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Evidence - Chimney Technique for Juxtarenal Aortic Aneurysm (Ch-EVAR)

vascular surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Summary of the Literature

    The so-called chimney technique for endovascular treatment of aortic aneurysms involving reno-visceral vessels was first described in 2003 as a "bailout" procedure and further developed in 2007 as an alternative endovascular therapy method [1, 2]. The first series with more than five abdominal cases were reported by Ohrlander et al. in 2008, by Hiramoto et al. in 2009, and by Donas et al. in 2009 [3, 4, 5]. The publications demonstrate the feasibility of the procedure with good results regarding 30-day morbidity and mortality.

    In 2013, two centers reported on the results of a CT angiography follow-up after 24 months in 124 high-risk patients, in whom pararenal aneurysms had been successfully excluded using the chimney technique in 90% of cases [6]. Another two-center study demonstrated that the combination of two different materials (Excluder (Gore) stent graft with Viabahn (Gore) and the Endurant prosthesis (Medtronic) with Advanta V12 (Getinge)) also has a good patency rate of 95% and a low incidence of type Ia endoleaks (2%) [7]. A 2012 in-vitro study came to the same conclusion [8].

    Numerous publications on this topic emerged from the PERICLES Registry("Collected World Experience About the Performance of the Snorkel/Chimney Endovascular Technique in the Treatment of Complex Aortic Pathologies"). Thus, in 2015, the world's largest experience with this technique was published based on 517 cases. The patency rate of the chimney grafts was 94.1%, and the regression of the diameter of the treated aneurysms averaged 6.5 cm. To minimize the risk of endoleak, the group recommended creating a new landing zone of 20 mm [9]. Meanwhile, numerous further publications have emerged from the registry [10-19].

    The occurrence of type Ia endoleak has been viewed by some authors as the "Achilles' heel" of chimney treatment [20]. A distinction is made between "high flow" (HF) and "low flow" (LF) endoleaks. In HF, the contrast medium exits outside the aortic graft immediately after application, while in LF, it appears significantly delayed in the late phase after contrast medium application. Studies show that LF endoleaks are no longer present after a short time and thus have no clinical relevance [21 - 24]. A study from Zurich (conservative with close-meshed CT monitoring) comes to a similar conclusion [25]. In contrast, HF endoleaks represent an absolute indication for intervention.

  2. Currently ongoing studies on this topic

  3. Literature on this topic

    1. Greenberg RK, Clair D, Srivastava S, BhandariG,TurcA,HamptonJ,Popa M, Green R, Ouriel K (2003) Should patientswith challenging anatomy be offered endovascular aneurysm repair? JVascSurg38:990–996

    2. Criado FJ (2007) Chimney grafts and bare stents: aortic branch preservation revisited. J Endovasc Ther 14:823–824

    3. Ohrlander T, Sonesson B, Ivancev K, Resch T, Dias N, Malina M (2008) The chimney graft: a technique for preserving or rescuing aortic branch vessels in stent-graft sealing zones. J Endovasc Ther 15:427–432

    4. Hiramoto JS, Chang CK, Reilly LM, Schneider DB, Rapp JH, Chuter TA (2009) Outcome of renal stenting for renal artery coverage during endovascular aortic aneurysm repair. J Vasc Surg 49:1100–1106

    5. Donas KP, Torsello G, Austermann M, Schwindt A, Troisi N, Pitoulias GA (2010) Use of abdominal chimney grafts is feasible and safe: short-term results. J Endovasc Ther 17:589–593

    6. Donas KP, Pecoraro F, Bisdas T, Lachat M, Torsello G, Rancic Z, Austermann M, Mayer D, Pfammatter T, Puchner S (2013) CT angiography at 24 months demonstrates durability of EVAR with the use of chimney grafts for pararenal aortic pathologies. J Endovasc Ther 20:1–6

    7. Donas KP, Pecoraro F, Torsello G, Lachat M, Austermann M, Mayer D, Panuccio G, Rancic Z (2012) Use of covered chimney stents for pararenal aortic pathologies is safe and feasible with excellent patency and low incidence of endoleaks. J Vasc Surg 55:659–665

    8. Mestres G, Uribe JP, García-Madrid C, Miret E, Alomar X, Burrell M, Riambau V (2012) The best conditions for parallel stenting during EVAR: an in vitro study. Eur J Vasc Endovasc Surg 44:468–473

    9. Donas KP, Lee JT, Lachat M, Torsello G, Veith FJ, PERICLES investigators (2015) Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: the PERICLES registry. Ann Surg 262:546–553

    10. Pitoulias GA, Torsello G, Austermann M, Pitoulias AG, Pipitone MD, Fazzini S, Donas KP. Outcomes of elective use of the chimney endovascular technique in pararenal aortic pathologic processes. J Vasc Surg. 2020 May 27. pii: S0741-5214(20)31284-2.

    11. Koenrades MA, Donselaar EJ, van Erp MAJM, Loonen TGJ, van Lochem P, Klein A, Geelkerken RH, Reijnen MMPJ. Electrocardiography-gated computed tomography angiography analysis of cardiac pulsatility-induced motion and deformation after  endovascular aneurysm sealing with chimney grafts. J Vasc Surg. 2020 Nov;72(5):1743-1752.e5.

