indications included complicated acute type B dissection or intramural haematoma with an unfavourable proximal landing zone (n = 49), type Ia endoleak subsequent to thoracic endovascular aortic repair due to acute type B dissection (n = 1) and distal arch degenerative aneurysms <15 mm from the left subclavian artery (n = 8).

RESULTS

The technical success rate was 94.8%. The 30-day mortality was 1.7%, and the perioperative ischaemic stroke rate was 1.7%. The incidence of perioperative complications was 10.3%. At a mean follow-up of 26.3 months (range, 7-44), all target vessels were patent. All-cause mortality was 5.2%. Estimated 1-, 2- and 3-year survival was 98.3 ± 1.7%, 96.4 ± 2.5% and 93.2 ± 3.9%, respectively.

CONCLUSION

The single fenestrated stent graft technique is feasible and effective for endovascular repair of thoracic aortic pathologies involving the distal aortic arch.

Endovascular aortic repairs combined with looping-chimney technique for repairing aortic arch lesions and reconstructing left common carotid artery

Background

The aim of this retrospective study was to evaluate the feasibility and efficacy of thoracic endovascular aortic repairs (TEVAR) combined with looping chimney technique (LCT) for repairing aortic arch lesions and reconstructing left common carotid artery.

Methods

Total of 14 patients (mean age 52.86±14.46 years; range, 27–79; 10 men, 4 women) were included in the study from December 2016 to December 2018. Aortic arch pathologies of all patients with insufficient proximal landing zone (PLZ) were repaired by TEVAR under local anesthesia, before TEVAR, the left common carotid artery (LCCA) was protected by the guiding sheath from the retrograde brachial access, after aortic stent graft deployed, chimney graft was implanted to restore LCCA by LCT if necessary. All patients underwent computed tomography angiograph (CTA) 2 weeks, 3 months, 6 months and 1 year after surgery.

Results

Pathology results of 14 patients included: type B aortic dissection (n=8), penetrating aortic ulcers (n=1), retrograde type A aortic dissection (n=1), thoracic aortic aneurysm (TAA) (n=2), and thoracic aortic pseudoaneurysm (n=2). In all patients, aortic arch lesions were repaired by TEVAR; while LCCA were successfully reconstructed by the LCT. In one case, the innominate artery (IA) was simultaneously reconstructed through the same percutaneous right brachial artery (RBA) access. Coiling eliminated type Ia endoleak in 3 patients, and type II endoleak vanished by plugging left subclavian artery (LSA) in 2 patients. In four patients, the chimney stent (CG) of LCCA was partially compressed and then another bare stent was implanted to restore patency rate. The mean follow-up duration was 9.77±6.64 months (range, 0–24) and no combinations were observed in 13 patients; except in one patient who died of cerebral hemorrhage due to abnormal coagulation function.

Conclusions

TEVAR combined with LCT has shown to be suitable surgical approach for aortic arch lesions. Either covered intentionally or inadvertently, the LCCA could be safely and effectively reconstructed via percutaneous RBA access. Short-term follow-up demonstrated satisfactory morbidity and mortality in high-risk patients; however, longer follow-up is required to assess the effectiveness and durability of this innovative endovascular procedure.

Endovascular management of chronic post-dissection aneurysms of the aortic arch

This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.

Long-Term Outcome of Chimney Technique Using a Balloon-Expandable Bare-Metal Stent to Preserve Supra-Arch Branches in Type B Aortic Dissection

PURPOSE

This study was performed to investigate the long-term effect of chimney technique using balloon-expandable bare-metal stents (BMSs) to preserve the supra-arch branches in type B aortic dissection (TBAD).

METHODS

Fifty patients with TBAD treated by thoracic endovascular aortic repair with the chimney technique (chTEVAR) using balloon-expandable BMSs from July 2009 to December 2013 were retrospectively assessed. Follow-up computed tomography angiography was performed to assess the postoperative outcomes. The primary end point was a persistent type Ia endoleak (ELIa). The secondary endpoints were chimney stent (CS)-based complications (stenosis, occlusion, fracture, or transposition), all-cause mortality, reintervention, and stroke.

