Department of Vascular Surgery, Henri Mondor University Hospital, AP-HP, Créteil, France.
Department of Vascular Surgery, University Hospital of Bordeaux, Bordeaux, France.
Eur J Vasc Endovasc Surg. 2020 May;59(5):776-784. doi: 10.1016/j.ejvs.2020.01.040. Epub 2020 Apr 7.
The chimney technique (ChEVAR) allows for proximal landing zone extension for endovascular repair of complex aortic aneurysms. The aim of the present study was to assess ChEVAR national outcomes in French university hospital centres.
All centres were contacted and entered data into a computerised online database on a voluntary basis. Clinical and radiological data were collected on all consecutive ChEVAR patients operated on in 14 centres between 2008 and 2016. Patients were deemed unfit for open repair. Factors associated with early (30 day or in hospital) mortality and type 1 endoleak (Type I EL) were calculated using multivariable analysis.
In total, 201 patients with 343 target vessels were treated. There were 94 juxtarenal (46.8%), 67 pararenal (33.3%), 10 Crawford type IV thoraco-abdominal (5%) aneurysms, and 30 (15.1%) proximal failures of prior repairs. The pre-operative diameter was 66.8 ± 16.7 mm and 28 (13.9%) ChEVAR were performed as an emergency, including six (2.9%) ruptures. There were 23 (11.7%) unplanned intra-operative procedures, mainly related to access issues. The rate of early deaths was 11.4% (n = 23). The elective mortality rate was 9.8% (n = 17). Nine patients (4.5%) presented with a stroke. The rate of early proximal Type I EL was 11.9%. Survival was 84.6%, 79.4%, 73.9%, 71.1% at 6, 12, 18, and 24 months, respectively. The primary patency of chimney stents was 97.4%, 96.7%, 95.2%, and 93.3% at 6, 12, 18, and 24 months, respectively. Performing unplanned intra-operative procedures (OR 3.7, 95% CI 1.3-10.9) was identified as the only independent predictor of post-operative death. A ChEVAR for juxtarenal aneurysm was independently associated with fewer post-operative Type I ELs (OR 0.17, 95% CI 0.05-0.58).
In this large national ChEVAR series, early results were concerning. The reasons may lie in heterogeneous practices between centres and ChEVAR use outside of current recommendations regarding oversizing rates, endograft types, and sealing zones. Future research should focus on improvements in pre-operative planning and intra-operative technical aspects.
烟囱技术（ChEVAR）可用于血管内修复复杂主动脉瘤的近端着陆区扩展。本研究的目的是评估法国大学医院中心的 ChEVAR 国家结果。
所有中心都被联系，并自愿将数据输入到一个计算机化的在线数据库中。在 2008 年至 2016 年期间，在 14 个中心对所有连续的 ChEVAR 患者进行了临床和影像学数据收集。认为患者不适合开放修复。使用多变量分析计算与早期（30 天或住院期间）死亡率和 1 型内漏（Type I EL）相关的因素。
共有 201 例 343 个靶血管患者接受了治疗。其中 94 例为肾下（46.8%），67 例为肾旁（33.3%），10 例 Crawford 型 IV 胸腹（5%）动脉瘤，30 例（15.1%）为先前修复的近端失败。术前直径为 66.8±16.7mm，28 例（13.9%）为急诊 ChEVAR，包括 6 例（2.9%）破裂。有 23 例（11.7%）为计划外术中手术，主要与入路问题有关。早期死亡率为 11.4%（n=23）。择期死亡率为 9.8%（n=17）。9 例（4.5%）患者发生卒中。早期近端 Type I EL 的发生率为 11.9%。6、12、18 和 24 个月的生存率分别为 84.6%、79.4%、73.9%和 71.1%。烟囱支架的主要通畅率分别为 97.4%、96.7%、95.2%和 93.3%，在 6、12、18 和 24 个月时。术中进行计划外手术（OR 3.7，95%CI 1.3-10.9）被确定为术后死亡的唯一独立预测因素。肾下动脉瘤的 ChEVAR 与术后较少发生 Type I EL 独立相关（OR 0.17，95%CI 0.05-0.58）。
在这个大型的全国性 ChEVAR 系列中，早期结果令人担忧。原因可能在于中心之间的实践存在异质性，以及在过大率、内植物类型和密封区方面超出了当前建议的范围使用 ChEVAR。未来的研究应侧重于改进术前规划和术中技术方面。
