Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair Adel Bin Jabr, MD, Bengt Lindblad, MD,

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Presentation transcript:

Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair Adel Bin Jabr, MD, Bengt Lindblad, MD, PhD, Nuno Dias, MD, PhD, Timothy Resch, MD, PhD, Martin Malina, MD, PhD Journal of Vascular Surgery Volume 61, Issue 4, Pages 886-894.e1 (April 2015) DOI: 10.1016/j.jvs.2014.11.078 Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 1 A mycotic thoracoabdominal aneurysm was managed with the sandwich technique and chimney grafts (CGs) to the superior mesenteric artery (SMA), right renal artery (RRA), and left renal artery (LRA). The celiac trunk was embolized. A, Intraoperative angiography shows patent SMA and renal CGs. B, Follow-up (FU) computed tomography (CT) angiography (CTA) shows obliterated aneurysm with three open CGs. No reinfection or other complications were seen during 3 years of FU. C, A three-dimensional reconstructed CT scan illustrates the positions of the three CGs between the proximal thoracic and inner abdominal aortic stent grafts. The white arrows point to the distal end of the proximal thoracic stent graft. Journal of Vascular Surgery 2015 61, 886-894.e1DOI: (10.1016/j.jvs.2014.11.078) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 2 Transverse and sagittal views of three consecutive computed tomography angiographies (CTAs) demonstrate the aortic arch with a contained rupture of a pseudoaneurysm (arrows) with hematoma (arrowheads) that was treated with thoracic endovascular aortic repair (TEVAR), chimney to the brachiocephalic trunk, and a carotid-to-carotid bypass. The left subclavian artery (LSA) was sacrificed. A, Preoperative CTA with the ruptured pseudoaneurysm. B, Proximal type I endoleak (EL-I), seen as continued opacification of the pseudoaneurysm (arrow) on postoperative day 4. C, The leak was successfully coiled, and the pseudoaneurysm was obliterated, with complete resorption of the hematoma seen on CT at the 2-year follow-up (FU). Journal of Vascular Surgery 2015 61, 886-894.e1DOI: (10.1016/j.jvs.2014.11.078) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 3 Twenty-nine patients with complex aortic lesions were urgently treated with the chimney graft (CG) technique and thoracic endovascular aortic repair (TEVAR). The Kaplan-Meier outcome curves estimate the freedom from CG occlusion (A), chimney-related mortality (B), 30-day mortality (C), type I endoleak (EL-I) (D), and all-cause mortality (E). Journal of Vascular Surgery 2015 61, 886-894.e1DOI: (10.1016/j.jvs.2014.11.078) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 4 One of the secondary type I endoleak (EL-I) patients was a 63-year-old woman who presented with extensive aortic dissection and distal ischemia due to an acutely compromised true lumen. A and B, She was operated on urgently with thoracic endovascular aortic repair (TEVAR) and chimney graft (CG) to the brachiocephalic trunk. C, After 8 months, an EL-I occurred due to (D) distal migration of the main aortic stent graft relative to the CG. The patient was observed for another 4 months before she was converted to open arch reconstruction, but died on postoperative day 3 of acute intestinal ischemia and multiorgan failure. Journal of Vascular Surgery 2015 61, 886-894.e1DOI: (10.1016/j.jvs.2014.11.078) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 5 A 75-year-old man presented with a ruptured arch aneurysm. A, The implanted chimney graft (CG) to the left common carotid artery (LCCA) was too short to seal the aneurysm, and (B) a proximal type I endoleak (EL-I) was seen on the immediate postoperative computed tomography angiography (CTA). C, The aortic stent graft and the CG were subsequently extended into the ascending aorta, adding another CG in the brachiocephalic trunk. D, The final CTA demonstrates successful exclusion of the sac without recurrence for >2 years of follow-up (FU). Journal of Vascular Surgery 2015 61, 886-894.e1DOI: (10.1016/j.jvs.2014.11.078) Copyright © 2015 Society for Vascular Surgery Terms and Conditions