RESULTS

Fifty supra-arch branches (left common carotid artery, n = 11; left subclavian artery, n = 39) were preserved via the chimney technique with 50 balloon-expandable BMSs. The technical success rate was 100%. An immediate ELIa was discovered in 9 (18%) patients. The median survival duration during follow-up was 77.3 months. Five (10%) patients had a persistent ELIa; 3 of these patients had an immediate ELIa. Asymptomatic CS-based complications were found in 3 (6%) patients. The all-cause mortality rate was 8% (4/50); 2 deaths were aortic-related deaths. Five (10%) patients underwent a reintervention. During the estimated 36-month survival period, the survival rate, the rate of freedom from persistent ELIa, and the rate of freedom from reintervention were 93.87%, 89.48%, and 95.56%, respectively.

CONCLUSIONS

The long-term outcomes showed that chTEVAR using balloon-expandable BMSs was safe and feasible for preservation of the supra-arch branches. Evaluation of more patients with a longer follow-up period is needed.

Off-the-Shelf Devices for Treatment of Thoracic Aortic Diseases: Midterm Follow-up of TEVAR With Chimneys or Physician-Made Fenestrations

Purpose: To evaluate the midterm outcomes of thoracic endovascular aortic repair (TEVAR) using chimney grafts (ch-TEVAR) or thoracic stent-grafts with fenestrations made on the back table (f-TEVAR) to treat thoracic aortic dissection (TAD) and thoracic aortic aneurysm (TAA). Materials and Methods: A retrospective analysis was conducted of 474 consecutive patients (mean age 62.3±10.7 years; 346 men) treated with either f-TEVAR (n=110) or ch-TEVAR (n=364) for 352 TADs (81 f-TEVAR and 271 ch-TEVAR) or 122 TAAs (29 f-TEVAR and 93 ch-TEVAR) from 2008 to 2016. The primary endpoints at 30 days and during follow-up were overall mortality, aorta-related mortality, and major complications. The secondary endpoints were endoleak and reintervention. The patency of the target branches, cost of hospitalization, and the use of antiplatelet drugs were also analyzed. Results: Intraoperative type I endoleaks were treated in 69 (14.6%) cases (4 f-TEVAR and 65 ch-TEVAR, p<0.01) to achieve 100% technical success. Four (0.8%) patients died within 30 days [1 (0.9%) f-TEVAR and 3 (0.8%) ch-TEVAR]. Perioperative cerebral ischemia (1 fatal stroke) occurred in 9 (1.9%) patients: (1 f-TEVAR and 8 ch-TEVAR, p=0.39). During the mean follow-up of 50.6±20.0 months (49.5±18.3 months in f-TEVAR and 50.9±20.6 months in ch-TEVAR), 11 (2.3%) patients died of an aorta-related event. Type I endoleak was present in 40 (8.4%) patients (1 f-TEVAR and 39 ch-TEVAR, p<0.01). Eleven (2.3%) patients experienced stent-graft migration and 13 (2.7%) had a retrograde dissection. One hundred (16.9%) of the 593 branch stents occluded (4/75 in the f-TEVAR group and 96/518 in the ch-TEVAR group, p<0.01). The branch reintervention rate was 7.2% (34/474). The f-TEVAR group had a significantly higher probability of freedom from branch occlusion (92%) than the ch-TEVAR group (83%, p=0.007). Conclusion: Off-the-shelf techniques employing chimney grafts and homemade fenestrations are both suitable options for TAD and TAA involving the supra-aortic branches, with a low incidence of reintervention. Fenestrated TEVAR seems to have more favorable short- and midterm outcomes. Further study of these off-the-shelf techniques for aortic arch repair is warranted.

Outcomes Of Chimney Technique For Aortic Arch Diseases: A Single-Center Experience With 226 Cases

Purpose

The goal of present study is to document our single-center experience with chimney technique for aortic arch diseases.

Patients and methods

From August 2012 to October 2017, 226 patients (mean age 54±12 years; 197 men) with aortic arch diseases underwent thoracic endovascular aortic repair combined with chimney stents. The aortic stent-grafts were deployed in zone 0 (n=22), zone 1 (n=13), or zone 2 (n=191).

Results

The technical success rate was 84% (189/226) and immediate type Ia endoleak (ELIa) happened in 37 (16%) patients. The 30-day mortality and morbidity rates were 2% (4/226) and 4% (8/226), respectively. Major adverse events include four major strokes, three spinal cord ischemia and one aortic rupture in the early-term. The clinical and imaging follow-up rates were 98% (218/222) and 78% (173/222), respectively. The average lengths of clinical and imaging follow-up were 22±16 months and 20±15 months, respectively. Chimney stent obstructions in left subclavian arteries were recorded in six (3%) patients. During follow-up, five patients died (2%) and two major strokes occurred (1%). One patient (0.5%) underwent reintervention.

