Abstract
Purpose
To compare the technical and clinical outcomes of fenestrated thoracic endovascular aortic repair (F-TEVAR) and chimney thoracic endovascular aortic repair (CH-EVAR) of aortic disease.
Methods
PubMed, Embase and Cochrane databases were systematically searched to identify studies on the management of thoracic aortic pathologies using chimney or fenestrated techniques published between 2000 and 2022. Individual studies provided at least one of the following essential outcomes: technical success, immediate and follow-up type I endoleak, 30-day and aorta-related mortality, cerebral events and supra-aortic branch patency.
Results
24 chimney (1106 patients) and 21 fenestrated technique studies (1040 patients) were included. The scope of the study encompassed various thoracic aortic conditions, such as thoracic aortic dissection, thoracic aortic aneurysm, thoracic aortic ulcer, and other thoracic aortic diseases. Technical success was defined as the handling of the principal ailment affecting the aorta, devoid of any instances of complications. The technical success rates were higher in fenestrated group compared with chimney group (98.0% vs. 95.8% p < 0.001), and the rate of type I endoleak either immediately or during follow-up was higher in the chimney technique group (9.3% vs. 1.3% p < 0.001, 4.0% vs. 0.0% p < 0.001). The chimney technique group had higher 30-day mortality and aorta-related mortality than those in the fenestrated technique group (2.1% vs. 0.3% p < 0.001, 0.4% vs. 0.0% p < 0.001). Morbidity rates of cerebral events and supra-aortic branch patency were same in both groups (2.2% vs. 1.1% p = 0.116, 98.2% vs. 99.4% p = 0.094). The chimney technique group had longer operative time (110.0 min vs. 90.8 min p < 0.001). Two groups had same fluoroscopy time (34.0 min vs. 33.4 min p = 0.614).
Conclusions
The finding suggest that both the chimney and fenestrated techniques are efficacious in supra-aortic branch reconstruction. However, the fenestrated technique exhibits potential superiority as an interventional strategy, as it demonstrates a lower incidence of type 1 Endoleak, 30-day mortality, and aorta-related death following TEVAR.
Graphical Abstract
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Data Availability
The data that support the findings of this study are available from the corresponding author, upon reasonable request.
References
Olsson C, et al. Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation. 2006;114(24):2611–8.
Zhu S, et al. Acute aortic dissection in young adult patients: clinical characteristics, management, and perioperative outcomes. J Invest Surg. 2020;33(3):211–7.
Matsumura JS, et al. International controlled clinical trial of thoracic endovascular aneurysm repair with the Zenith TX2 endovascular graft: 1-year results. J Vasc Surg. 2008;47(2):247–57.
Goldfinger JZ, et al. Thoracic aortic aneurysm and dissection. J Am Coll Cardiol. 2014;64(16):1725–39.
Manning BJ, Ivancev K. Techniques for supra-aortic trunk preservation in thoracic endovascular aneurysm repair. Acta Chir Belg. 2010;110(1):112–5.
Appoo JJ, et al. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol. 2014;30(1):52–63.
Slim K, et al. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712–6.
Shu C, et al. Endovascular treatment for aortic arch pathologies: chimney, on-the-table fenestration, and in-situ fenestration techniques. J Thorac Dis. 2020;12(4):1437–48.
Zhang J, et al. Endovascular aortic repairs combined with looping-chimney technique for repairing aortic arch lesions and reconstructing left common carotid artery. J Thorac Dis. 2020;12(5):2270–9.
Shu C, et al. Early results of a novel gutter-free chimney stent-graft system to treat aortic arch dissection: single-center data from a prospective clinical trial. J Endovasc Ther. 2022;29(2):258–65.
Gehringhoff B, et al. Use of chimney grafts in aortic arch pathologies involving the supra-aortic branches. J Endovasc Ther. 2011;18(5):650–5.
Ahmad W, et al. Long-term outcomes after thoracic endovascular aortic repair using chimney grafts for aortic arch pathologies: 10 years of single-center experience. Ann Vasc Surg. 2021;72:400–8.
Shu C, et al. Early results of left carotid chimney technique in endovascular repair of acute non-a-non-B aortic dissections. J Endovasc Ther. 2011;18(4):477–84.
