Technical aspects, current indications, and results of chimney grafts for juxtarenal aortic aneurysms

Abstract

Juxtarenal aortic aneurysms (JAA) can be successfully treated by fenestrated/branched endografts (FBE), but with significant cost and a long manufacturing process. "Chimney" grafts (CG) have been advocated as a cheaper and immediately available alternative. Because scant data are available, the aim of this study was to report our early experience with CG to treat JAA. From 2000 to 2010, data were prospectively collected for 975 consecutive endovascular aortic repairs (EVAR). Among them, 57 patients undergoing EVAR for JAA were retrospectively reviewed, and those undergoing planned CG were analyzed further. All CG patients were thought to be at high risk for open surgery and were usually unsuitable for FBE. The series included 16 patients with CGs for JAA, and 14 (88%) were men. Median age was 73 years old (range, 22-91 years). Median aneurysm diameter was 62 mm (range, 30-100 mm). Indications for CG were an anatomic condition precluding FBE in four patients (including three with iliac occlusion), emergent repair of painful or ruptured aneurysm in four, a large-diameter aneurysm whose treatment could not wait for the manufacturing delay of an FBE in three, type Ia endoleak in three patients previously treated by infrarenal EVAR, and elective in two. Treatment involved 26 target vessels (6 superior mesenteric arteries, 20 renal arteries). Intraoperative technical success was 94% (1 type Ia endoleak). Postoperatively, one patient died of a retroperitoneal hemorrhage and one patient died of mesenteric ischemia after leaving the hospital against medical advice. One patient had a stroke, and four presented with local vascular complications (iliac dissection, hematoma). The postoperative computed tomography scan showed two patients (12.5%) had a type Ia endoleak. With a median follow-up of 10.5 months (range, 2-19 months), two more patients died (not aneurysm-related). No rupture occurred. All target vessels were patent (primary patency rate, 96%), and one type Ia endoleak persisted. CG is feasible and efficient to treat JAA in patients unsuitable for FBE. However, in this preliminary experience, complications of devices insertion and type I endoleaks were not rare. Until the anatomic applicability of FBE is extended and off-the-shelf FBE devices are available, CG remains a feasible endovascular option for high-risk JAA patients.