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Challenging AAA Neck Anatomy: Does the Fenestrated or Snorkel/Chimney Technique Improve Mortality and Freedom from Reintervention Relative to Open Repair?

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Difficult Decisions in Vascular Surgery

Part of the book series: Difficult Decisions in Surgery: An Evidence-Based Approach ((DDSURGERY))

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Abstract

Complex endovascular aneurysm repair (EVAR) most often refers to extension of the proximal seal zone with preservation of branch vessel patency, thereby expanding the applicability of aortic endografts from the infrarenal to the suprarenal aorta. Snorkel/chimney (ch-EVAR) and fenestrated EVAR (f-EVAR) are the two most commonly utilized advanced endovascular techniques to combat hostile proximal neck anatomy. The current literature examining this topic is limited to level II data and therefore should be interpreted with appropriate caution. Nevertheless, available data to date does provide low quality evidence supporting a promising trend towards improved perioperative outcomes, including reduced perioperative mortality, with complex EVAR compared to open surgical repair, although this early clinical benefit may come at the expense of increased need for secondary intervention.

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References

  1. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg. 1991;5:491–9.

    Article  CAS  PubMed  Google Scholar 

  2. Schwarze ML, Shen Y, Hemmerich J, et al. Age-related trends in utilization and outcome of open and endovascular repair for abdominal aortic aneurysm in the United States, 2001-2006. J Vasc Surg. 2009;50:722–9.

    Article  PubMed  Google Scholar 

  3. Giles KA, Pomposelli F, Hamdan A, et al. Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair. J Vasc Surg. 2009;49:543–50.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Wilderman M, Sanchez LA. Fenestrated grafts or debranching procedures for complex abdominal aortic aneurysms. Perspect Vasc Surg Endovasc Ther. 2009;21:13–8.

    Article  PubMed  Google Scholar 

  5. West CA, Noel AA, Bower TC, et al. Factors affecting outcomes of open surgical repair of pararenal aortic aneurysms: a 10-year experience. J Vasc Surg. 2006;43:921–7.

    Article  PubMed  Google Scholar 

  6. Jean-Claude JM, Reilly LM, Stoney RJ, et al. Pararenal aortic aneurysms: the future of open aortic aneurysm repair. J Vasc Surg. 1999;29:902–12.

    Article  CAS  PubMed  Google Scholar 

  7. Sarac TP, Clair DG, Hertzer NR, et al. Contemporary results of juxtarenal aneurysm repair. J Vasc Surg. 2002;36:1104–11.

    Article  PubMed  Google Scholar 

  8. Raux M, Patel VI, Cochennec F, et al. A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms. J Vasc Surg. 2014;60:858–63.

    Article  PubMed  Google Scholar 

  9. Kabbani LS, West CA, Viau D, et al. Survival after repair of pararenal and paravisceral abdominal aortic aneurysms. J Vasc Surg. 2014;59:1488–94.

    Article  PubMed  Google Scholar 

  10. Knott AW, Kalra M, Duncan AA, et al. Open repair of juxtarenal aortic aneurysms (JAA) remains a safe option in the era of fenestrated endografts. J Vasc Surg. 2008;47:695–701.

    Article  PubMed  Google Scholar 

  11. Katsargyris A, Oikonomou K, Klonaris C, et al. Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift? J Endovasc Ther. 2013;20:159–69.

    Article  PubMed  Google Scholar 

  12. Komori K, Furuyama T, Maehara Y. Renal artery clamping and left renal vein division during abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2004;27:80–3.

    Article  CAS  PubMed  Google Scholar 

  13. Kudo FA, Nishibe T, Miyazaki K, et al. Postoperative renal function after elective abdominal aortic aneurysm repair requiring suprarenal aortic cross-clamping. Surg Today. 2004;34:1010–3.

    Article  PubMed  Google Scholar 

  14. Ryan SV, Calligaro KD, McAfee-Bennett S, et al. Management of juxtarenal aortic aneurysms and occlusive disease with preferential suprarenal clamping via a midline transperitoneal incision: technique and results. Vasc Endovasc Surg. 2004;38:417–22.

    Article  Google Scholar 

  15. Back MR, Bandyk M, Brandner M, et al. Critical analysis of outcome determinants affective repair of intact aneurysms involving the visceral aorta. Ann Vasc Surg. 2005;19:648–56.

    Article  PubMed  Google Scholar 

  16. Chiesa R, MaroneEM BC, et al. Open repair of pararenal aortic aneurysms: operative management, early results, and risk factor analysis. Ann Vasc Surg. 2006;20:739–46.

    Article  PubMed  Google Scholar 

  17. Wahlgren CM, Piano G, Desai T, et al. Transperitoneal versus retroperitoneal suprarenal cross-clamping for repair of abdominal aortic aneurysm with a hostile infrarenal aortic neck. Ann Vasc Surg. 2007;21:687–94.

    Article  PubMed  Google Scholar 

  18. Illuminati G, D'Urso A, Ceccanei G, et al. Surgical treatment of pararenal aortic aneruysms in the elderly. J Cardiovasc Surg (Torino). 2007;48:705–10.