    12. Ramdon A, Patel R, Hnath J, Yeh CC, Darling RC 3rd. Chimney stent graft for left  subclavian artery preservation during thoracic endograft placement. J Vasc Surg.  2020 Mar;71(3):758-766

    13. Taneva GT, Criado FJ, Torsello G, Veith F, Scali ST, Kubilis P, Donas KP; PERICLES collaborators. Results of chimney endovascular aneurysm repair as used  in the PERICLES Registry to treat patients with suprarenal aortic pathologies. J  Vasc Surg. 2020 May;71(5):1521-1527

    14. Stenson K, Patterson B, Grima MJ, de Bruin J, Holt P, Loftus I. Early results of  endovascular aneurysm sealing with chimney grafts to treat juxtarenal and suprarenal abdominal aortic aneurysms. J Vasc Surg. 2019 Jul;70(1):43-52

    15. Wang SK, Drucker NA, Dalsing MC, Sawchuk AP, Gupta AK, Motaganahalli RL, Murphy MP, Fajardo A. Adjunctive visceral artery chimney in patients undergoing Zenith Fenestrated aortic repair. J Vasc Surg. 2018 Dec;68(6):1688-1695

    16. Scali ST, Beck AW, Torsello G, Lachat M, Kubilis P, Veith FJ, Lee JT, Donas KP; PERICLES investigators. Identification of optimal device combinations for the chimney endovascular aneurysm repair technique within the PERICLES registry. J Vasc Surg. 2018 Jul;68(1):24-35

    17. Voskresensky I, Scali ST, Feezor RJ, Fatima J, Giles KA, Tricarico R, Berceli SA, Beck AW. Outcomes of thoracic endovascular aortic repair using aortic arch chimney stents in high-risk patients. J Vasc Surg. 2017 Jul;66(1):9-20

    18. Bin Jabr A, Lindblad B, Kristmundsson T, Dias N, Resch T, Malina M. Outcome of visceral chimney grafts after urgent endovascular repair of complex aortic lesions. J Vasc Surg. 2016 Mar;63(3):625-33

    19. Carroccio A, Conway AM, Giangola G, Jernigan EG, Nguyen Tran N, Qato K. Outcomes of Chimney or Snorkel Endovascular Repair for Symptomatic and Ruptured Abdominal Aortic Aneurysms, J Vasc Surg. 2020  Jul;72(1):e101

    20. Antoniou GA, Snyth JV, Antoniou SA et al (2012) Endoleak is the Achilles‘ heel of the chimney technique for the treatment of complex aortic disease. Int Angiol 31:595–596

    21. Donas KP, Torsello G, Austermann M et al (2010) Use of abdominal chimney grafts is feasible and safe: short-term results. J Endovasc Ther 17:589–593

    22. Donas KP, Pecoraro F, Torsello G et al (2012) Use of chimney stents for pararenal aortic pathologies is safe and feasible with excellent patency and low incidence of endoleaks. J Vasc Surg 55:659–665

    23. Donas KP, Pecoraro F, Bisdas T et al (2013) CT angiography at 24 months demonstrates durability of EVAR with the use of chimney grafts for pararenal aortic pathologies. J Endovasc Ther 20:1–6

    24. Donas KP, Bisdas T, Austermann M et al (2013) The chimney technique has a complentary role in the endovascular repair of juxtarenal aneurysms: there is no need for paradigm shift but for accurate patient selection. J Endovasc Ther 20:584–587

    25. Lachat M, Veith FJ, Pfammaer T et al (2013) Chimney and periscope grafts observed over 2 years after their us to revascularize 169 renovisceral branches in 77 patients with complex aortic aneurysms. J Endovasc Ther 20:597–605

  4. Reviews

    Mazzaccaro D, Settembrini AM, Muzzarelli L, Ambrogi F, Milani V, Nano G. Sealing Devices in Chimney Aortic Repair (CH EVAS) Versus Chimney Aortic Repair with Conventional Devices (CH EVAR): A Systematic Review. Cardiovasc Intervent Radiol. 2019 Apr;42(4):487-494

    Carter R, Wee IJY, Petrie K, Syn N, Choong AM. Chimney parallel grafts and thoracic endovascular aortic repair for blunt traumatic thoracic aortic injuries: A systematic review. Vascular. 2019 Apr;27(2):204-212

    Yaoguo Y, Zhong C, Lei K, Yaowen X. Treatment of complex aortic aneurysms with fenestrated endografts and chimney stent repair: Systematic review and meta-analysis. Vascular. 2017 Feb;25(1):92-100

    Lindblad B, Bin Jabr A, Holst J, Malina M. Chimney Grafts in Aortic Stent Grafting: Hazardous or Useful Technique? Systematic Review of Current Data. Eur J Vasc Endovasc Surg. 2015 Dec;50(6):722-31

  5. Guidelines

  6. literature search

    Literature search on the pages of pubmed.