Fenestrate What You Can't Snorkel?

Chimney endovascular aneurysm repair (ChEVAR) for hostile neck complex aneurysm

OBJECTIVE

Recent guidelines recognize the role of chimney endovascular aneurysm repair (ChEVAR) in the treatment of complex aortic disorders. The optimal configuration and number of visceral vessels that can be incorporated is still controversial. We aim to review outcomes from a multi-institutional decade-long experience with ChEVAR.

METHODS

Patients undergoing ChEVAR with multiple (≥2) chimney branches were selected from a prospectively maintained database at the two academic university hospitals. All patients were poorly suited for fenestrated or branched endograft repair (F/BEVAR) and deemed poor-risk for open surgery.

RESULTS

Forty-nine multiple ChEVAR were performed in 44 men and 5 women, with complete outcome data at a mean follow-up of 18 months. Overall, 2 patients died during follow-up (4%) with no aneurysm-related mortality and two ruptures after ChEVAR (4.1%) due to a type Ib endoleak from iliac limb pullout and persistent gutter-flow, both repaired with endovascular means. No stroke or spinal cord ischemia was noted during the follow-up period. Reintervention was undertaken in eight patients (16.3%) with five reinterventions for persistent gutter-flow and four chimney graft-associated. Three-vessel ChEVAR was performed in 16 patients, with two-vessel ChEVAR in 33 patients for a total of 114 chimney branches (mean 2.3 chimneys per patient). There were 21 superior mesenteric artery (SMA), 45 right renal, 46 left renal artery (LRA), and two accessory LRA chimneys placed. Antegrade configuration of chimney branches was chosen in 43 patients (88%). There were no significant differences between three-vessel and two-vessel ChEVAR upon univariate analysis in aneurysm size (65.6 vs 60.5 mm; p = 0.059), iliac diameter (7.3 vs 7.1 mm; p = 0.85), or endograft oversizing (30 vs 32.5%; p = 0.43). Three-vessel ChEVAR was associated with a larger aneurysm neck diameter (28.4 vs 25.0 mm; p = 0.021), shorter native infrarenal neck (0.5 vs 3.37 mm; p = 0.002) as well as longer seal zone (36.33 vs 22.67 mm; p = 0.005) compared with two-vessel ChEVAR. At follow-up, there were no significant differences in gutter area between three-vessel and two-vessel ChEVAR (18.9 vs 15.7 mm³; p = 0.73) nor the rate of persistent gutter-flow (12.5 vs 9.1%; p = 0.71).

CONCLUSION

Reintervention to multiple chimney grafts and for persistent gutter-flow is higher compared to single chimneys and demands close surveillance. However, based upon this combined transantlantic experience, we believe multiple ChEVAR provides a reasonable and safe option for complex aortic aneurysm repair when open or custom endografts are not available or indicated based on their Instructions For use, even when triple chimney grafts are required. The optimal configuration for multiple ChEVAR still warrants further study, although theoretical preliminary advantages may exist for a combination of antegrade and retrograde chimneys.

Snorkel endovascular abdominal aortic aneurysm repair versus fenestrated endovascular aneurysm repair: is it a competition?

The endovascular treatment of juxtarenal abdominal aortic aneurysm (AAA) can be performed by either a standard endovascular stent graft with additional snorkle grafts to aorta branches (snorkel endovascular aneurysm repair) or implantation of a fenestrated stent graft (fenestrated endovascular aneurysm repair). While many vascular surgeons consider snorkel endovascular aneurysm repair and fenestrated endovascular aneurysm repair to be competing techniques or alternate strategies, published procedural outcomes suggest more complementary roles. In this clinical review, the advantages and disadvantages of these two approaches are debated, as much can be learned from both strategies. Because the indications and circumstances for juxtarenal AAA repair vary based on patient-specific comorbidities and anatomy, it is recommended that vascular surgeons have access to, and experience with, both treatment strategies. Based on published outcomes, patient outcomes, stent-graft patency, and re-intervention rates are generally similar and acceptable compared with open AAA repair. We conclude that there is a time and a place for both snorkel endovascular aneurysm repair and fenestrated endovascular aneurysm repair for the endovascular management of juxtarenal and pararenal AAA anatomy.

Endovascular treatment of bilateral common iliac artery aneurysms using bifurcated-unibody stent grafts

BACKGROUND

Endovascular treatment of bilateral common iliac artery aneurysms (CIAA) is a promising alternative to open surgical repair. However, endovascular treatment is challenging when the CIAAs have short proximal necks and internal iliac artery needs to be preserved.

METHODS/RESULTS

We report a case of a 62-year-old man who presented with bilateral CIAA with short proximal necks, with the right-side aneurysm extended into the internal iliac artery. The aneurysms were successfully excluded by using a bifurcated-unibody stent graft on the left with preservation of its internal iliac artery; a conventional tubular covered stent was used on the right with occlusion of its internal iliac artery. In addition, an aorta-bi-iliac artery stent was used to provide extended proximal landing zones for the iliac stents.

CONCLUSIONS

Endovascular repair using an iliac bifurcated-unibody stent graft can be a useful approach for the treatment of CIAAs. An aorta-bi-iliac endograft may also be needed to provide a reliable landing zone when the proximal neck of the iliac aneurysm is short.