Conclusion

The current study documented that the chimney technique is effective and safe for treating aortic arch diseases in different aortic zones. Cautions are needed to assess the permanency of chimney stent and to reduce the immediate ELIa rate.

A Shorter Aortic Arch Sealing Ring (< 10 mm) Distal to the Most Distal Chimney Seems to Be an Additional Important Factor Contributing to a Gutter Endoleak in Aortic Arch TEVAR

BACKGROUND

The aim of the present study was to define the possible anatomical and technical parameter that might predict the occurrence of gutter endoleak or type Ia endoleak (EL Ia) in patients treated with the chimney graft (CG) technique for the brachiocephalic trunk (BCT) and left common carotid artery (LCCA) due to aortic arch pathologies.

METHODS

We reviewed our institutional endovascular aortic database of patients, who between 2010 and 2018 had undergone thoracic endovascular aortic repair (TEVAR) with chimney graft technique (ChTEVAR) as a debranching method of the supraaortic arteries.

RESULTS

ChTEVAR was performed in 45 patients of whom a chimney in both the LCCA and the BCT was used in 32 patients, only in the LCCA in twelve patients, and only in the BCT in one patient. Eight patients (17.8%) had an EL Ia (based on postoperative computed tomography angiography). No late EL Ia was detected during the follow-up period. All patients with a postoperative EL Ia received 2 CGs with one each for the BCT, and LCCA had either no or a sealing ring distal to the most distal chimney of less than 10 mm versus patients with a longer sealing zone (P = 0.043). Patients with an endoleak did not differ from those without endoleak with respect to stent-graft oversizing, the diameter of the proximal and distal landing zones, or the aortic diameter directly proximal to the pathology.

CONCLUSIONS

A sealing ring distal to the most distal chimney of more than 10 mm seems to be associated with a reduced risk of an EL Ia. The relatively few patients and the single-center nature require larger studies to verify the present results.

Long-term outcomes of balloon-expandable bare stent as chimney stent in thoracic endovascular aortic repair for supra-aortic branches reconstruction

Background

To report the long-term outcomes of balloon-expandable bare stent (BEBS) as chimney stent (CS) in thoracic endovascular aortic repair (TEVAR) for supra-aortic branches reconstruction.

Methods

A total of 33 patients with thoracic aortic diseases underwent TEVAR using BEBSs as CSs for supra-aortic branches reconstruction in our center from 2010 to 2015. The demographics and procedural details were prospectively collected and retrospectively reviewed. All patients were followed up at 1, 3, 6 months and every 1 year thereafter. Postoperative complications and long-term outcomes were recorded.

Results

The technical success rate was 100%. A total of 36 BEBSs were utilized as CSs to reconstruct the supra-aortic branches during TEVAR. The rate of immediate endoleak was 42.4% (14/33), including 12 (36.4%) type Ia endoleaks and 2 (6.1%) type II endoleaks. Two of type Ia endoleaks were managed by balloon dilation and disappeared, while the rest were left with close follow-up. Two type II endoleaks were embolized by coils and excluded by a plug, respectively. One patient (3.0%) died 2 days after the procedure due to the acute rupture of aortic dissection. The mean follow-up time was 61.8 (ranged from 12 to 102) months. The unmanaged 10 type Ia endoleaks were closely observed during the follow-up, of which 7 disappeared at 1 year and 1 disappeared at 2 years. The rest 2 type Ia endoleaks existed without further dilation of the aorta. One patient (3.0%) was re-intervened for the increased false lumen due to the distal residual tears. The long-term mortality was 9.1% (3/33). All CSs kept patent till the end of follow-up. No other complications were found.

Conclusions

The balloon-expandable stent (BES) is a feasible choice as CS for supra-aortic branches reconstruction with long-term patency during TEVAR. However, BEBS may be related to a higher rate of early endoleak.

Mid- and Long-Term Effects of Endovascular Surgery and Hybrid Procedures for Complex Aortic Diseases

Objective

To assess the efficacy and short- and mid-term results of endovascular surgery and hybrid surgical procedures in treatment of complex aortic dissection.

Methods

Clinical data of 90 patients with complex aortic dissection admitted from June 2012 to June 2018 were retrospectively analyzed. Among the patients, 60 cases were male and 30 cases were female, and their ages were ranged from 32 to 79, with an average age of 55 years old; different endovascular techniques and/or hybrid procedures were performed in these patients.