Mangialardi N, et al. Chimney technique for aortic arch pathologies: an 11-year single-center experience. J Endovasc Ther. 2014;21(2):312–23.
Xue Y, et al. The chimney technique for preserving the left subclavian artery in thoracic endovascular aortic repair. Eur J Cardiothorac Surg. 2015;47(4):623–9.
Zhu Y, et al. The single-centre experience of the supra-arch chimney technique in endovascular repair of type B aortic dissections. Eur J Vasc Endovasc Surg. 2013;45(6):633–8.
Huang C, et al. Early results of chimney technique for type B aortic dissections extending to the aortic arch. Cardiovasc Intervent Radiol. 2016;39(1):28–35.
Zou J, et al. Early- and mid-term results of the chimney technique in the repair of aortic arch pathologies. Cardiovasc Intervent Radiol. 2016;39(11):1550–6.
Liu H, et al. Endovascular aortic repair combined with chimney technique in the treatment of stanford type B aortic dissection involving aortic arch. Ann Vasc Surg. 2015;29(4):758–63.
Ahmad W, et al. A shorter aortic arch sealing ring (<10 mm) distal to the most distal chimney seems to be an additional important factor contributing to a gutter endoleak in aortic arch tevar. Ann Vasc Surg. 2019;61:116–23.
Bi J, et al. Midterm outcomes of fenestrated TEVAR using physician-modified endovascular grafts for zone 2. Vascular. 2022;30(3):432–40.
Bosiers MJ, et al. European multicenter registry for the performance of the chimney/snorkel technique in the treatment of aortic arch pathologic conditions. Ann Thorac Surg. 2016;101(6):2224–30.
Canaud L, et al. Homemade fenestrated stent-graft for thoracic endovascular aortic repair of zone 2 aortic lesions. J Thorac Cardiovasc Surg. 2018;155(2):488–93.
Ding H, et al. Outcomes of chimney technique for preservation of the left subclavian artery in type B aortic dissection. Eur J Vasc Endovasc Surg. 2019;57(3):374–81.
Falkensammer J, et al. Assessment of pull-out forces in tevar and anaconda fevar combination and early clinical results: creation of a proximal landing zone for fevar in patients with extent I and extent IV TAAAs. Ann Vasc Surg. 2020;66:160–70.
Li X, et al. Early experience and technical aspects of physician-modified fenestration in thoracic endovascular aortic repair for aortic arch pathologies. J Int Med Res. 2020;48(2):300060519870903.
Li X, et al. Self-radiopaque markers guiding physician-modified fenestration (S-fenestration) in aortic arch endovascular repair. Front Cardiovasc Med. 2021;8:713301.
Piffaretti G, et al. Comparison of two different techniques for isolated left subclavian artery revascularization during thoracic endovascular aortic repair in zone 2. J Endovasc Ther. 2018;25(6):740–9.
Shahverdyan R, et al. Single-center mid-term experience with chimney-graft technique for the preservation of flow to the supra-aortic branches. Vascular. 2018;26(2):175–82.
Sun G, et al. Long-term outcome of chimney technique using a balloon-expandable bare-metal stent to preserve supra-arch branches in type B aortic dissection. Vasc Endovasc Surg. 2020;54(4):333–40.
Tan GWL, et al. Early experience and lessons learnt with customized fenestrated thoracic endovascular aortic reconstruction for aortic arch pathology in an Asian population. Cardiovasc Intervent Radiol. 2018;41(4):544–53.
Tsilimparis N, et al. Branched versus fenestrated endografts for endovascular repair of aortic arch lesions. J Vasc Surg. 2016;64(3):592–9.
Wang L, et al. Application of triple-chimney technique using C-TAG and viabahn or excluder iliac extension in tevar treatment of aortic arch dilation diseases. J Thorac Dis. 2018;10(6):3783–90.
Wang T, et al. Thoracic endovascular aortic repair with single/double chimney technique for aortic arch pathologies. J Endovasc Ther. 2017;24(3):383–93.
Wang T, et al. First experience with the double chimney technique in the treatment of aortic arch diseases. J Vasc Surg. 2017;66(4):1018–27.
