Chimney Graft Technique Combined With Embolization for Treating Ruptured Aortic Arch Lesions

Abstract

Background: This study aimed to share the experience in applying the chimney graft technique combined with embolization for treating aortic arch rupture under emergency conditions and evaluating early-term results in these patients. Methods: This study retrospectively included patients with ruptured aortic arch lesions who received the chimney graft technique combined with embolization between March 2016 and March 2021. The primary endpoint was a technical success, deemed as successful stent graft deployment to the planned location, patency of the target branch vessel, and absence of significant type I endoleak. The secondary endpoint was clinical success defined with the size of false lumen in follow-up remaining unchanged or decreasing over time, 30-day mortality, complication, and primary patency of chimney graft. Results: This study included 12 patients (age, 61 ± 12 years; male, 83%). Five patients (42%) received single chimney, one patient (8%) received double chimney, and six patients (50%) received triple chimney. Intraoperative type I endoleak occurred in six patients (50%) who underwent endovascular embolization in the primary operation. Post-operative type I endoleak, evaluated by computed tomography angiography examination following the primary operation, occurred in seven patients (58%), including one patient who received endovascular embolization two times. All patients with post-operative type I endoleak were successfully re-treated using coil and Onyx glue within 1 week, and the median length of stay was 22 ± 11 days (range: 7-44 days). Overall technical success was 100%. Eleven patients had completed their follow-up (median, 12 months, range: 1-34 months), and one patient was out of contact. The 30-day mortality was 9% (1/11, post-operative death of a patient with cerebral hemorrhage). No major complications and no chimney compression, migration, occlusion, or stenosis were recorded during follow-up. Seven patients (58%) have ≥6 months of clinical follow-up time with appropriate imaging. In four (57%) of these patients, diameter stabilization was detected, whereas three (43%) experienced significant reduction (≥5 mm). Conclusion: The patients in this study had satisfactory early-term outcomes. The chimney graft technique combined with coil and Onyx glue embolization may be a safe and effective treatment for ruptured aortic arch lesions under emergency conditions.

Keywords: chimney graft; embolization; endoleak; endovascular treatment; ruptured aortic arch lesions.

Figure 1

(A) Intraoperative DSA showing this patient was treated with TEVAR before, and a new pseudoaneurysm occurred. cTEVAR was performed in the first operation. (B) Endovascular treatment was shown by cartoon graph. (C) Post-operative EL-I was revealed by CTA reexamination, and pseudoaneurysm (arrow) almost occupied the entire left thoracic cavity. (D) The guidewire and catheter entered into FL through gutters by choosing femoral artery as the access artery in the second operation. (E) The cartoon graph demonstrated the method of selecting guidewire into FL (arrow). (F) Onyx glues were injected into FL through a microcatheter (arrow). (G) Onyx glues were injected into gutters (arrow). (H) Endoleak disappeared in the last aortography.

Figure 2

(A) Three-dimensional reconstructions of pre-operative CTA showing concomitant aortic arch pseudoaneurysm (arrow) of traumatic aortic dissection. (B) Pre-operative CTA showing the entry tear (arrow) of aortic dissection. (C) Intraoperative DSA showing deployment of aortic stent graft and CGs, and angiography through a pre-road catheter to FL revealed intraoperative EL-I (arrow). (D) Onyx glues were injected into gutters (arrow) through a microcatheter. (E) Coils and Onyx glues were deployed into FL (arrow) through a pre-road catheter. (F) The aortic dissection and pseudoaneurysm were entirely excluded while endoleak disappeared (arrow) in post-operative CTA.

Figure 3

(A) Aortic arch pseudoaneurysm (arrow) was found after TEVAR by CTA admission. (B) Intraoperative DSA identified the location of lesion again (arrow). (C) Intraoperative aortography showing deployment of aortic stent graft and CGs. (D) CTA reexamination revealed post-operative EL-I (arrow). (E) The guidewire and catheter entered into FL through gutters by choosing left brachial artery as the access artery in the second operation. (F) Coils were deployed into FL and gutters. (G) Onyx glues were deployed into FL and gutters through a microcatheter. (H) A final aortography confirmed the patency of arch branches and the exclusion of EL-I. (I) CTA examination was performed 3 months after the second operation showing that endoleak disappeared (arrow).