Chimney technique for aortic arch dissection: middle-term result

烟囱技术治疗主动脉夹层的中期结果

Dept. of Vascular Surgery, the 2nd Xian-Ya Hospital, CSU. ChangShu

中南大学湘雅二医院血管外科湖南省大血管病微创及介入治疗中心

舒 畅

Introduction

From 09/2007 to 06/2013: 41 patients Male: 23 Female 18 Left carotid artery chinmey : 37 Left subclavian artery chinmey: 1 Left subclavian & left carotid bichinmey: 3 Follow up: 1 month---67 months

Methods• Puncture of the carotid or left

subclavian: 3

• Dissect of the carotid: 38

• Puncture of the right subclavian: 3

Stent-grafts: 43 Stent: 2

• Emergency chimney: 2

Result

• Instantly success: 41/41

• Primary endoleak: 5

• Migration of the chimney stent: 1

Complications

Endoleaks: 5/41

4 endoleaks stopped 2 weeks-13months

1 endoleak still pending

Migration of the chimney stent: 1

Stenosis or oclusion of the branched artery: 0

Assistant Medicine used in the cases

• Anticoagulation: 39

7 days-14 days

Antiplatelet: 39

2 month-6 months: 39

Special patients

• Connective tissue diseases

• During puerperal state

A female, 49 years old. the aortic arch dissection related LSA. There was not enough proximal landing zone.

The left common carotid artery was reconstructed with a chimney stent-graft

The patient recovered well. The left common carotid artery was reconstructed by chimney stent-graft. No endoleak, ischemia happened.

To this patient, the proximal landing zone was not enough. There was a potential risk to cover left carotid artery in TEVAR.

a huge type B aortic dissection. The primary entry tear was next to LSA. There was no enough distance between LSA and Left common carotid artery.

Though little contrast extravasated into the false lumen immediately after stent-graft deployed. The patient recovered well in follow-up.

So, a Fluency® stent-graft was deployed in the orifice of the left common carotid artery in case overstenting of the vital branch, and prevented cerebral ischemia. So, chimney technique can be considered as a good preventive measure.

Chimney technique used in aortic artery ulcer combined with dissection

This is a aortic arch ulcer between the left carotid artery and the LSA. Chimney technique is the best choice with minimal operative trauma. The patient recovered uneventfully.

Dissection combined with TAA

Male

60 years old

Hypertension for more than 20 years.

Abrupt chest and back pain for two days

Male 60-y Type B AD LSA is involved in the dissection The first entry tear is tremendous True lumen is wispy and surrounded by the false lumen

LCCA was preserved by the chimney stent-graft. The LSA was covered by the aortic stent-graft. No ischemia of left upper extremity happened because of the collateral circulation from refluent left vertebral artery.

MFS associated with puerperal state

A female,29 years old, suffered

from abrupt severe back pain after

caesarean section.

After pregnancy and caesarean

section, the patient was weak.

With conservative therapy, the

severe symptoms didn’t release

and hypertension persisted.

The primary entry tear located at

the orifice of the LSA ( white

arrow ).

MFS associated with puerperal state

1 month later, the patient recovered well without any symptoms. However, CT angiography detected mild contrast in the false lumen, and the patent false lumen communicated with LSA. So, too aggressive surgical management, no matter open or endovascular, is not appropriate ! Conservative treatment with anti-hypertension and beta-blocker was adopted.

MFS associated with puerperal state

TEVAR + Chimney for MFS +

puerperal state

13 months later, the patient recovered uneventfully. Endoleak disappeared ! No migration, new entry tear formation.

MFS associated with puerperal state

Bi-chimney technique used in aortic arch dissection

A 50y male, suffered from abrupt chest and back pain. The primary entry tear was unclear in CT scans.

Angiography indicated a typical non-A-non-B aortic dissection involve aortic arch. The primary entry tear was between the orifices of innominate artery and LCA.

It’s definitely that the primary entry tear was between the innominate artery and LCA.

Bilateral vertebral arteries were patent.

How to do? -open surgery

-extra-anatomic bypass

-hybrid surgery

-chimney technique

Bi-chimney was selected. Chimney stent-grafts were used to reconstruct innominate artery and LCA. LSA was covered.

Bi-chimney stent-grafts were preset. Tips were in ascending aorta.

After operation, aortic dissection has been covered, innominate artery and LCA were preserved.

The proximal ends of bi-chimney stent-graft were deployed in ascending aorta.

6 months later

PDA occlude for type II endoleak

• AD related LSA• Chimney tenique should be used

• Chimney stent-graft reconstructed left common carotid artery.

• Typical type II endoleak from LSA

• PDA occlude was used to seal type II endoleak.

2 weeks after TEVAR, no type II endoleak lasted.

The rupture area near left caroted A left carotid is compress by false lumen

—Journal of Endovascular

Therapy ， 2011

—Journal of Endovascular

Therapy ， 2011

Conclusion

1. Chimney technique is a effective method for thoracic aortic disease.

2. Middle term result is well, endoleak can be prevented by some methods

3. Bi-chimney technique can be used to reconstruct all supra-aortic branches.Bi-chimney technique is a minimal invasive, security and brief method, compared with extra-anatomic bypass and hybrid surgery.

4. However, bi-chimney technique has some technological difficulties and underlying life-threatening complications. So, it should be performed cautiously, even for the most experienced angiologist.

Thank you very much !