CASE 10495 Published on 27.02.2013

Chimney technique to preserve a subclavian artery during TEVAR


Interventional radiology

Case Type

Clinical Cases


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

Struttura Complessa di Radiologia,
Az. Ospedaliero-Universitaria Ospedali Riuniti di Trieste,
*Struttura Complessa di Chirurgia Vascolare,
Az. Ospedaliero-Universitaria Ospedali Riuniti di Trieste, Italy

58 years, male

Area of Interest Arteries / Aorta ; Imaging Technique CT-Angiography, Catheter arteriography
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).
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
Case information
DOI: 10.1594/EURORAD/CASE.10495
ISSN: 1563-4086