Results

Technical success rate was 100% for the entire group of patients. Type I endoleak occurred in 8 patients immediately after stent-graft placement, which in 2 cases disappeared after a proximal Cuff placement, and the other cases received no special treatment. Follow-up was conducted from 1 month to 72 months, with an average of 36.3 months, and no stent-graft migration or organ ischemia was noted. In the follow-up patients, no type I endoleak occurred but type II endoleak was found in 2 cases, which were cured without treatment; no patient had paraplegia.

Conclusion

Endovascular surgery and hybrid procedures have demonstrable mid- and long-term efficacy in treatment of complex aortic diseases. However, this conclusion still requires multicenter, large-sample studies to further confirm.

Outcomes of Chimney Technique for Preservation of the Left Subclavian Artery in Type B Aortic Dissection

OBJECTIVE

To report outcomes of the chimney technique for preservation of the left subclavian artery (LSA) in patients with type B aortic dissection (TBAD).

METHODS

A retrospective analysis was performed of a prospectively maintained database from August 2012 to October 2017. Primary endpoints were 30 day and overall mortality. Secondary endpoints were technical success, type Ia endoleak, chimney stent occlusion, aortic rupture, stroke, spinal cord ischaemia, and re-intervention rate.

RESULTS

A total of 159 patients (mean age 54 ± 11 years; 141 men) with TBAD were treated using the chimney technique for LSA revascularisation. Acute, subacute, and chronic TBAD accounted for 64%, 28%, and 8% of cases, respectively. One hundred and six cases (67%) were complicated TBAD. One hundred and fifty-six patients (98%) were treated electively, while three (2%) were treated urgently because of intestinal or lower extremity ischaemia. The 30 day mortality and morbidity rates were 2% (3/159) and 4% (7/159), respectively. The technical success rate was 81% (129/159) and immediate type Ia endoleak occurred in 30 (19%) patients. Three major strokes, two spinal cord ischaemia and one aortic rupture, occurred early on. During a mean follow up of 23 ± 16 months (range 1-65 months), three more patients died: from aortic rupture, cerebral haemorrhage, and rectal cancer, respectively. Chimney stent occlusions were observed in four patients and all these chimney stents were self expanding. During follow up, two major strokes, one late type Ia endoleak and one re-intervention, occurred. According to the Kaplan-Meier curve, the estimated one and three year survival rates were 98.1 ± 1.1% and 94.4 ± 2.4%, respectively.

CONCLUSION

Short and mid-term outcomes in the present study demonstrate that the chimney technique is safe and feasible for preservation of the LSA in patients with TBAD, but the durability of chimney stent needs to be evaluated carefully and immediate type Ia endoleak is a concern.

Comparison of Two Different Techniques for Isolated Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair in Zone 2

Purpose: To analyze the results of isolated left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) using carotid-subclavian bypass (CSbp) or chimney grafts (CGs). Methods: A retrospective multicenter, observational study identified 73 patients (mean age 68±13 years, range 22–87; 56 men) with acute or chronic thoracic aortic lesions who underwent TEVAR with isolated LSA revascularization using either CSbp (n=42) or CGs (n=31) from January 2010 and February 2017. Primary endpoints were TEVAR-related mortality, postoperative stroke, freedom from type Ia endoleak, and LSA patency. Results: Primary technical success was achieved in all cases. Early TEVAR-related mortality was 4.2% (CSbp 2% vs CG 6%, p=0.571). Two (3%) patients had major ischemic strokes (one in each group). Mean follow-up was 24±21 months (range 1–72; median 15). Estimated freedom from TEVAR-related mortality was 93%±3% (95% CI 84.3% to 97.0%) at 12 and 36 months, with no significant difference between CSbp and CG (p=0.258). Aortic reintervention did not differ between the groups (CSbp 5% vs CG 6%, p=0.356); nor did freedom from type Ia endoleak (CSbp 98% vs CG 87%, p=0.134). Gutter-related endoleaks occurred in 4 (13%) CG patients, but none of the patients experienced sac enlargement or the need for reintervention and none died. Primary patency of the LSA was 100% for the entire group during the observation period. Conclusion: In our experience, LSA revascularization proved most satisfactory and equally effective with both the CSbp and CG techniques, without discernible differences at midterm follow-up.

