The chimney technique for preserving the left subclavian artery in thoracic endovascular aortic repair
Selected in European Journal of Cardio-Thoracic Surgery by Rylski
Xue Y, Sun L, Zheng J, Huang X, Guo X, Li T, Huang L
Eur J Cardiothorac Surg. 2015 Apr;47(4):623-9
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In patients with thoracic aortic pathology with inadequate proximal landing zone, endovascular therapy might require coverage of the left subclavian artery. The authors evaluated short- and mid-term outcomes of the left subclavian artery chimney stent implantation during thoracic endovascular aortic repair (TEVAR).
- Single center report on 59 TEVAR patients with chimney stent in the left subclavian Artery operated on between 2010 and 2012.
- Elective settings were performed in 72% and emergent in 38%.
- The immediate endoleak type I was observed in 8% and type II in 7%; stroke in 3% and left upper limb ischaemia in 2%.
- During the follow-up (median 16.5 months) the mortality rate was 5%, endoleak type I rate was 8% and one patient developed retrograde type A aortic dissection. There were 3 collapses and 2 occlusions of the chimney stent.
There are several options to extend the proximal landing zone in patients scheduled for TEVAR for pathologies starting immediately distal to the left subclavian artery. The authors report on the chimney technique performed in the largest cohort till now available in the literature. They conclude that the overall results are good. However, there are 8 (14%) patients who did not benefit after TEVAR with chimney stent for reasons related to this technology including 5 endoleaks type I, 1 retrograde type A dissection and 2 strokes. In the light of these results it seems to be important to consider another treatment options in these patients. (I) Overstenting of the left subclavian artery without revascularisation is associated with very low risk of endoleaks type I however it may lead to increased stroke rate. (II) Implantation of fenestrated or branched stentgraft prosthesis requires advanced endovascular skills and the long-term follow-up data are not available now. (III) Surgical revascularization of the lefts subclavian artery performing a carotid-subclavian bypass or transposition is the most frequently applied technique, which can be achieved with a low risk of complications and low risk of endoleak type I. (III) An open surgical repair with hybrid prostheses in elephant trunk or frozen elephant trunk allow establishing a very stable and long proximal landing zone for definitive secondary TEVAR procedure, but it requires use of cardio-pulmonary bypass, hypothermic circulatory arrest and selective cerebral perfusion.
Summarizing, there are endovascular, surgical and hybrid treatment options available for patients with aortic pathology starting immediately distal to the left subclavian artery. The decision on the treatment strategy must always be done individually depending on aortic anatomy, patients’ comorbidities and the surgeons’ technical expertise.