CardioVascular and Interventional Radiology

, Volume 36, Issue 6, pp 1443–1451 | Cite as

Endovascular Aortic Aneurysm Repair with Chimney and Snorkel Grafts: Indications, Techniques and Results

  • Rakesh P. Patel
  • Athanasios Katsargyris
  • Eric L. G. Verhoeven
  • Donald J. Adam
  • John A. HardmanEmail author


The chimney technique in endovascular aortic aneurysm repair (Ch-EVAR) involves placement of a stent or stent-graft parallel to the main aortic stent-graft to extend the proximal or distal sealing zone while maintaining side branch patency. Ch-EVAR can facilitate endovascular repair of juxtarenal and aortic arch pathology using available standard aortic stent-grafts, therefore, eliminating the manufacturing delays required for customised fenestrated and branched stent-grafts. Several case series have demonstrated the feasibility of Ch-EVAR both in acute and elective cases with good early results. This review discusses indications, technique, and the current available clinical data on Ch-EVAR.


Aorta Aneurysm Chimney technique Endovascular repair 


Conflict of interest

Rakesh P. Patel and Athanasios Katsargyris have no conflict of interest.


Eric L. G. Verhoeven has received educational Grants and is a consultant for Cook Inc., W.L. Gore & Associates, Siemens, and Atrium-Maquet. Donald J. Adam has received Proctor/consultancy for William Cook Europe. John A. Hardman has received Proctor/consultancy for Lombard Medical and William Cook Europe.