Emergency Endovascular Management of a Symptomatic Pseudoaneurysm of the Left Subclavian Artery Ostium Using a Combination of an Abdominal Aortic Stent-Graft Extension Cuff and a Periscope Stent Graft

A pseudoaneurysm located at the subclavian artery ostium is an infrequent but life-threatening pathology that usually requires major thoracic surgery with a high risk of mortality and morbidity. Endovascular therapy applied to the aortic arch branches is a recent alternative technique, which is still in its early stages because dedicated endovascular devices for the aortic arch are lacking. In this article, we present the emergency endovascular management of a symptomatic pseudoaneurysm of the left subclavian artery ostium which was presumably secondary to an atherosclerotic plaque rupture. Endovascular exclusion required a combination of an abdominal aortic stent-graft extension cuff, which was placed via a retroperitoneal iliac access, and a subclavian artery periscope stent graft.

The strategies and outcomes of left subclavian artery revascularization during thoracic endovascular repair for type B aortic dissection

This study was to analyze the outcomes of left subclavian artery (LSA) revascularization during thoracic endovascular repair (TEVAR) for type B aortic dissections (TBAD). From 2011 to 2017, TBAD patients who underwent LSA revascularization during TEVAR were enrolled. Technical success, endoleaks, mortality, complication, reintervention, and patency of target vessels were analyzed. 38 patients were included, 14 underwent carotid-subclavian bypass (CSB), and 24 underwent chimney graft (CG) implantation. Technical success rates were 92.9% and 100% in CSB and CG group. Eleven immediate type I endoleak (EL-I) was detected, including one from CSB group and ten from CG group. Three immediate type II endoleak (EL-II) was detected in CSB group. Perioperative complications showed no difference, but CSB group had longer intensive care unit (ICU) stay time. Median follow-up time was 26.2 months, and overall mortality was 14.3% and 0% in each group. Three EL-I and one EL-II underwent reintervention. All the LSA showed good patency, except one suffered from CG collapse. Both CSB and CG were feasible strategies to preserve the antegrade blood flow of LSA, and each strategy had its advantages and disadvantages. Based on our current experience, we preferred CG for high-risk patients. However, the evidence was still not strong enough, further well-designed studies are necessary to identify the criteria for LSA revascularization strategy during TEVAR.

Outcomes of Chimney and/or Periscope Techniques in the Endovascular Management of Complex Aortic Pathologies

Background:

The chimney/periscope technique has been used to address complex aortic pathologies. This study aimed to report the outcomes and experiences of chimney and/or periscope grafts (CPGs) used in the endovascular management of complex aortic pathologies.

Methods:

Twenty-two patients with complex aortic pathologies were retrospectively studied from January 2013 to August 2016 in two vascular centers of teaching hospitals. All patients were diagnosed using computed tomography angiography (CTA). The patients were followed up at postoperative 1, 3, 6, and 12 months and yearly thereafter with X-ray, ultrasound, and/or CTA.

Results:

Twenty-two cases (17 males; mean age 60.7 ± 16.3 years) with complex aortic pathologies were analyzed. Nineteen patients underwent CPGs only, and the other three cases underwent the simultaneous implantation of chimney/periscope and fenestrated/scallop grafts. Twenty-six arteries were managed with forty CPGs during the procedures. Complete angiographies revealed two Type I endoleaks, one Type III endoleak, and one Type IV endoleak. Other intraoperative complications included brachial thrombosis, external iliac artery rupture, and left renal stenosis. The 30-day mortality was 0. The mean follow-up was 26.1 ± 10.1 months with a range of 2–39 months. During the follow-up, two Type I endoleaks and one Type IV endoleak were observed. One right renal stent occlusion occurred in the 5^th month and turned patent after reintervention. Three patients died during the follow-up, one due to an aneurysm rupture as a Type I endoleak, and two due to myocardial infarction. The instant technical success was 96%. The primary and secondary patencies were 92% and 96%, respectively. The overall survival rates were 95%, 84%, and 84% at 12, 24, and 36 months, respectively. Stent migration was not observed in any patient.

Conclusions:

Chimney/periscope techniques could be used to tackle complex aortic pathologies, but the indications must be strictly controlled, and additional experiences are required.

A Feasibility Study of a New Unibody Branched Stent Graft Applied to Reconstruct the Canine Aortic Arch

OBJECTIVES

The aim was to evaluate the feasibility and safety of a new unibody branched stent graft for the reconstruction of the canine aortic arch.

