title: Outcome of visceral chimney grafts after urgent endovascular repair of complex aortic lesions.
abstract: OBJECTIVE
  Endovascular abdominal aortic repair requires an adequate sealing zone. The chimney graft (CG) technique may be the only option for urgent high-risk patients who are unfit for open repair and have no adequate sealing zone. This single-center experience provides long-term results of CGs with endovascular repair for urgent and complex aortic lesions.
  
  
  METHODS
  Between July 2006 and October 2012, 51 patients (16 women) with a median age of 77 years (interquartile range, 72-81 years), were treated urgently (within 24 hours [61%]) or semiurgently (within 3 days [39%]) with endovascular aortic repair and visceral CGs (n = 73). Median follow-up was 2.3 years (interquartile range, 0.8-5.0 years) for the whole cohort, 3 years for 30-day survivors, and 4.8 years for patients who are still alive.
  
  
  RESULTS
  Five patients (10%) died within 30 days. All of them had a sacrificed kidney. All-cause mortality was 57% (n = 29), but the chimney- and procedure-related mortality was 6% (n = 3) and 16% (n = 8), respectively. Chimney-related death was due to bleeding, infection, renal failure, and multiple organ failure. There were two postoperative ruptures; both were fatal although not related to the treated disease. The primary and secondary long-term CG patencies were 89% (65 of 73) and 93% (68 of 73), respectively. Primary type I endoleak (EL-I) occurred in 10% (5 of 51) of the patients, and only one patient had recurrent EL-I (2%; 1 of 51). No secondary endoleak was observed. Chimney-related reintervention was required in 16% (8 of 51) of the patients because of EL-I (n = 3), visceral ischemia (n = 4), and bleeding (n = 2). The reinterventions included stenting (n = 5), embolization (n = 3), and laparotomy (n = 2). Thirty-one visceral branches were sacrificed (9 celiac trunks, 9 right, and 13 left renal arteries). Among the 30-day survivors, 8 of 17 patients (47%) with a sacrificed kidney required permanent dialysis; of these, seven underwent an urgent index operation. The aneurysm sac shrank in 63% (29 of 46) of cases.
  
  
  CONCLUSIONS
  The 6% chimney-related mortality and 93% long-term patency seem promising in urgent, complex aortic lesions of a high-risk population and may justify a continued yet restrictive applicability of this technique. Most endoleaks could be sealed endovascularly. However, sacrifice of a kidney in this elderly cohort was associated with permanent dialysis in 47% of patients.
authors.affiliation: Vascular Center, Skåne University Hospital/Malmö, Medical Faculty, Lund University, Malmö, Sweden. Electronic address: adel.bengabr@med.lu.se.
authors.forename: Adel
authors.initials: A
authors.lastname: Bin Jabr
authors.affiliation: Vascular Center, Skåne University Hospital/Malmö, Medical Faculty, Lund University, Malmö, Sweden.
authors.forename: Bengt
authors.initials: B
authors.lastname: Lindblad
authors.affiliation: Vascular Center, Skåne University Hospital/Malmö, Medical Faculty, Lund University, Malmö, Sweden.
authors.forename: Thorarinn
authors.initials: T
authors.lastname: Kristmundsson
authors.affiliation: Vascular Center, Skåne University Hospital/Malmö, Medical Faculty, Lund University, Malmö, Sweden.
authors.forename: Nuno
authors.initials: N
authors.lastname: Dias
authors.affiliation: Vascular Center, Skåne University Hospital/Malmö, Medical Faculty, Lund University, Malmö, Sweden.
authors.forename: Timothy
authors.initials: T
authors.lastname: Resch
authors.affiliation: Vascular Center, Skåne University Hospital/Malmö, Medical Faculty, Lund University, Malmö, Sweden.
authors.forename: Martin
authors.initials: M
authors.lastname: Malina
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001012:Aorta, Abdominal / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D002423:Cause of Death; D004630:Emergencies; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D011474:Prosthesis Design; D019233:Retreatment; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013548:Sweden; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014654:Vascular Patency