  1. 1.
    De Bruin JL, Baas AF, Buth J et al (2010) Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 362(20):1881–1889PubMedCrossRefGoogle Scholar
  2. 2.
    Greenhalgh RM, Brown LC, Powell JT et al (2010) Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 362(20):1863–1871PubMedCrossRefGoogle Scholar
  3. 3.
    Abbruzzese TA, Kwolek CJ, Brewster DC et al (2008) Outcomes following endovascular abdominal aortic aneurysm repair (EVAR): an anatomic and device-specific analysis. J Vasc Surg 48(1):19–28PubMedCrossRefGoogle Scholar
  4. 4.
    Leurs LJ, Kievit J, Dagnelie PC et al (2006) Influence of infrarenal neck length on outcome of endovascular abdominal aortic aneurysm repair. J Endovasc Ther 13(5):640–648PubMedCrossRefGoogle Scholar
  5. 5.
    AbuRahma AF, Campbell J, Stone PA et al (2009) The correlation of aortic neck length to early and late outcomes in endovascular aneurysm repair patients. J Vasc Surg 50(4):738–748PubMedCrossRefGoogle Scholar
  6. 6.
    AbuRahma AF, Campbell J, Stone PA et al (2010) Early and late clinical outcomes of endovascular aneurysm repair in patients with an angulated neck. Vascular 18(2):93–101PubMedCrossRefGoogle Scholar
  7. 7.
    Greenberg RK, Clair D, Srivastava S et al (2003) Should patients with challenging anatomy be offered endovascular aneurysm repair? J Vasc Surg 38(5):990–996PubMedCrossRefGoogle Scholar
  8. 8.
    Ohrlander T, Sonesson B, Ivancev K et al (2008) The chimney graft: a technique for preserving or rescuing aortic branch vessels in stent-graft sealing zones. J Endovasc Ther 15(4):427–432PubMedCrossRefGoogle Scholar
  9. 9.
    Lee JT, Greenberg JI, Dalman RL (2012) Early experience with the snorkel technique for juxtarenal aneurysms. J Vasc Surg 55(4):935–946PubMedCrossRefGoogle Scholar
  10. 10.
    Kolvenbach RR, Yoshida R, Pinter L et al (2011) Urgent endovascular treatment of thoraco-abdominal aneurysms using a sandwich technique and chimney grafts—a technical description. Eur J Vasc Endovasc Surg 41:54–60PubMedCrossRefGoogle Scholar
  11. 11.
    Sugiura K, Sonesson B, Akesson M et al (2009) The applicability of chimney grafts in the aortic arch. J Cardiovasc Surg (Torino) 50(4):475–481Google Scholar
  12. 12.
    Coscas R, Kobeiter H, Desgranges P, Becquemin JP (2011) Technical aspects, current indications, and results of chimney grafts for juxtarenal aortic aneurysms. J Vasc Surg 53(6):1520–1527PubMedCrossRefGoogle Scholar
  13. 13.
    Mosquera Arochena N, Rodriquez Feijoo G, Carballo fernandez C et al (2011) Use of modified sandwich-graft technique to preserve hypogastric artery in EVAR treatment of complex aortic aneurysm anatomy. J Cardiovasc Surg (Torino) 52:643–649Google Scholar
  14. 14.
    Donas KP, Pecoraro F, Torsello G et al (2012) Use of covered chimney stents for pararenal aortic pathologies is safe and feasible with excellent patency and low incidence of endoleaks. J Vasc Surg 55(3):659–665PubMedCrossRefGoogle Scholar
  15. 15.
    Bruen KJ, Feezor RJ, Daniels MJ et al (2011) Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms. J Vasc Surg 53(4):895–904PubMedCrossRefGoogle Scholar
  16. 16.
    Mohabbat W, Greenberg RK, Mastracci TM et al (2009) Revised duplex criteria and outcomes for renal stents and stent grafts following endovascular repair of juxtarenal and thoracoabdominal aneurysms. J Vasc Surg 49:827–837PubMedCrossRefGoogle Scholar
  17. 17.
    Hiramoto JS, Chang CK, Reilly LM et al (2009) Outcome of renal stenting for renal artery coverage during endovascular aortic aneurysm repair. J Vasc Surg 49(5):1100–1106PubMedCrossRefGoogle Scholar
  18. 18.
    Resch TA, Sonesson B, Dias N, Malina M (2011) Chimney grafts: is there a need and will they work? Perspect Vasc Surg Endovasc Ther 23(3):149–153PubMedCrossRefGoogle Scholar
  19. 19.
    Donas KP, Torsello G, Austermann M et al (2010) Use of abdominal chimney grafts is feasible and safe: short-term results. J Endovasc Ther 17(5):589–593PubMedCrossRefGoogle Scholar
  20. 20.
    Donas KP, Pecoraro F, Bisdas T et al (2013) CT Angiography at 24 months demonstrates durability of EVAR with the use of chimney grafts for pararenal aortic pathologies. J Endovasc Ther 20(1):1–6PubMedCrossRefGoogle Scholar
  21. 21.
    Moulakakis KG, Mylonas SN, Avgerinos E et al (2012) The chimney graft technique for preserving visceral vessels during endovascular treatment of aortic pathologies. J Vasc Surg 55:1497–1503PubMedCrossRefGoogle Scholar
  22. 22.
    Katsargyris A, Oikonomou K, Klonaris C et al (2013) Treatment of juxtarenal aneurysms: are we ready for a paradigm shift? J Endovasc Ther 20(2):159–169PubMedCrossRefGoogle Scholar
  23. 23.
    Brechtel K, Ketelsen D, Endisch A et al (2012) Endovascular repair of acute symptomatic pararenal aortic aneurysm with three chimney and one periscope graft for complete visceral artery revascularization. Cardiovasc Intervent Radiol 35(2):413–417PubMedCrossRefGoogle Scholar
  24. 24.
    Ketelsen D, Kalender G, Heuschmid M et al (2011) Endovascular aneurysm repair using a reverse chimney technique in a patient with Marfan syndrome and contained ruptured chronic type B dissection. Cardiovasc Intervent Radiol 34(5):1080–1084PubMedCrossRefGoogle Scholar
  25. 25.
    Kolvenbach RR, Yoshida R, Pinter L et al (2010) Urgent endovascular treatment of thoraco-abdominal aneurysms using a sandwich technique and chimney grafts–a technical description. Eur J Vasc Endovasc Surg 41(1):54–60PubMedCrossRefGoogle Scholar
  26. 26.
    Lachat M, Frauenfelder T, Mayer D et al (2010) Complete endovascular renal and visceral artery revascularization and exclusion of a ruptured type IV thoracoabdominal aortic aneurysm. J Endovasc Ther 17(2):216–220PubMedCrossRefGoogle Scholar
  27. 27.
    Rancic Z, Pfammatter T, Lachat M et al (2010) Periscope graft to extend distal landing zone in ruptured thoracoabdominal aneurysms with short distal necks. J Vasc Surg 51(5):1293–1296PubMedCrossRefGoogle Scholar
  28. 28.
    Lobato AC (2011) Sandwich technique for aortoiliac aneurysms extending to the internal iliac artery or isolated common/internal iliac artery aneurysms: a new endovascular approach to preserve pelvic circulation. J Endovasc Ther 18(1):106–111PubMedCrossRefGoogle Scholar
  29. 29.
    Ricci C, Ceccherini C, Cini M et al (2012) Single-center experience and 1 year follow up results of “sandwich technique” in the management of common iliac artery aneurysms during EVAR. Cardiovasc Intervent Radiol 35:1195–1200PubMedCrossRefGoogle Scholar
  30. 30.
    Mestres G, Uribe JP, Garcia-Madrid C et al (2012) The best conditions for parallel stenting during EVAR: an in vitro study. Eur J Vasc Endovasc Surg 44(5):468–473PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2013

Authors and Affiliations

  • Rakesh P. Patel
    • 1
  • Athanasios Katsargyris
    • 2
  • Eric L. G. Verhoeven
    • 2
  • Donald J. Adam
    • 3
  • John A. Hardman
    • 4
    Email author
  1. 1.Department of Vascular RadiologyNorthwick Park HospitalHarrowUK
  2. 2.Department of Vascular and Endovascular SurgeryKlinikum NürnbergNurembergGermany
  3. 3.Department of Vascular SurgeryHeartlands HospitalBirminghamUK
  4. 4.Department of Vascular RadiologyRoyal United Hospital BathBathUK

Personalised recommendations