Outcomes of Chimney or Snorkel Endovascular Repair for Symptomatic and Ruptured Abdominal Aortic Aneurysms

Abstract

Symptomatic and ruptured abdominal aortic aneurysms (AAAs) are increasingly managed with endovascular aneurysm repair (EVAR). We aimed to identify the 30-day outcomes of symptomatic and ruptured AAAs that underwent EVAR with chimney or snorkel techniques (Ch-EVAR). A retrospective cohort study was performed using the Vascular Quality Initiative registry from March 2013 to July 2019. All patients with symptomatic and ruptured AAAs with proximal aortic zone of disease from 6 through 9 who underwent Ch-EVAR were included. Outcomes were analyzed per the Society for Vascular Surgery reporting standards for EVAR. Ch-EVAR was performed in 77 patients (35 [45.5%] ruptures, 42 [54.5%] symptomatic). Median age was 73 (interquartile range [IQR], 67-81) years, and 54 (70.1%) patients were male. Maximum aneurysm diameter was 67.5 (IQR, 54.5-83.3) mm. All patients were assigned to American Society of Anesthesiologists class 3 or above, with 56 (72.7%) class 4. Among ruptured AAAs, the mean lowest preoperative systolic blood pressure was 95.3 (±29.3) mm Hg. Fluoroscopy time was 57.4 (IQR, 41.2-79.0) minutes. The proximal aortic zone of disease was zone 6 in 9 (11.7%), zone 7 in 21 (27.3%), zone 8 in 36 (46.8%), and zone 9 in 11 (14.3%) patients. Ch-EVAR involved one vessel in 28 (36.4%) patients, two vessels in 22 (9.1%) patients, three vessels in 19 (24.7%) patients, and four vessels in 8 (10.4%) patients. Configurations of the Ch-EVAR are shown in Table I. Technical success was achieved in 67 (87.0%) patients. Outcomes of symptomatic and ruptured Ch-EVAR are summarized in Table II. Reintervention was required in 10 (13.0%) patients at a median time of 9 postoperative days. This involved the aorta/chimneys in five (6.5%) patients, access ischemia in one (1.3%), complete device removal in one (1.3%), new stent placement in two (2.6%), and glue repair of endoleak in one (1.3%). Postoperatively, 31 (40.3%) patients had a major complication, including 4 (5.2%) access site hematomas, 1 (1.3%) access site occlusion, 2 (2.6%) strokes, 2 (2.6%) pneumonias, 5 (6.5%) reintubations, 8 (10.4%) renal ischemia, 11 (14.3%) postoperative dialysis, 4 (5.2%) intestinal ischemia, 3 (3.9%) leg ischemia, and 1 (1.3%) leg compartment syndrome. Ch-EVAR for symptomatic and ruptured AAAs may be performed with acceptable rates of morbidity and mortality. Long-term data are needed to determine durability.Table IConfigurations of Ch-EVARConfigurationNumber of patients (n = 77) (%)Bilateral Renal10 (13.0)Left Renal11 (14.3)Right Renal10 (13.0)SMA, Bilateral Renal16 (20.8)SMA, Left Renal4 (5.2)SMA, Right Renal5 (6.5)SMA7 (9.1)Celiac, SMA3 (3.9)Celiac, SMA, Left Renal3 (3.9)Celiac, SMA, Bilateral Renal8 (10.4) Open table in a new tab Table IIComparison between ruptured and symptomatic Ch-EVAROutcomeRuptured (n = 35)Symptomatic (n = 42)Overall (n = 77)P-valueMortality4 (11.4%)3 (7.1%)7 (9.1%).695Converted to Open Procedure1 (2.9%)1 (2.4%)2 (2.6%)1.000Type 1 Endoleak7 (20.0%)2 (4.8%)9 (11.7%).071Type 2 Endoleak0 (0.0%)4 (9.52%)4 (5.2%).121Type 3 Endoleak0 (0.0%)1 (2.4%)1 (1.3%)1.000Postoperative length of stay (days)13.67.610.3.110Number of vessels stented1.82.32.1.038 Open table in a new tab