Wang S Keisin, Drucker Natalie A, Dalsing Michael C, Sawchuk Alan P, Gupta Alok K, Motaganahalli Raghu L, Murphy Michael P, Fajardo Andres
Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind.
Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind.
J Vasc Surg. 2018 Dec;68(6):1688-1695. doi: 10.1016/j.jvs.2018.03.421.
Visceral artery chimneys have been employed as an adjunct to endovascular aneurysm repair (EVAR) to treat short-neck infrarenal and juxtarenal aortic aneurysms for more than two decades. With the widespread introduction of fenestrated endovascular aneurysm repair by the Food and Drug Administration-approved Zenith Fenestrated endograft (ZFEN; Cook Medical, Bloomington, Ind) to the United States in 2012, clinicians gained the ability to apply the chimney technique to these custom devices for difficult anatomy. The purpose of this report was to demonstrate feasibility and to provide evidence on the performance of chimneys for the treatment of complex juxtarenal aneurysms that could not be adequately treated with ZFEN alone.
A retrospective analysis was performed of a prospectively maintained institutional ZFEN database capturing 110 fenestrated endovascular aneurysm repairs from October 2012 to January 2018 to identify patients undergoing a concomitant visceral artery chimney. All patients with <12 months of follow-up were excluded from further analysis. Demographic, anatomic, intraoperative, perioperative, and follow-up characteristics were tabulated and analyzed.
Six patients met criteria and were included in this investigation. They were universally male with a mean age of 76.2 years at the time of ZFEN/chimney. Chimneys were placed in a total of six visceral arteries (n = 1 per patient) consisting of three renal arteries, two celiac arteries, and one accessory renal artery. Mean estimated blood loss and operative time were 283 mL and 298 minutes, respectively. Technical success was achieved in all cases. Two small type IA "gutter" endoleaks were detected early; both spontaneously resolved on follow-up. We observed no instances of chimney migration, stenosis, or thrombosis perioperatively or on follow-up. Two reinterventions were performed in these six patients; these consisted of a repeated renal stent for ostial stenosis at a main body fenestration and a common femoral artery endarterectomy and patch angioplasty for an access-related common femoral artery occlusion.
Use of ZFEN in conjunction with a singular chimney is safe, feasible, and durable in patients with difficult anatomy who do not meet instructions for use as demonstrated in this limited series.
二十多年来，内脏动脉烟囱技术一直被用作血管内动脉瘤修复术（EVAR）的辅助手段，以治疗短颈肾下和近肾主动脉瘤。随着美国食品药品监督管理局批准的Zenith开窗型腔内移植物（ZFEN；Cook Medical，印第安纳州布卢明顿）于2012年在美国广泛引入开窗型血管内动脉瘤修复术，临床医生有能力将烟囱技术应用于这些针对复杂解剖结构的定制装置。本报告的目的是证明其可行性，并提供有关烟囱技术用于治疗无法仅用ZFEN充分治疗的复杂近肾动脉瘤的性能证据。
对一个前瞻性维护的机构ZFEN数据库进行回顾性分析，该数据库记录了2012年10月至2018年1月期间的110例开窗型血管内动脉瘤修复术，以识别同时接受内脏动脉烟囱技术的患者。所有随访时间不足12个月的患者均被排除在进一步分析之外。将人口统计学、解剖学、术中、围手术期和随访特征制成表格并进行分析。
6例患者符合标准并纳入本研究。他们均为男性，在进行ZFEN/烟囱技术时的平均年龄为76.2岁。总共在6条内脏动脉中放置了烟囱（每位患者1条），包括3条肾动脉、2条腹腔动脉和1条副肾动脉。平均估计失血量和手术时间分别为283毫升和298分钟。所有病例均取得技术成功。早期检测到2例小型IA型“沟槽”内漏；两者在随访中均自行消失。我们在围手术期或随访中未观察到烟囱移位、狭窄或血栓形成的情况。这6例患者进行了2次再次干预；其中包括对主体开窗处的开口狭窄进行重复肾支架置入，以及对与入路相关的股总动脉闭塞进行股总动脉内膜切除术和补片血管成形术。
如本有限系列研究所示，对于不符合使用说明的解剖结构复杂的患者，联合使用ZFEN和单个烟囱技术是安全、可行且持久的。