XiaoHui M, et al. Comparison of supra-arch in situ fenestration and chimney techniques for aortic dissection involving the left subclavian artery. Vascular. 2019;27(2):153–60.
Zhang H, et al. Comparison of chimney technique and single-branched stent graft for treating patients with type B aortic dissections that involved the left subclavian artery. Cardiovasc Intervent Radiol. 2019;42(5):648–56.
Zhang R, et al. Inducing false lumen thrombosis for retrograde type A aortic dissection. J Thorac Cardiovasc Surg. 2017;153(1):57–65.
Zhu J, et al. Fenestrated thoracic endovascular aortic repair using physician-modified stent grafts (PMSGs) in zone 0 and zone 1 for aortic arch diseases. Cardiovasc Intervent Radiol. 2019;42(1):19–27.
Zhu J, et al. Fenestrated thoracic endovascular aortic repair using physician modified stent grafts for acute type B aortic dissection with unfavourable landing zone. Eur J Vasc Endovasc Surg. 2018;55(2):170–6.
Bai J, et al. Mid-term results of in situ fenestration stented with balloon-expandable bare metal stents during thoracic endovascular aortic repair. Catheter Cardiovasc Interv. 2020;95(6):1163–8.
Canaud L, et al. Total arch thoracic endovascular aortic repair using double fenestrated physician-modified stent-grafts: 100 patients. J Endovasc Ther. 2022;596:15266028221116748.
Chastant R, et al. Homemade fenestrated physician-modified stent grafts for arch aortic degenerative aneurysms. J Vasc Surg. 2022;76(5):1133–11402.
Luo M, et al. Midterm results of retrograde in situ needle fenestration during thoracic endovascular aortic repair of aortic arch pathologies. J Endovasc Ther. 2021;28(1):36–43.
Qin J, et al. Laser fenestration of aortic arch stent grafts for endovascular treatment of retrograde type A dissection. Int J Cardiol. 2021;328:69–74.
Yan D, et al. Outcomes of emergency in situ laser fenestration-assisted thoracic endovascular aortic repair in patients with acute Stanford type A aortic dissection unfit for open surgery. J Vasc Surg. 2020;71(5):1472–14791.
Li C, et al. Early and midterm outcomes of in situ laser fenestration during thoracic endovascular aortic repair for acute and subacute aortic arch diseases and analysis of its complications. J Vasc Surg. 2020;72(5):1524–33.
Shu X, et al. Midterm outcomes of an adjustable puncture device for in situ fenestration during thoracic endovascular aortic repair. Eur J Vasc Endovasc Surg. 2022;63(1):43–51.
Zhao Z, et al. In situ laser stent graft fenestration of the left subclavian artery during thoracic endovascular repair of type B aortic dissection with limited proximal landing zones: 5-year outcomes. J Vasc Interv Radiol. 2020;31(8):1321–7.
Chuter TA, et al. Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg. 2008;47(1):6–16.
McWilliams RG, et al. In situ stent-graft fenestration to preserve the left subclavian artery. J Endovasc Ther. 2004;11(2):170–4.
Zhang L, et al. Off-the-shelf devices for treatment of thoracic aortic diseases: midterm follow-up of tevar with chimneys or physician-made fenestrations. J Endovasc Ther. 2020;27(1):132–42.
Donas KP, et al. Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: the PERICLES registry. Ann Surg. 2015;262(3):546–53.
Chassin-Trubert L, et al. Midterm follow-up of fenestrated and scalloped physician-modified endovascular grafts for zone 2 tevar. J Endovasc Ther. 2020;27(3):377–84.
Kurimoto Y, et al. Thoracic endovascular aortic repair for challenging aortic arch diseases using fenestrated stent grafts from zone 0. Ann Thorac Surg. 2015;100(1):24–32.
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This research was supported by the National Natural Science Foundation of China (G. Nos. 82170507, 81970402 and 81800407).
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Liu, M., Wu, X., Wu, S. et al. Comparison of Chimney and Fenestrated Techniques for Supra-Aortic Branch Revascularization During Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 46, 1315–1328 (2023). https://doi.org/10.1007/s00270-023-03537-4
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DOI: https://doi.org/10.1007/s00270-023-03537-4