Abstract
Lesions in the aortic arch or descending aorta can be treated using open or endovascular methods. However, involvement of the supra-aortic branches makes treatment demanding. Alternatively to branched custom made aortic arch endografts, the chimney /periscope technique is a total, one-stage endovascular solution. Its advantages include the possibility to treat urgent and acute pathologies by use of off-the-shelf devices. The stroke rates do not differ from the other therapeutic options. Disadvantages include the gutter-related endoleaks. However, as shown in a multicenter European registry, half of them disappear spontaneously during the first month.
Keywords
chimney technique, endovascular repair, periscope technique, thoracic and aortic arch aneurysm, urgent repair
Lesions in the aortic arch or descending aorta can be treated using open or endovascular methods. When the lesion is located close to or involves the supra-aortic branches, treatment becomes more difficult, and hybrid approaches may be necessary. In such cases, debranching must be performed to create an adequate landing zone for the thoracic endograft. The requirement for more than one procedure in hybrid cases makes them less attractive than total endovascular repair with, for example, custom-made branched or fenestrated endografts. The obligatory delay between stages of a hybrid treatment comes with a high cost. With these limitations in mind, the chimney technique was developed as a total, one-stage endovascular solution to treat urgent and acute pathologies with off-the-shelf devices. (See also Chapter 6 , Chapter 7 , Chapter 8 .)
Procedure
Case Presentation
A 77-year-old woman presented with a contained rupture of an aortic arch aneurysm. A total endovascular repair using the chimney technique was elected. Fig. 16.1 shows the ruptured aortic arch, as well as a lusoria artery (aberrant subclavian artery).
Exposure of left axillary/proximal brachial artery
The patient’s arm was abducted to 90 degrees. The proximal brachial artery was exposed through a 3- to 4-cm longitudinal incision in the groove between biceps and triceps, distally to the attachment of the pectoralis major muscle. The axillary (or proximal brachial) artery was carefully exposed, taking care to avoid injury of the median nerve, and prepared for puncture along its ventral surface. This approach facilitates the use of 7-French (7F) or 8F sheaths. Alternatively, when a single chimney graft is required, a percutaneous approach to the brachial artery in the antecubital fossa can also be performed. We recommend this only with planned placement of bare-metal stents as chimney grafts, since they are compatible with sheaths less than 7F in size.
Puncture of left brachial artery and cannulation of subclavian artery
The axillary artery is punctured using Seldinger technique, and after insertion of a short 5F sheath, 5000 units of heparin is administered. The next step is the insertion of the soft Terumo wire in the aortic arch and the advance of a 5F pigtail catheter in the ascending aorta, followed by a 7F sheath ( Fig. 16.2 ).
Percutaneous transfemoral access
As in standard thoracic endovascular aneurysm repair (TEVAR), stiff wires are advanced using the Prostar XL device (Abbott).
Deployment of the thoracic endograft
Thoracic endografts are used per the center’s standard, including devices with stainless steel or nitinol endoskeletons. The thoracic device will cover the orifice of the left subclavian artery and part of the orifice of the next supra-aortic vessel. The sheath is placed in the ascending aorta proximal to the covered part of the thoracic device ( Fig. 16.3 ). Note the position of the C-arm in 30-degree left anterior oblique (LAO) position and the magnification of the images.
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