Technical considerations and results of chimney grafts for the treatment of juxtarenal aneursyms

Objective: To present our initial experience and technical considerations for the use of chimney grafts in the treatment of patients that require endovascular aneurysm repair with aortic branch preservation. Methods: All patients treated with a chimney procedure between October 2009 and June 2011 were included in our analyses. Chimney procedures were only performed in patients that were unsuitable for open repair and without opportunity to use fenestrated grafts (because of unsuitable anatomy or emergency operation). Open brachial or axillary access was used to deploy covered chimney grafts in the target vessels, and subsequently, a stent graft was deployed via femoral cut-down access. Results: Thirteen patients (12 males; mean age, 77.2 +/- 6.2 years; mean maximal diameter, 71.4 +/- 10.2 mm) underwent a chimney procedure with the preservation of 22 aortic side branches. Primary technical success was 92.3% due to occlusion of one renal artery within 24 hours. Thirty-day mortality was 0%. Infrarenal mean neck length was 2.6 mm +/- 3.2 mm (range, 0-8 mm) and could be extended to 27.3 mm +/- 9.9 mm (range, 18-53 mm) by the use of chimney grafts. During follow-up (median, 10.8 months; interquartile range, 7.4-19.4), one patient died from complications from mesenteric ischemia based on a stenosis of the celiac trunk attributable to the bare stent of the stent graft, and one patient died from aneurysm rupture. Other complications included late occlusion of one renal artery and a type II endoleak, which was unsuccessfully treated with coil embolization and required laparotomy. If we disregard the ruptured patient who had an enormous increase of aneurysm diameter, mean aortic aneurysm diameter reduced from 70.7 +/- 10.3 mm (range, 54-89 mm) to 66.7 +/- 13.9 mm (range, 48-96 mm) during follow-up (P = .13). In three patients, the aneurysm diameter decreased by more than 5 mm and in two patients, the diameter increased by more than 5 mm. The aneurysm diameter remained stable in the other eight patients. Conclusions: Until off-the-shelf fenestrated or branched stent grafts become available, the chimney procedure offers a minimally invasive treatment option in patients requiring aneurysm exclusion with side branch revascularization. Although long-term follow-up has to be awaited, the initial results show that chimney grafts can help to decrease or stabilize the aneurysm diameter in most patients, but aneurysm rupture was not prevented in all patients.