The single-centre experience of the supra-arch chimney technique in endovascular repair of type B aortic dissections

Y Zhu, W Guo, X Liu, X Jia, J Xiong, L Wang
European Journal of Vascular and Endovascular Surgery 2013, 45 (6): 633-8

OBJECTIVES: We summarised the data performed at our centre to evaluate the feasibility of the chimney technique in type B aortic dissections (ADs) with supra-aortic vessel involvement.

METHODS: From September 2006 to December 2011, 34 thoracic endovascular aortic repairs (TEVARs) for ADs were performed combined with reconstruction of the arch branches with chimney stents (innominate artery, IA, n = 3; left common carotid artery, LCCA, n = 8; left subclavian artery, LSA, n = 23). Indications for these chimney stents included an inadequate proximal landing zone (<1.5 cm); high surgical-risk patients who are not suitable for open repair or hybrid procedures; and emergent endovascular repair of ADs. The series consisted of 13 acute, 12 sub-acute and 9 chronic cases. The right common carotid-left common carotid-left subclavian artery bypasses were performed in the IA chimney cases to reserve an adequate cerebral perfusion from the LCCA and left vertebral artery, while the left common carotid-left subclavian artery bypasses were performed in the cases having dominant left vertebral arteries. All the TEVARs, chimney stents and bypasses were performed as a single stage. Follow-ups were performed at 3, 6 and 12 months, and yearly thereafter.

RESULTS: Endografts were deployed in Zone 0 (n = 3, 9%), Zone 1 (n = 8, 24%) and Zone 2 (n = 23, 67%). Twenty-five (74%) balloon-expandable and 9 (26%) self-expanding stents were used, of which seven (21%) were covered and 27 (79%) were bare stents. The technical success rate was 82% (28/34). Immediate type I endoleaks were observed in five patients (5/34, 15%), all of which underwent bare chimney-stent repairs. Three self-expanding chimney stents were compressed by endografts and another balloon expandable stent was deployed inside the first one. Five patients underwent surgical bypasses (RCCA-LCCA-LSA, n = 3; LCCA-LSA, n = 2). Perioperative morbidity included one ST-elevation myocardial infarction. No perioperative death or stroke was observed. The mean follow-up was 16.3 months (range, 3-60 months). Primary patency was maintained in all the chimney stents as well as the surgical bypasses. No stent fracture or recurrent chimney-related endoleak was observed during the follow-up period.

CONCLUSIONS: In repairs for type B ADs, the chimney technique provides a minimally invasive way of preserving flow to the arch branches combined with a favourable mid-term outcome. The bare stents seemed to be related to a higher probability of the immediate type I endoleaks. A balloon-expandable stent should be regarded as the first choice due to its greater radial strength.

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