METHODS

The unibody branched stent grafts included single branched stent grafts and double branched stent grafts. The main stent graft and branched limbs were sutured together. The branched stent grafts were folded into the introducer system, which consisted of a double channel catheter, a detachable sleeve, and an introducer sheath. The branched stent grafts were introduced and deployed into the aortic arch by the delivery system. Twenty adult mongrel dogs were used for the experiments. Ten dogs were implanted with single branched stent grafts; the other 10 were implanted with double branched stent grafts. The surviving animals were followed up for 3 months. Computed tomography angiography (CTA) was performed to observe the status of the branched stent grafts.

RESULTS

All the unibody branched stent grafts were successfully implanted into the canine aortic arches. The technical success rate was 100%. There was no cerebral infarction, paraplegia or incision infection. CTA showed that all the branched stent grafts were patent; there was no endoleak or stent migration.

CONCLUSIONS

The unibody branched stent graft system could be used to reconstruct the aortic arch. The animal experimental procedures demonstrated the safety and feasibility of the unibody branched stent graft system.

Hybrid operation versus the chimney technique for reconstruction of a single aortic arch branch: a single-centre experience

OBJECTIVES

Both hybrid and chimney techniques are used for reconstruction of supra-arch branches during thoracic endovascular aorta repair (TEVAR). Our objective was to summarize our experience with reconstruction of the left common carotid artery (LCCA) or left subclavian artery (LSA) and evaluate the indications for these 2 strategies.

METHODS

The records of patients treated with hybrid or chimney TEVAR when 1 aortic branch (LSA/LCCA) needed to be covered were reviewed retrospectively. The angulations of the LSA and the LCCA were measured for analysis.

RESULTS

The average ages of the patients in the hybrid (n = 26) and chimney groups (n = 31) were 52.6 (SD 12.7) and 55.4 (SD 11.3) years, respectively. The immediate type I endoleak rate was significantly higher in the chimney group (58.1% vs 15.4%, P = 0.001). No in-hospital deaths occurred in either group, and the follow-up mortality rate was 11.5% in the hybrid group and 3.2% in the chimney (P = 0.32) group, whereas the aortic-related mortality rates were 3.8% and 0%, respectively (P = 0.46). The rates of type I endoleaks were significantly higher if the angles of the LSA/LCCA were larger than 38.3°/37.9° [LSA: >38.3°, 100% (10 of 10) vs < 38.3°, 10% (1 of 10), P < 0.001; LCCA: >37.9°, 100% (6 of 6) vs < 37.9°, 20% (1 of 5), P = 0.015].

CONCLUSIONS

Branch angulation and oversizing are crucial factors for type I endoleaks and should be taken into account when choosing the surgical procedure. Our results indicated that the chimney TEVAR is more suitable in cases with small target branch angulation. Additional oversizing may help to prevent post-TEVAR endoleaks.

Chimney Technique in Supra-Aortic Branch Reconstruction in China: A Systematic and Critical Review of Chinese Published Experience

BACKGROUND

The chimney graft (CG) technique has been proposed as a complete endovascular supra-aortic branch reconstruction for aortic pathologies. Due to the rapid growth of thoracic endovascular aortic repair (TEVAR) in China, we aimed to investigate the current data of the CG technique in this most populous country.

METHODS

Studies of supra-aortic branch reconstruction using the CG technique from Chinese centers were collected and analyzed.

RESULTS

A total of 294 patients from Chinese centers who underwent TEVAR with CGs were included. There were 301 CGs performed, with a technical successful rate of 97.7%. The rate of early type I endoleaks was 7.1%, and the patency rate of the CGs was desirable. Balloon-expandable bare CGs were significantly associated with good early outcomes and a low rate of endoleaks.

CONCLUSION

Current data from China revealed positive outcomes using CGs for supra-aortic branch reconstruction. Balloon-expandable bare CGs may be the first choice according to the data available but should be considered with caution.

Aortic Dissection: Novel Surgical Hybrid Procedures

The management of patients with aortic dissection is challenging and its treatment is an area of development and innovation. Conventional surgical techniques are associated with significant risks in terms of mortality and morbidity in such high-risk patients. As a result of cumulative advances in technology, classical surgical techniques have been improved and enhanced by the newer endovascular approaches, leading to novel surgical hybrid procedures. Impressive early results have been seen with frozen elephant techniques, revascularisation of the supra-aortic branches and branched/fenestrated thoracic endovascular aortic repair-alone procedures. This review describes the techniques involved in the latest hybrid procedures for aortic dissection and their outcomes.