    CAS  Google Scholar 

  19. Ockert S, Schumacher H, Bockler D, et al. Comparative early and midterm results of open juxtarenal and infrarenal aneurysm repair. Langenbecks Arch Surg. 2007;392:725–30.

    Article  PubMed  Google Scholar 

  20. Pearce JD, Edwards MS, Stafford JM, et al. Open repair of aortic aneurysm s involving the renal vessels. Ann Vasc Surg. 2007;21:676–86.

    Article  PubMed  Google Scholar 

  21. Yeung KK, Jongkind V, Coveliers HM, et al. Routine continuous cold perfusion of the kidneys during elective juxtarenal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2008;35:446–51.

    Article  CAS  PubMed  Google Scholar 

  22. Marrocco-Trischitta MM, Melissano G, Kahlberg A, et al. The impact of aortic clamping site on glomerular filtration rate after juxtarenal aneurysm repair. Ann Vasc Surg. 2009;23:770–7.

    Article  PubMed  Google Scholar 

  23. Chisci E, Kristmundsson T, de Donato G, et al. The AAA with a challenging neck: outcome of open versus endovascular repair with standard and fenestrated stent-grafts. J Endovasc Ther. 2009;16:137–46.

    Article  PubMed  Google Scholar 

  24. Landry GJ, Lau IH, Liem TK, et al. Adjunctive renal artery revascularization during juxtarenal and suprarenal abdominal aortic aneurysm repairs. Am J Surg. 2010;199:641–5.

    Article  PubMed  Google Scholar 

  25. Bruen KJ, Feezor RJ, Daniels M, et al. Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms. J Vasc Surg. 2011;53:895–904.

    Article  PubMed  Google Scholar 

  26. Tsai S, Conrad MF, Patel VI, et al. Durability of open repair of juxtarenal abdominal aortic anuerysms. J Vasc Surg. 2012;56:2–7.

    Article  PubMed  Google Scholar 

  27. Donas KP, Torsello G, Bisdas T, et al. Early outcomes for fenestrated and chimney endografts in the treatment of pararenal aortic pathologies are not significantly different: a systematic review with pooled data analysis. J Endovasc Ther. 2013;19:723–8.

    Article  Google Scholar 

  28. Canavati R, Millen A, Brennan J, et al. Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair. J Vasc Surg. 2013;57:362–7.

    Article  PubMed  Google Scholar 

  29. Halak M, Goodman MA, Baker SR. The fate of target visceral vessels after fenestrated endovascular aortic repair--general considerations and mid-term results. Eur J Vasc Endovasc Surg. 2006;32:124–8.

    Article  CAS  PubMed  Google Scholar 

  30. Muhs BE, Verhoeven EL, Zeebregts CJ, et al. Mid-term results of endovascular aneurysm repair with branched and fenestrated endografts. J Vasc Surg. 2006;44:9–15.

    Article  PubMed  Google Scholar 

  31. O'Neill S, Greenberg RK, Haddad F, et al. A prospective analysis of fenestrated endovascular grafting: intermediate-term outcomes. Eur J Vasc Endovasc. 2006;32:115–23.

    Article  Google Scholar 

  32. Semmens JB, Lawrence-Brown MM, Hartley DE, et al. Outcomes of fenestrated endografts in the treatment of abdominal aortic aneurysm in Western Australia (1997-2004). J Endovasc Ther. 2006;13:320–9.

    Article  PubMed  Google Scholar 

  33. Ziegler P, Avgerinos ED, Umscheid T, et al. Fenestrated endografting for aortic aneurysm repair: a 7-year experience. J Endovasc Ther. 2007;14:609–18.

    Article  PubMed  Google Scholar 

  34. Scurr JR, Brennan JA, Gilling-Smith GL, et al. Fenestrated endovascular repair for juxtarenal aortic aneurysm. Br J Surg. 2008;95:326–32.

    Article  CAS  PubMed  Google Scholar 

  35. Bicknell CD, Cheshire NJ, Riga CV, et al. Treatment of complex aneurysmal disease with fenestrated and branched stent grafts. Eur J Vasc Endovasc Surg. 2009;37(2):175–81.

    Article  CAS  PubMed  Google Scholar 

  36. Kristmundsson T, Sonesson B, Malina M, et al. Fenestrated endovascular repair for juxtarenal aortic pathology. J Vasc Surg. 2009;49:568–74.

    Article  PubMed  Google Scholar 

  37. Greenberg RK, Sternbergh 3rd WC, Makaroun M, et al. Intermediate results of a United States multicenter trial of fenestrated endograft repair for juxtarenal abdominal aortic aneurysms. J Vasc Surg. 2009;50:730–7.

    Article  PubMed  Google Scholar 

  38. Amiot S, Haulon S, Becquemin JP, et al. Fenestrated endovascular grafting: the French multicentre experience. Eur J Vasc Endovasc Surg. 2010;39:537–44.

