Chimney Endovascular Aneurysm Repair is now Officially Recommended as an Alternative Treatment Option Based on the New European Society for Vascular Surgery Abdominal Aortic Aneurysm Guidelines of 2019: Do We Want to Keep Looking at the Tree and Not the Forest?

Abstract

We read the commentary from Alric and Canaud1Alric P. Canaud L. Is chimney EVAR an acceptable endovascular technique?.EJVES Short Rep. 2019; 42: 43https://doi.org/10.1016/j.ejvssr.2019.01.001Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar regarding our case of a symptomatic patient unfit for open repair symptomatic with persistent gutter related type Ia endoleak after chimney endovascular aneurysm repair (ch-EVAR).2Ballesteros-Pomar M. Taneva G.T. Austermann M. Fernández-Samos R. Torsello G. Donas K.P. Successful management of a type B gutter related endoleak after chimney EVAR by coil assisted onyx embolisation.EJVES Short Rep. 2019; 42: 38-42https://doi.org/10.1016/j.ejvssr.2018.12.002Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The goal of our case presentation was to provide information about possible solutions for suboptimal performance, as a lesson learned after 10 years of clinical experience and treatment of more than 250 cases by ch-EVAR.3Donas K.P. Lee J.T. Lachat M. Torsello G. Veith F.J. Dalman R.L. et al.Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: the PERICLES registry.Ann Surg. 2015; 262: 546-552https://doi.org/10.1097/SLA.0000000000001405Crossref PubMed Scopus (221) Google Scholar, 4Donas K.P. Torsello G.B. Piccoli G. Pitoulias G.A. Torsello G.F. Bisdas T. et al.The PROTAGORAS study to evaluate the performance of the Endurant stent graft for patients with pararenal pathologic processes treated by the chimney/snorkel endovascular technique.J Vasc Surg. 2016; 63: 1-7https://doi.org/10.1016/j.jvs.2015.07.080Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar As the authors published when they reported on the role of physician modified endografts “to break the rules you must first master them.”5Canaud L. Gandet T. Ozdemir B.A. Sfeir J. Alric P. Commentary: physician-modified thoracic stent-graft: to break the rules you must first master them.J Endovasc Ther. 2018; 25: 464-465https://doi.org/10.1177/1526602818779394Crossref PubMed Scopus (1) Google Scholar And, in this context, we believe that presentation of successful management of challenging cases with persistent post-operative flow to the aneurysm sack is of particular importance, having as a sustained goal of optimising the outcome in favour of the patient. The authors are wondering whether ch-EVAR is in general, an alternative option. The answer could be very easily given from recommendation 97 of the European Society for Vascular Surgery (ESVS)'s newest guidelines regarding juxtarenal aneurysms.6Wanhainen A. Verzini F. Herzeele I Van Allaire E. Bown M. Cohnert T. et al.European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg 2019. 2018; https://doi.org/10.1016/j.ejvs.2018.09.020Abstract Full Text Full Text PDF Scopus (1165) Google Scholar It is stated that ch-EVAR can be considered as an alternative option when fenestrated endografting (f-EVAR) is not indicated or not available. The level of evidence (C) is the same as for f-EVAR,6Wanhainen A. Verzini F. Herzeele I Van Allaire E. Bown M. Cohnert T. et al.European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg 2019. 2018; https://doi.org/10.1016/j.ejvs.2018.09.020Abstract Full Text Full Text PDF Scopus (1165) Google Scholar and our case is in full alignment with this recommendation. There is no evidence in the new guidelines supporting other alternative therapies rather than chimney grafts as the authors of the commentary suggested. In summary, the use of chimney grafts is no longer a matter of faith but a fact. The evidence in the literature supports its complementary role for the treatment of juxtarenal aneurysms and in agreement with that the ongoing ENCHANT Study as a fully prospective multicentre trial of ch-EVAR (clinicaltrials.gov identifier: NCT03320252) will provide further evidence bringing the technique to a higher level of evidence (B) than f-EVAR (C). Do we want to keep looking at the tree and not the forest?