Thoracic Endovascular Aortic Repair With Single/Double Chimney Technique for Aortic Arch Pathologies

Purpose: To summarize a single-center experience using the single/double chimney technique in association with thoracic endovascular aortic repairs (TEVAR) for aortic arch pathologies. Methods: From November 2007 to March 2016, 122 patients (mean age 50.4±12.7 years, range 29–80; 92 men) with aortic arch pathologies underwent TEVAR combined with single (n=101) or double (n=21) chimney grafts to reconstruct the supra-aortic branches: 21 innominate arteries, 114 left common carotid arteries, and 8 left subclavian arteries (LSA). Pathologies included type B aortic dissection (n=47), aortic arch dissection (n=49), retrograde type A aortic dissection (n=8), thoracic aortic aneurysm (n=7), penetrating aortic arch ulcer (n=9), and post-TEVAR type I endoleak (n=2). Follow-up examinations included computed tomography at 0.5, 3, 6, and 12 months and yearly thereafter. Results: The aortic stent-grafts were deployed in zone 0 (n=21), zone 1 (n=93), and zone 2 (n=8). One (0.8%) of the 122 patients died at 4 days due to a perforated peptic ulcer. Type Ia endoleaks were found intraoperatively in 13 (10.7%) patients, including 3 with the double chimney technique. Type II endoleaks occurred in 6 (4.9%) patients; 3 were treated with duct occluders in the LSA. Postoperative chimney graft migration occurred in 1 (0.8%) patient with double chimneys; additional stent-grafts were deployed in both chimneys. Median follow-up was 32.3 months, during which 1 (0.8%) patient died after a stroke at 3 months. Chimney stent-graft patency was observed in the remaining 120 patients. Two (1.7%) secondary TEVARs were performed for distal aortic dissection. Nine asymptomatic type Ia endoleaks and 1 type II endoleak persisted in follow-up; a type II endoleak in 1 patient with Marfan syndrome sealed in 52 months. Conclusion: TEVAR with the chimney technique provides a safe, minimally invasive alternative with good chimney graft patency and low postoperative mortality during midterm follow-up. The double chimney technique should be used judiciously owing to its potential complications.

Results From a Nationwide Registry on Scalloped Thoracic Stent-Grafts for Short Landing Zones

Purpose: To report the perioperative results and short-term follow-up of patients treated with scalloped thoracic stent-grafts. Methods: A multicenter registry in the Netherlands captured data on 30 patients (mean age 68 years; 17 men) with thoracic aortic pathology and a short (<20 mm) proximal or distal landing zone who received a custom-made scalloped stent-graft between January 2013 and February 2016. Patients were treated for saccular (n=13) aneurysms, fusiform (n=9) aneurysms, pseudoaneurysms (n=4), or chronic type B dissections (n=4). The scallop was used to preserve flow in the left subclavian artery (LSA) (n=17), left common carotid artery (n=5), innominate artery (n=1), and celiac trunk (n=7). In 7 (23%) patients, the scallop also included the adjacent artery. Results: Technical success was achieved in 28 (93%) patients. In 1 patient, a minor type Ia endoleak was observed intraoperatively, which was no longer visible on computed tomography angiography at 3 months. In another patient, the LSA was unintentionally obstructed due to migration of the stent-graft on deployment. Concomitant carotid-carotid or carotid-subclavian bypass was performed in 4 patients. There was no retrograde type A dissection or conversion to open surgery. In-hospital mortality was 3%, and the perioperative ischemic stroke rate was 3%. At a mean follow-up of 9.7 months (range <1 to 31), 29 of 30 target vessels were patent. Conclusion: The scalloped stent-graft appears to be a safe and relatively simple alternative for the treatment of thoracic aortic lesions with short landing zones. Larger patient series and long-term follow-up are required to confirm these early results.

