Critical analysis of results after chimney endovascular aortic aneurysm repair raises cause for concern

Abstract

"Chimney" techniques used to extend landing zones for endovascular aortic repair (chEVAR) have been increasingly reported; however, concerns about durability and patency remain. The purpose of this analysis was to examine midterm outcomes of chEVAR. All patients at the University of Florida treated with chEVAR were reviewed. Major adverse events (MAEs) were recorded and defined as any chimney stent thrombosis, type Ia endoleak in follow-up, reintervention, 30-day/in-hospital death, or ≥25% decrease in estimated glomerular filtration rate after discharge. Primary end points included chimney stent patency and freedom from MAE. Secondary end points included complications and long-term survival. From 2008 to 2012, 41 patients (age± standard deviation, 73± 8years; male, 66% [n= 27]) were treated with a total of 76 chimney stents (renal, n= 51; superior mesenteric artery, n= 16; celiac artery, n= 9) for a variety of indications: juxtarenal, 42% (n= 17, one rupture), suprarenal, 17% (n= 7), and thoracoabdominal aneurysm, 17% (n=7); aortic anastomotic pseudoaneurysm, 15% (n= 6; three ruptures); type Ia endoleak after EVAR, 7% (n= 3); and atheromatous disease, 2% (n= 1). Two patients had a single target vessel abandoned because of cannulation failure, andone had a type Ia endoleak at case completion (technical success, 93%). Intraoperative complications occurred in seven patients (17%), including graft maldeployment with unplanned mesenteric chimney (n= 2) and access vessel injury requiring repair (n= 5). Major postoperative complications developed in 20% (n= 8). The 30-day mortality and in-hospital mortality were 5% (n= 2) and 7% (n= 3), respectively. At median follow-up of 18.2months (range, 1.4-41.5months), 28 of 33 patients (85%) with available postoperative imaging experienced stabilization or reduction of abdominal aortic aneurysm sac diameters. Nine patients (32%) developed endoleak at some point during follow-up (type Ia, 7% [n= 3]; type II, 10% [n= 4]; indeterminate, 7% [n= 3]), and one patient underwent open, surgical conversion. The estimated probability of freedom from reintervention (±standard error mean) was 96%± 4% at both 1year and 3years. Primary patency of all chimney stents was 88%± 5% and 85%± 5% at 1year and 3years, respectively. Corresponding freedom from MAEs was 83%± 7% and 57%± 10% at 1year and 3years. The actuarial estimated survival for all patients at 1year and 5years was 85%± 6% and 65%± 8%, respectively. These results demonstrate that chEVAR can be completed with a high degree of success; however, perioperative complications and MAEs during follow-up, including loss of chimney patency and endoleak, may occur at a higher rate than previously reported. Elective use of chEVAR should be performed with caution, and comparison to open and fenestrated EVAR is needed to determine long-term efficacy of this technique.