Vascular unit, Department of Surgery

Prince of Songkla University (PSU)

Chimney EVAR Juxtarenal, pararenal & suprarenal AAA

Wittawat Tantarattanapong, MD Boonprasit Kritpracha, MD Dhanakom Premprabha, MD Jitpreedee Sungsiri, MD Sorracha Rookapan, MD Pong Juntarapatin, MD Suthathip Saemoo, MD

Disclosure

Speaker name:

Dr. Wittawat Tantarattanapong

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interest

J ENDOVASC THER 2006;13:640–648

Juxtarenal/Pararenal/Suprarenal Aneurysm

- Open repair

- Hybrid debranching procedure

- Chimney EVAR / Snorkeling EVAR

- Fenestrated and branched

endografts

J Vasc Surg. 2003;38:990–996.

Parallel branch vessel stenting during intentional endograft

coverage of the vessel origin to maintain branch perfusion

Endurant Atrium

Excluder Viabahn

Best performance regarding gutter area and freedom from chimney graft compression in case of :

Oversize 25-30% Sealing 20 mm.

European Journal of Vascular and Endovascular Surgery 44 (2012) 468-473 J Vasc Surg 2012;55:659-65.

- Munster Germany VS Zurich Switzerland

- Balloon-expandable covered stent VS Self-expanding covered stent

- 46 target vessels (Advanta, Atrium) VS 81 target vessels (Viabahn, Gore)

- Success rate 97% VS 100%

- Perioperative Type Ia : 1 VS 5 cases

- Renal insufficiency need for H/D : 0%

- 30 days or Procedure-related mortality rate 0%

J Vasc Surg 2012;55:659-65.

No Difference

Access

Current evidence base

Does it work?

Evidences

• Limited in Number of patients

• Variation of the aortic or parallel graft

• 517 pt. ch-EVAR : 2008-2014

• 119 pt. in US

• 398 pt. in Europe

• 898 CG : – 692 Renal arteries

– 156 SMAs

– 50 Celiac trunks

PERICLES Registry

PERICLES Registry

Abdominal MB Endograft Endurant 260 (50.2%)

Zenith 91 (17.2%)

Excluder 75 (14.5%)

Jotec 17 (3.2%)

Other 74 (14.9%)

Chimney grafts Balloon expandable stent 49.2%

Self expanding stent 39.6%

Bare metal stent 11.2%

• followup of 17.1 months (1-70 months)

– primary patency : 94%

– secondary patency : 95.3%

• Type Ia endoleak 5.7%

• Secondary intervention rates 37.9%.

• Overall survival : 79%

PERICLES Registry

• Data : June 2010 – June 2015 ( 5 yr. )

• Chimney procedure as adjunct procedure

total 89 cases

PSU experience

Abdomen : 51 cases

Thoracic 34 cases

Thoracoabdomen : 4 cases

• No of Pt. : 51

• Male vs Female : 79% vs 21%

• Age 72 yr. ( 65-87 )

• Comorbidity

– CAD (75%), HT (87%)

– DM (35%), CKD (15%)

– ASA class 3 or worse

PSU : Abdominal EVAR

Result (N=51)

Elective 40 cases (78%)

- Juxtarenal AAA 35 cases

- type 1a : 5 cases

Emergency 11 cases (22%)

- Leakage 3 cases

- Infected 8 cases

Perioperative Data ( N=51) Aneurysm Diameter (mm.) 64 (42-97)

Infrarenal neck length (mm.) 2 (0-10)

Infrarenal neck angulation

(degree)

1. < 45 ‘ : 32

2. 45-75’ : 9

3. > 75’ : 10

Fluoroscopy time (min) 118 (32-390)

Opertive time (min) 250 (135-505)

Estimated blood loss (ml) 700 (250-3000)

Contrast dose (ml) 195 (63-420)

ICU length of stay (days) 2 (0-7)

Hospital length of stay (days) 11 (2-30)

Endograft

Chimney grafts

Balloon expandable stent

iCast, V12 (Atrium) 73 (75%)

Self expanding stent

Viabahn (GORE) 16 (17%)

Fluency (BARD) 8 (8%)

Main aortic graft

Endurant 49 (96%)

Zenith 2 (4%)

Target vessels and Chimney grafts

1.9 vessels/patient

N = 51

19 ( 37%) 17 ( 33%) 13 ( 25%) 2 ( 4%)

97% technical success

1 dirrupted from RA 2 severe stenosis

Target vessels and Chimney grafts

Target vessels N=97 ( from 100)

Renal arteries 75 (77%)

SMA 16 (16%)

Celiac trunk 6 (6%)

Primary Patency of chimney graft

F/U : 19 months (2-24)

Overall patency rate 93% 95%CI (0.86-1.00)

Kaplan-Meier estimate of patency of chimney

stents.

Mortality rate

Over all mortality = 18%

• 30 days mortality : (6/51)

- 4 cardiac event

- 1 bowel ischemia

- 1 kidney injury

• Late mortality : (3/45)

- Ishcemic stroke

- CA cervix

- Pneumonia

11%

7%

1 month F/U

3 cases : 4 occluded renal

Chimney graft

Type Ia : 6 cases (13%) • Extension : 1 case

• Open : 3 cases

• No need Tx : 2 cases

Type II : 4 cases

no sac enlargement

Endoleak

Infected thoracic & abdominal aorta

• 8 cases

• 20/20 bracnhes preserved

celia

c SM

A

R r

enal

L re

nal

Large leakage of Infected aneurysm , just above celiac axis

EVAR with

- Chimney celiac & SMA

- Sandwich R & L renal

Pre op 1 yr. F/U

Chimney celiac

Sandwish Rt. RA

Periscope Lt. RA

Infect Thoracic and abdominal part

2 yr.

• 8 cases

• 20/20 branches preserved

At 6-36 months

• 100% patence

• No endoleak

• Mortality 0%

Infected thoracic & abdominal aorta

Conclusion

- Choice : adjunct procedure

“High risk patient, Urgent case (+ infected)”

- Suitable short to midterm result

- An “Off the shelf” technique “Relies on skills/techniques/devices we are comfortable with…”

Prince of Songkla University

PSU Hospital

THANK YOU

Vascular unit, Department of Surgery

Prince of Songkla University (PSU)

Chimney EVAR Juxtarenal, pararenal & suprarenal AAA

Wittawat Tantarattanapong, MD Boonprasit Kritpracha, MD Dhanakom Premprabha, MD Jitpreedee Sungsiri, MD Sorracha Rookapan, MD Pong Juntarapatin, MD Suthathip Saemoo, MD