Short- and Long-term Results of Hybrid Arch and Proximal Descending Thoracic Aortic Repair

Purpose: To evaluate the short- and long-term outcomes of hybrid repair of the arch and proximal descending aorta in a single tertiary center for aortic disease. Methods: A retrospective analysis was performed of 55 patients (median age 67 years; 36 men) who underwent hybrid repair of thoracic aortic pathology with involvement of the arch between January 2005 and May 2015 at a single tertiary center. The pathologies included 40 (73%) with aneurysmal disease, 10 (18%) acute type B aortic dissections, 2 with acute aortic syndrome, an acute type A dissection, and left and aberrant right subclavian artery aneurysms. Seven (13%) procedures were performed as an emergency. Demographics and procedure characteristics were collected for analysis of survival and reinterventions. Results: Complete aortic debranching was performed in 14 (25%) to facilitate endograft placement in zone 0; debranching was partial in 20 (36%) patients for zone 1 deployments and 21 (38%) for zone 2. Primary technical success was achieved in 51 (93%) cases. One patient died in-hospital from aneurysm rupture following aortic debranching prior to stent-graft repair. In another, the stent-graft procedure proved infeasible and was abandoned. The other 2 technical failures were due to type Ia endoleaks. Five (9%) patients died in-hospital (4 of 48 elective and 1 of 7 emergency cases); 2 of these patients died within 30 days (4%). Eight (14%) patients had a stroke, 6 of 48 elective and 2 of the 7 emergency patients. Spinal cord ischemia was reported in 3 (6%) patients. Mean follow-up was 74.6 months. Overall cumulative survival was 70% at 1 year, 68% at 2 years, and 57% at 5 years. Reintervention to the proximal landing zone for type Ia endoleak was required in 6% of cases. The overall rate of aortic reintervention was 18% at 1 year, 21% at 2 years, and 36% at 5 years. Overall extra-anatomic graft patency was 99%. Conclusion: Hybrid repair of the aortic arch and proximal descending thoracic aorta is technically feasible, with acceptable short-term mortality. There is a low rate of proximal landing zone reintervention when hybrid techniques are used to create an adequate proximal landing zone. Extra-anatomic bypass grafts have good long-term patency. Ongoing disease progression means that further distal aortic interventions are often necessary in patients with extensive disease.

Use of Suture-Mediated Closure Device in Percutaneous Direct Carotid Puncture During Chimney-Thoracic Endovascular Aortic Repair

BACKGROUND

Insertion of a carotid chimney graft during thoracic endovascular aortic repair (Ch-TEVAR) is a recognized technique to extend the proximal landing zone into the aortic arch in the treatment of thoracic aortic disease. Conventional technique requires surgical exposure of the carotid artery for insertion of the carotid chimney graft.

METHODOLOGY

We describe our experience in the use of a suture-mediated closure device in percutaneous Ch-TEVAR in four patients.

RESULTS

Successful hemostasis was achieved in all four patients. No complications related to the carotid puncture were recorded.

CONCLUSION

We conclude that using suture-mediated closure device for carotid closure appears feasible and deserves further studies as a potential alternative to conventional surgical approach.

Chimney Grafts in Aortic Stent Grafting: Hazardous or Useful Technique? Systematic Review of Current Data

BACKGROUND

The chimney graft (CG) technique was introduced to rescue accidentally covered aortic branches during aortic endovascular repair. It extends the sealing zone. There is concern about "gutter" type I endoleak (EL-I) and about the durability of CGs. The aim of the present report was to analyze the rapidly increasing existing data.

METHODS

A search was performed (PRISMA criteria) for all studies of visceral and thoracic/arch chimney grafts. Technical and clinical details and outcome were assessed.

RESULTS

The present review includes 831 patients who underwent EVAR/TEVAR (endovascular aneurysm repair/thoracic endovascular aneurysm repair) with one or more chimney, periscope, or sandwich grafts. For aortic visceral vessels 517 patients received 911 visceral CGs and 314 patients received 364 arch CGs. Most procedures (81% visceral and 69% arch CGs) were elective. Thirty day mortality was 4% for both groups. The rate of early EL-I was 13% (visceral CGs) and 11% (arch CGs). Most EL-I were handled conservatively (observation: 70% for visceral CG and 45% for arch CG). Early CG patency was high (97-99%) and remained high during follow up (median 17 months). Late (after 30 days) EL-I was reported in nine visceral (2%) and 12 arch (4%) CG cases. Few other late complications were reported, but those losing a kidney at the initial repair seemed to have a high risk of requiring permanent hemodialysis.

CONCLUSION

Increasing amounts of data support the benefit of visceral and arch chimney graft techniques. In particular, the low early mortality and complication rates and high long-term patency seem advantageous; however, the majority of cases have been treated electively, and there is a high risk of bias in all studies. Mid- to long-term data suggest few late complications, except in cases where one renal artery was sacrificed. The CG technique is valuable for complex urgent patients and needs further documentation for other patient groups.