Lachat, M.

Mayer, D.

Rančić, Z.

Veith, F.

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LETTER TO THE EDITORReverse Chimney or Periscope: Some Issues have to be Addressed‘‘Re: Endovascular Aneurysm Repair Using a Reverse ChimneyTechnique in a Patient with Marfan Syndrome and ContainedRuptured Chronic Type B Dissection’’Z. Rancˇic´ • D. Mayer • F. J. Veith • M. LachatPublished online: 30 June 2011 Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2011Ketelsen and colleagues [1] present a patient with Marfansyndrome and contained ruptured chronic type B dissec-tion. We acknowledge the procedure and excellent resultbut would like the authors to address the following points.Our group was the first to describe the techniquedescribed in the authors’ case report in which they describeit as the ‘‘reverse chimney’’ technique. We decided not touse the term ‘‘reverse chimney,’’ because the term chimneymight result in special disadvantages when the ‘‘chimney’’originates from below the aortic stent-graft. Therefore, weintroduced the term ‘‘periscope grafts’’ to describe thisspecial endograft design. In the first report, we presentedtwo patients with ruptured thoracoabdominal aneurysmsthat were treated successfully using two periscopes in eachpatient [2]. Later, we published an additional case treatedwith two chimney grafts and two periscope grafts [3]. Inboth articles, we described some drawbacks of thetechnique that have been completely overlooked in Ketel-sen’s paper. We think that these points are of greatimportance and should be considered when performing andreporting periscope or ‘‘reverse chimney’’ techniques.Periscope or reverse chimney grafts might narrow theaortic lumen at the level of the distal aortic stent graftlanding zone and, therefore, can produce a pressure gradientand flow limitation in the distal aorta and the periscope graftor grafts. This is quite different from standard chimneygrafts that, even when producing aortic narrowing in theproximal landing zone, still allow unrestricted chimneyflow into the branch arteries, because the chimneys origi-nate above the proximal end of the aortic stent-graft.Because the visceral artery perfusion through the periscopeor reverse chimney graft is in a retrograde fashion, anyblood flow or pressure restriction in the distal aorta mightlead to end organ ischemia. To rule out such flow restric-tions, selective pressure measurement in the distal aorticand branch lumens must be made with periscope grafts. Ifblood flow or pressure restriction is detected, it must becorrected by implanting stents or by extra-anatomic revas-cularization (e.g., axillofemoral bypass).Finally, we recommend using our original terminologyfor ‘‘periscope grafts’’ rather than ‘‘reverse’’ chimneys.This will standardize the terminology for a single proce-dure and avoid confusion.Conflict of interest The authors declare that they have no conflictof interest.References1. Ketelsen D, Kalender G, Heuschmid M et al (2011) Endovascularaneurysm repair using a reverse chimney technique in a patientwith Marfan syndrome and contained ruptured chronic type BZ. Rancˇic´ (&)  D. Mayer  F. J. Veith  M. LachatClinic for Cardiovascular Surgery, University Hospital Zurich,Raemistrasse 100, 8091 Zurich, Switzerlande-mail: zoran.rancic@usz.chD. Mayere-mail: dieter.mayer@usz.chF. J. Veithe-mail: fjvmd@msn.comM. Lachate-mail: Mario.lachat@usz.chF. J. VeithNew York University Medical Center, New York, NY, USAF. J. VeithThe Cleveland Clinic, Cleveland, Ohio, USA123Cardiovasc Intervent Radiol (2012) 35:700–701DOI 10.1007/s00270-011-0210-2dissection. Cardiovasc Intervent Radiol doi:10.1007/s00270-011-0106-12. Rancic Z, Pfammatter T, Lachat M et al (2010) Periscope graft toextend distal landing zone in ruptured thoracoabdominal aneu-rysms with short distal neck. J Vasc Surg 51:1293–12963. Lachat M, Frauenfelder T, Mayer D et al (2010) Completeendovascular renal and visceral artery revascularization andexclusion of ruptured type IV thoracoabdominal aortic aneurysm.J Endovasc Ther 17:216–220Z. Rancˇic´ et al.: Reverse Chimney or Periscope 701123

Reverse Chimney or Periscope: Some Issues have to be Addressed "Re: Endovascular Aneurysm Repair Using a Reverse Chimney Technique in a Patient with Marfan Syndrome and Contained Ruptured Chronic Type B Dissection”

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Reverse Chimney or Periscope: Some Issues have to be Addressed "Re: Endovascular Aneurysm Repair Using a Reverse Chimney Technique in a Patient with Marfan Syndrome and Contained Ruptured Chronic Type B Dissection”

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