title: Using a Chimney to Make a Sandwich: Salvage of a Multibranched Thoracoabdominal Aortic Endograft with a Type IIIb Endoleak.
abstract: BACKGROUND
  The advent of branched and fenestrated aortic endografts has facilitated the treatment of increasingly complex aortic pathology. The management of complications and endoleaks involving the branches and fenestrations of these grafts represents an increasingly significant clinical and technical challenge.
  
  
  METHODS
  A 79-year-old woman developed a rare type IIIb endoleak from a tear in the graft fabric immediately posterior to the celiac axis branch 3 years after the placement of an off-the-shelf branched endograft for a type II thoracoabdominal aortic aneurysm. The patient presented urgently with abdominal pain and a maximal aneurysm diameter of 15.3 cm.
  
  
  RESULTS
  The operative plan was to create a chimney graft completely within the original branched endograft to cover the defect and maintain celiac branch flow. The celiac trunk was accessed from a left axillary approach and access for the main endograft body was achieved via the left femoral artery. Two balloon-expandable covered stents were deployed from the celiac branch extending into the main endograft as a chimney and molded to 2 aortic extension cuffs to cover the fabric defect. The resultant configuration was a modified-sandwich graft within the original stent graft and resulted in successful exclusion of the endoleak. Postoperative imaging at 1, 6, and 12 months has demonstrated continued patency of the celiac trunk, no further endoleak, and a 16-mm reduction in aneurysm size.
  
  
  CONCLUSIONS
  The chimney technique was successfully applied as an endovascular option to salvage a multibranched endograft with a significant and anatomically unfavorable defect. Careful follow-up and additional clinical study are required to clarify the role of off-the-shelf solutions in complex endoleak management.
authors: Division of Vascular Surgery, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada. Electronic address: jon.misskey@gmail.com.
authors: Jonathan
authors: J
authors: Misskey
authors: Division of Vascular Surgery, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada.
authors: Steven
authors: S
authors: Johnson
authors: Division of Vascular Surgery, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada.
authors: Keith
authors: K
authors: Baxter
authors: Division of Vascular Surgery, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada.
authors: Joel
authors: J
authors: Gagnon
mesh_terms: D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D001807:Blood Vessel Prosthesis / Q000009:adverse effects*; D019917:Blood Vessel Prosthesis Implantation; D057867:Endoleak / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D012086:Reoperation; D015607:Stents / Q000009:adverse effects*