Objective: Patients with juxtarenal, pararenal, or thoracoabdominal
aneurysms require complex surgical open repair, which is associated with
increased mortality and morbidity. The “chimney graft” or
“snorkel” technique has evolved as a potential alternative to
fenestrated and side-branched endografts. The purpose of this study is
to review all published reports on chimney graft (CG) technique
involving visceral vessels and investigate the safety and efficacy of
the technique.
Methods: Studies were included in the present review if visceral
revascularization during endovascular treatment of aortic pathologies
was achieved via a CG implantation. Reports on the chimney technique for
aortic arch branches revascularization were excluded. A multiple
electronic health database search was performed on all articles
published until April 2011.
Results: The electronic literature search yielded 15 reports that
fulfilled the inclusion criteria. A total of 93 patients (81.3% male;
mean age, 71.9 +/- 0.9 years) were analyzed. In 77.4% of the patients,
the CG procedure was applied for the treatment of abdominal aortic
aneurysms. Out of the 93 patients, 24.7% were operated on in an urgent
setting (symptomatic or ruptured aneurysm). A total of 134 CGs were
implanted: 108 to the renal arteries, 20 to the superior mesenteric
artery, five to the celiac trunk, and one to the inferior mesenteric
artery. In 57 patients, a single CG was deployed; in 32 patients, two
CGs; in three patients, three CGs; and in one patient, four CGs were
deployed. Ninety-four percent of CGs were directed proximally, whereas
6.0% were directed caudally. Primary technical success was achieved in
all patients. A total of 13 patients (14.0%) developed a type I
endoleak. Three were detected and treated intraoperatively.
Postoperatively, 10 type I endoleaks were revealed, four of which
required secondary intervention. During a mean follow-up period of 9.0
+/- 1.0 months, 131 of 134 (97.8%) CGs remained patent. Two CGs to the
renal arteries and one to the superior mesenteric artery occluded.
Postoperatively, 11.8% of patients suffered renal function impairment
and 2.1% a myocardial infarction. Ischemic stroke presented in 3.2% of
patients. The 30-day in-hospital mortality was 4.3%.
Conclusions: The role of the chimney technique in the management of
complex abdominal aortic aneurysms is still unclear. This technique has
relatively good results, considering the anatomic limitations of the
aortic neck. However, long-term endograft durability and proximal
fixation remains a significant concern. Thus, there is a reasonable
hesitation to embrace the method for widespread use in the absence of
long-term data. (J Vasc Surg 2012;55:1497-1503.