title: Natural history of gutter-related type Ia endoleaks after snorkel/chimney endovascular aneurysm repair.
abstract: OBJECTIVE
  Alternative endovascular strategies using parallel or snorkel/chimney (chimney endovascular aneurysm repair [ch-EVAR]) techniques have been developed to address the lack of widespread availability and manufacturing limitations with branched/fenestrated aortic devices for the treatment of complex abdominal aortic aneurysms. Despite high technical success and midterm patency of snorkel stent configurations, concerns remain regarding the perceived increased incidence of early gutter-related type Ia endoleaks. We aimed to evaluate the incidence and natural history of gutter-related type Ia endoleaks following ch-EVAR.
  
  
  METHODS
  Review of medical records and available imaging studies, including completion angiography and serial computed tomographic angiography, was performed for all patients undergoing ch-EVAR at our institution between September 2009 and January 2015. Only procedures involving ≥1 renal artery with or without visceral snorkel stents were included. Primary outcomes of the study were presence and persistence or resolution of early gutter-related type Ia endoleak. Secondary outcomes included aneurysm sac shrinkage and need for secondary intervention related to the presence of type Ia gutter endoleak.
  
  
  RESULTS
  Sixty patients (mean age, 75.8 ± 7.6 years; male, 70.0%) underwent ch-EVAR with a total of 111 snorkel stents (97 renal [33 bilateral renal], 12 superior mesenteric artery, 2 celiac). A mean of 1.9 ± 0.6 snorkel stents were placed per patient. Early gutter-related type Ia endoleaks were noted on 30.0% (n = 18) of initial postoperative imaging studies. Follow-up imaging revealed spontaneous resolution of these gutter endoleaks in 44.3%, 65.2%, and 88.4% of patients at 6, 12, and 18 months postprocedure, respectively. Long-term anticoagulation, degree of oversizing, stent type and diameter, and other clinical/anatomic variables were not significantly associated with presence of gutter endoleaks. Two patients (3.3%) required secondary intervention related to persistent gutter endoleak. At a mean radiologic follow-up of 20.9 months, no difference in mean aneurysm sac size change was observed between those with or without early type Ia gutter endoleak (-6.1 ± 10.0 mm vs -4.9 ± 11.5 mm; P = .23).
  
  
  CONCLUSIONS
  Gutter-related type Ia endoleaks represent a relatively frequent early occurrence after ch-EVAR, but appears to resolve spontaneously in the majority of cases during early to midterm follow-up. Given that few ch-EVAR patients require reintervention related to gutter endoleaks and the presence of such endoleak did not correlate to increased risk for aneurysm sac growth, its natural history may be more benign than originally expected.
authors.affiliation: Providence Heart and Vascular Institute, Portland, Ore.
authors.forename: Brant W
authors.initials: BW
authors.lastname: Ullery
authors.affiliation: Division of Vascular Surgery, Stanford University Medical Center, Stanford, Calif.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Tran
authors.affiliation: Division of Vascular Surgery, Stanford University Medical Center, Stanford, Calif.
authors.forename: Nathan K
authors.initials: NK
authors.lastname: Itoga
authors.affiliation: Division of Vascular Surgery, Stanford University Medical Center, Stanford, Calif.
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Dalman
authors.affiliation: Division of Vascular Surgery, Stanford University Medical Center, Stanford, Calif. Electronic address: jtlee@stanford.edu.
authors.forename: Jason T
authors.initials: JT
authors.lastname: Lee
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods / Q000401:mortality; D000072226:Computed Tomography Angiography; D057867:Endoleak / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality / Q000628:therapy; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records; D011474:Prosthesis Design; D019233:Retreatment; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome