Outcomes Of Chimney Technique For Aortic Arch Diseases: A Single-Center Experience With 226 Cases

Figures & data

Table 1 Demographic Characteristics, Coexisting Medical Conditions And Indications For TEVAR

	Zone 0 (N=22)	Zone 1 (N=13)	Zone 2 (N=191)	Total (N=226) Or Mean ± SD
Demographic characteristics
Age	54 ± 13	56 ± 13	54 ± 12	54 ± 12
Male	22	12	163	197
Coexisting medical conditions
Hypertension	14	10	154	178
Coronary artery disease	6	2	30	38
Diabetes mellitus	2	1	16	19
Hyperlipidemia	9	5	55	69
Stroke	2	0	9	11
Chronic obstructive pulmonary disease	2	0	4	6
Chronic kidney disease	2	0	20	22
Acute kidney injury	3	1	9	13
Peripheral arterial disease	1	0	10	11
Abdominal Aortic Aneurysm	2	0	5	7
Smoke	9	4	57	70
Prior aortic surgery	0	1	5	6
Traumatic aortic disease	0	0	5	5
Marfan syndrome	0	1	1	2
ARSA	1	0	0	1
Left vertebral artery originates from aortic arch	0	0	5	5
Common origin of the IA and LCCA	0	0	4	4
Indications for TEVAR
TBAD	10	12	163	185
Acute TBAD	4	6	104	114
Subacute TBAD	2	5	45	52
Chronic TBAD	4	1	14	19
Aortic arch aneurysm	9	1	0	10
Aortic arch pseudoaneurysm	2	0	0	2
Descending thoracic aortic aneurysm	0	0	3	3
Descending thoracic aortic pseudoaneurysm	0	0	8	8
Penetrating aortic ulcer	0	0	7	7
Intramural hematoma	0	0	7	7
Aortic rupture	1	0	3	4

Abbreviations: ARSA, aberrant right subclavicular artery; IA, innominate artery; LCCA, left common carotid artery; TBAD, type B aortic dissection; TEVAR, thoracic endovascular aortic repair.

Table 2 Details Of The Operation, Aortic Stent-Grafts And Chimney Stents

	Zone 0 (N=22)	Zone 1 (N=13)	Zone 2 (N=191)	Total (N=226) OrMean ± SD
Details of the operations
Emergency setting	2	1	7	10
General anesthesia/Local anesthesia	22/0	0/13	0/191	22/204
Preliminary supra-aortic bypasses
RSA-LCCA bypass	1	0	0	1
RSA-LCCA-LSA bypass	17	0	0	17
RCCA-LCCA-LSA bypass	3	0	0	3
RCCA-ARSA + RCCA-LCCA-LSA bypasses	1	0	0	1
Restrictive bare stent	2	1	13	16
Double chimney technique (LCCA + LSA)	0	4	0	4
Chimney technique use as bailout setting	0	6	0	6
Details of aortic stent-grafts
More than one aortic stent-grafts	2	2	14	18
Brand of aortic stent-grafts
Valiant (Medtronic, MN, USA)	3	5	75	83
Zenith TX2 (Cook, IN, USA)	0	0	8	8
TAG (Gore, AZ, USA)	1	1	2	4
cTAG (Gore, AZ, USA)	12	1	39	52
Ankura (Lifetech, Shenzhen, China)	6	7	53	66
Hercules-T (Microport, Shanghai, China)	3	1	10	14
Aortic (YTH, Beijing, China)	0	0	18	18
Details of chimney stent-grafts
Bare/Covered	11/11	17/0	165/26	193/37
Self-expanding/Balloon-expandable	11/11	13/4	154/37	178/52
Brand of chimney stent-grafts
Complete SE (Medtronic, MN, USA)	0	7	57	64
Express LD (Boston Scientific, MA, USA)	11	4	37	52
Wallstent Monorail (Boston Scientific, MA, USA)	0	0	1	1
Acculink (Abbott, CA, USA)	0	0	1	1
Fluency Plus (Bard Tempe, AZ, USA)	1	0	12	13
E.Luminexx (Bard Tempe, AZ, USA)	0	0	54	54
Maris (Invatec, Brescia, Italy)	0	5	15	20
Viabahn (Gore, AZ, USA)	4	0	13	17
Protégé RX (ev3, MN, USA)	0	1	0	1
Excluder (Gore, AZ, USA)	6	0	1	7

Abbreviations: ARSA, aberrant right subclavicular artery; LCCA, left common carotid artery; LSA, left subclavian artery; RCCA, Right common carotid artery; RSA, right subclavian artery.

Figure 1 Chimney stent was deployed as a bailout to reconstruct the LCCA. TBAD was confirmed by preoperative CTA (A). The aortic stent-graft was planned to deploy between LCCA and LSA (yellow arrow) (B), but the ostia of LCCA was partially covered (blue arrow) accidentally (C). Double chimney technique (LCCA + LSA) was conducted (D), and postoperative CTA showed that both chimney stents were patent without endoleak at 6 months follow-up (E and F).

Abbreviations: CTA, computed tomography angiography; LCCA, left common carotid artery; LSA, left subclavian artery; TBAD, type B aortic dissection.

Table 3 Early- And Mid-Term Outcomes Of Chimney Technique For Aortic Arch Diseases

	Zone 0 (N=22)	Zone 1 (N=13)	Zone 2 (N=191)	Total (N=226) or Mean ± SD
Early-term outcomes
Duration of postoperative hospital stay, days	10 ± 5	10 ± 4	7 ± 5	8 ± 5
Immediate type Ia endoleak	2	1	34	37
Puncture site complications	2	0	4	6
Femoral artery stenosis or occlusion	1	0	3	4
Brachial artery pseudoaneurysm	1	0	0	1
Brachial artery local infection	0	0	1	1
Major adverse events	1	1	7	9
All-cause death	1	0	3	4
Aortic rupture	0	0	1	1
Stroke	1	0	3	4
Spinal cord ischemia	0	1	2	3
Reintervention	0	0	0	0
Mid-term outcomes
Follow-up time, months	13 ± 11	40 ± 10	22 ± 16	22 ± 16
Late type Ia endoleak	0	0	2	2
Chimney stent occlusion	0	0	6	6
Major adverse events	1	0	6	7
All-cause death	1	0	4	5
Aortic rupture	1	0	2	3
Stroke	0	0	2	2
Spinal cord ischemia	0	0	0	0
Reintervention	0	0	1	1

Table 4 Details Of The Chimney Stent Occlusions

No.	Sex/Age (yrs)	Pathology	Aortic Stent-Graft	Brand Of Chimney Stent	Type Of Chimney Stent	Time Of Occlusion (Months)
1	M/56	TBAD	Ankura	Maris	Self-expanding/Bare	16
2	M/69	TBAD	Valiant	Complete SE	Self-expanding/Bare	15
3	F/60	IMH	Ankura	E.Luminexx	Self-expanding/Bare	24
4	F/52	PAU	Zenith TX2	E.Luminexx	Self-expanding/Bare	8
5	M/47	TBAD	cTAG	E.Luminexx	Self-expanding/Bare	3
6	M/33	TBAD	cTAG	Viabahn	Self-expanding/Covered	6

Abbreviations: IMH, intramural hematoma; PAU, penetrating aortic ulcer; TBAD, type B aortic dissection.

Table 5 Details Of Preoperative CTA And Follow-Up CTA

	Zone 0 (N=22)	Zone 1 (N=13)	Zone 2 (N=191)	Total (N=226) Or Mean ± SD
Preoperative CTA features
TBAD	10	12	163	185
Maximum diameter of aorta, mm	37.8±3.7	38.5±2.5	38.1±2.8	38.1±2.8
Size of primary entry tear, mm	10.3±2.6	11.0±2.2	10.3±2.8	10.3±2.7
Blood supply of visceral arteries
Celiac artery (TL/FL/TF)	2/6/2	10/1/1	73/46/44	85/53/47
Superior mesenteric artery (TL/FL/TF)	6/0/4	5/4/3	71/41/51	82/45/58
Left renal artery (TL/FL/TF)	2/2/6	3/3/6	61/45/57	66/50/69
Right renal artery (TL/FL/TF)	3/4/3	6/3/3	68/55/40	77/62/46
False Lumen Status
Completely thrombosed	2	1	13	16
Partially thrombosed	1	2	38	41
Patent	7	9	112	128
Aneurysm	11	1	11	23
Maximum diameter of aorta, mm	62.0±6.6	62.4	58.9±3.5	60.5±5.3
Mural thrombus	3	0	7	10
Other pathologise	1	0	17	18
Domination of vertebral artery
Left dominant	9	4	79	92
Right dominant	7	5	77	89
Equality dominant	6	4	35	45
Follow-up CTA features				173
TBAD	10	6	123	139
Maximum diameter of aorta, mm	36.1±3.3	37.2±3.5	37.0±2.8	36.9±2.9
Original type Ia endoleak persisted	0	0	4	4
Late type Ia endoleak	0	0	2	2
Aneurysm	10	1	9	20
Maximum diameter of aorta, mm	57.7±5.2	61.2	56.3±4.9	57.2±4.9
Sac regression	3	0	2	5
Other pathologies	1	0	13	14

Abbreviations: FL, false lumen; TF, true lumen and false lumen; TL, true lumen; TBAD, type B aortic dissection.

Figure 2 Kaplan–Meier curves among patients with zone 0, zone 1 and zone 2 aortic arch diseases. Cumulative all-cause death curves (A), aorta-specific death curves (B) and major adverse event curves (C) in patients with zone 0, zone 1 and zone 2 aortic arch diseases. The number of patients at risk at each year was listed in the bottom of the figure.

Figure 3 Kaplan–Meier curves among patients with immediate type Ia endoleak and non-immediate type Ia endoleak. Cumulative all-cause death curves (A), aorta-specific death curves (B) and major adverse event curves (C) in patients with immediate type Ia endoleak and non-immediate type Ia endoleak. The number of patients at risk at each year was listed in the bottom of the figure.