Chimney versus fenestrated endovascular aortic repair for juxta-renal aneurysms

Abstract

Introduction: Anatomical constrains, high price and manufacturing delay restrict fenestrated (F)-endovascular aortic repair (EVAR) to elective patients in specialized centers. Chimney graft (CG)-EVAR offers an alternative but uncertainties remain over target vessel's patency and type Ia endoleaks (ELs).

Evidence acquisition: We reviewed the literature reporting F-EVAR and CG-EVAR for juxta-renal aneurysms between January 2005 and July 2016.

Evidence synthesis: Fifteen studies on F-EVAR, 8 on CG-EVAR and 5 on both techniques were included; 1748 F-EVAR patients (3993 target vessels) vs. 757 (1158 target vessels, 13% symptomatic and 7% ruptured). F-EVAR patients suffered from significantly less comorbidities, technical success was lower (94% vs. 99%; P<0.0001) but with more reconstructed vessels/patient (2.2±0.4 vs. 1.5±0.3; P<0.0001) and 30-day mortality was lower (2% vs. 4%, P=0.02). There were more re-interventions after F-EVAR (20% vs. 8%; P<0.0001); mainly EL (44% vs. 25%) and target vessels related (36% vs. 32%); less type I ELs (1% vs. 6%; P=0.002) but more type III (2% vs. 0%; P<0.0001). The rates of chronic kidney disease (9% vs. 15%; P=0.0002) and dialysis (1% vs. 3%; P=0.007) were lower after F-EVAR, with less target vessel's occlusions (3% vs. 6%; P<0.0001). The meta-analysis on 5 comparative studies supported F-EVAR in terms of 30-day mortality (OR 0.94 [0.25, 3.55]), target vessel's occlusions (OR 2.40 [0.95, 6.06]) and type I EL (OR 0.62 [0.10, 3.93]); and CG-EVAR in terms of technical success (OR 3.28 [0.67, 15.93], type II (OR 1.25 [0.48, 3.28]) and III ELs (OR 1.62 [0.29, 8.94]) and re-intervention (OR 1.77 [0.89, 3.52]) without a significant difference.

Conclusions: Current evidence does not support CG-EVAR's widespread use in all elective patients but CG-EVAR seems justified in symptomatic patients, as bailout, or in elective patients who are poor candidates for open repair and F-EVAR.