    Article  CAS  PubMed  Google Scholar 

  39. Verhoeven EL, Vourliotakis G, Bos WT, et al. Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: an 8-year single-centre experience. Eur J Vasc Endovasc Surg. 2010;39:529–36.

    Article  CAS  PubMed  Google Scholar 

  40. Tambyraja AL, Fishwick NG, Bown MJ, et al. Fenestrated aortic endografts for juxtarenal aortic aneurysm: medium term outcomes. Eur J Vasc Endovasc Surg. 2011;42:54–8.

    Article  CAS  PubMed  Google Scholar 

  41. Manning BJ, Agu O, Richards T, et al. Early outcome following endovascular repair of pararenal aortic aneurysms: triple- versus double- or single-fenestrated stent-grafts. J Endovasc Ther. 2011;18:98–105.

    Article  PubMed  Google Scholar 

  42. Lee JT, Lee GK, Chandra V, Dalman RL. Early experience and lessons learned with fenestrated endografts compared with the snorkel/chimney technique. J Vasc Surg. 2014;60:849–56.

    Article  PubMed  Google Scholar 

  43. Banno H, Cochennec F, Marzelle J, et al. Comparison of fenestrated endovascular aneurysm repair and chimney graft techniques for pararenal aortic aneurysm. J Vasc Surg. 2014;60:31–9.

    Article  PubMed  Google Scholar 

  44. Larzon T, Eliasson K, Gruber G. Top-fenestrating technique in stent-grafting of aortic diseases with mid-term follow-up. J Cardiovasc Surg (Torino). 2008;49:317–22.

    CAS  Google Scholar 

  45. Coscas R, Kobeiter H, Desgranges P, et al. Technical aspects, current indications, and results of chimney grafts for juxtarenal aortic aneurysms. J Vasc Surg. 2011;53:1520–7.

    Article  PubMed  Google Scholar 

  46. Lee JT, Greenberg J, Dalman RL. Early experience with snorkel technique for juxtarenal aneurysms. J Vasc Surg. 2012;55:935–46.

    Article  PubMed  Google Scholar 

  47. Linsen MA, Jongkind V, Nio D, et al. Pararenal aortic aneurysm repair using fenestrated endografts. J Vasc Surg. 2012;56:238–46.

    Article  PubMed  Google Scholar 

  48. Wilson A, Zhou S, Bachoo P, et al. Systematic review of chimney and periscope grafts for endovascular aneurysm repair. Br J Surg. 2013;100:1557–64.

    Article  CAS  PubMed  Google Scholar 

  49. Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302:1535–42.

    Article  CAS  PubMed  Google Scholar 

  50. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2): randomised controlled trial. Lancet. 2005;365:2187–92.

    Google Scholar 

  51. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet. 2005;365:2179–86.

    Google Scholar 

  52. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004;35:1607–18.

    Article  Google Scholar 

  53. Tsilimparis N, Perez S, Dayama A, et al. Endovascular repair with fenestrated-branched stent grafts improves 30-day outcomes for complex aortic aneurysms compared with open repair. Ann Vasc Surg. 2013;27:267–73.

    Article  PubMed  Google Scholar 

  54. Nordon IM, Hinchliffe RJ, Holt PJ, et al. Modern treatment of juxtarenal abdominal aortic aneurysms with fenestrated endografting and open repair--a systematic review. Eur J Vasc Endovasc Surg. 2009;38:35–41.

    Article  CAS  PubMed  Google Scholar 

  55. Donas KP, Eisenack M, Panuccio G, et al. The role of open and endovascular treatment with fenestrated and chimney endografts for patients with juxtarenal aortic aneurysms. J Vasc Surg. 2012;56:285–90.

    Article  PubMed  Google Scholar 

  56. Lee JT, Donas KP, Lachat M, Torsello G, Veith FJ. 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.

    Google Scholar 

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Authors and Affiliations

  1. Cardiovascular Surgery, Providence Heart and Vascular Institute, Portland, OR, USA

    Brant W. Ullery MD

  2. Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA, USA

    Jason T. Lee MD

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  1. Brant W. Ullery MD
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  2. Jason T. Lee MD
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Correspondence to Jason T. Lee MD .

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Editors and Affiliations

  1. The University of Chicago Medical Center and Biological Science Division, Chicago, Illinois, USA

    Christopher L. Skelly

  2. The University of Chicago Medical Center and Biological Science Division, Chicago, Illinois, USA

    Ross Milner

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Ullery, B.W., Lee, J.T. (2017). Challenging AAA Neck Anatomy: Does the Fenestrated or Snorkel/Chimney Technique Improve Mortality and Freedom from Reintervention Relative to Open Repair?. In: Skelly, C., Milner, R. (eds) Difficult Decisions in Vascular Surgery. Difficult Decisions in Surgery: An Evidence-Based Approach. Springer, Cham. https://doi.org/10.1007/978-3-319-33293-2_5

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  • DOI: https://doi.org/10.1007/978-3-319-33293-2_5

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