CASE 10495 Published on 27.02.2013

Chimney technique to preserve a subclavian artery during TEVAR

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Fabio Pozzi Mucelli, *Roberto Adovasio, Luca De Paoli, Ferruccio Degrassi, Maria Assunta Cova

Struttura Complessa di Radiologia,
Az. Ospedaliero-Universitaria Ospedali Riuniti di Trieste,
Italy; Email:pozzi-mucelli@libero.it
*Struttura Complessa di Chirurgia Vascolare,
Az. Ospedaliero-Universitaria Ospedali Riuniti di Trieste, Italy

Patient

58 years, male

Categories

Area of Interest Arteries / Aorta ; Imaging Technique CT-Angiography, Catheter arteriography

Procedure Computer Applications-3D, Computer Applications-Detection, diagnosis, Stents ; Special Focus Aneurysms ;

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Clinical History

Male patient, 57 years old, recent cardiac infarct. Triple aortocoronaric bypass in 2008. CT examination shows an aneurysmatic dilatation of the descending thoracic aorta (diameter: 5.5cm) enlarging in size at CT follow-up after 6 months (Fig. 1, 2). Due to relatively young age and growing pattern of the aneurysm an endovascular treatment was proposed to the patient.

Imaging Findings

Preoperative CT showed a short proximal landing zone of this descending thoracic aneurysm and for this reason we decided to apply Chimney technique. A surgical cutdown was done on the right groin and on the left axilla. Due to quite acute angle of the aortic arch we decided to deploy 2 Bolton devices (Relay Plus and Relay NBS-plus). From the axillary access a covered stent (Fluency-Bard 8x40 mm) was advanced at the ostium of the left subclavian artery (Fig. 3). Simultaneous ballooning of both stent-graft was performed. CT follow-up shows regular patency of the subclavian stent, absence of type 1 endoleak and stable size of the aneurysm (Fig. 4, 5).

Discussion

The current guidelines strongly suggest endovascular stent grafting (thoracic endovascular aortic repair - TEVAR) for those patients with degenerative or traumatic aneurysms of the descending aorta (maximum diameter exceeding 5.5 cm), when feasible [1, 2]. Proximal fixation is often a limiting factor for TEVAR and the stent-graft may need to cover the origin of the arch branch vessels. In this particular case the coverage of the left subclavian artery was absolutely contraindicated due to previous coronary bypass (done with mammarian artery). To overcome this problem the simultaneous deployment of the aortic stent-graft and covered stent at the origin of the aortic branches to preserve flow have been proposed. This technique has been named "Chimney" or "Double Barrel" technique and first reports appeared in 2008 and 2009 [3, 4].
On the other hand, open surgical repair technique is more stressful for the patient, requiring mild hypothermia, left heart bypass with a centrifugal pump and cerebral spinal fluid drainage. Regarding side effects, neurological complications and periprocedural deaths were less frequent with TEVAR technique rather than open surgical repair [2], although thanks to recent new surgical strategies (use of intraoperative somatosensory evoked-potential monitoring, cerebrospinal fluid drainage and epidural cooling) nowadays these rates are significantly low and both surgical and endovascular strategies lead to 5-7.4 % of periprocedural (within 30 days) deaths and 3.8-6 % of hemiplegia/paraplegia [1, 2, 5-7].

Differential Diagnosis List

Advanced TEVAR treatment for descending thoracic aortic aneurysm

Penetrating aortic ulcer

Acute aortic dissection

Final Diagnosis

Advanced TEVAR treatment for descending thoracic aortic aneurysm

References

[1] Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM; American College of Cardiology Foundation/A (2010) 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease. Circulation Jul 27;122(4):e410 (PMID: 20233780)

[2] Isselbacher EM. (2005) Thoracic and abdominal aortic aneurysms. Circulation Feb 15;111(6):816-28 (PMID: 15710776)

[3] Baldwin ZK, Chuter TA, Hiramoto JS, Reilly LM, Schneider DB. (2008) Double-barrel technique for preservation of aortic arch branches during thoracic endovascular aortic repair. Ann Vasc Surg Nov;22(6):703-9 (PMID: 18684589)

[4] Sugiura K, Sonesson B, Akesson M, Björses K, Holst J, Malina M. (2009) The applicability of chimney grafts in the aortic arch. J Cardiovasc Surg (Torino) Aug;50(4):475-81 (PMID: 19734832)

[5] Coselli JS, Conklin LD, LeMaire SA. (2002) Thoracoabdominal aortic aneurysm repair: review and update of current strategies. Ann Thorac Surg Nov;74(5):S1881-4; discussion S1892-8. (PMID: 12440686)

[6] Coselli JS, Bozinovski J, LeMaire SA. (2007) Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg Feb;83(2):S862-4; discussion S890-2. (PMID: 17257942)

[7] Shahverdyan R, Gawenda M, Brunkwall J. (2012) Triple-barrel Graft as a Novel Strategy to Preserve Supra-aortic Branches in Arch-TEVAR Procedures: Clinical Study and Systematic Review. Eur J Vasc Endovasc Surg Nov 1. pii: S1078-5884(12)00664-8. doi: 10.1016/j.ejvs.2012.09.023. (PMID: 23123094)

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