Endovascular Repair Of Abdominal And Thoracoabdominal Aneurysms Using Chimneys And Periscopes Is Associated With Poor Outcomes
Patrick Cherfan, MD, Othman M. Abdul-Malak, MD, Nathan L. Liang, MD, Mohammad H. Eslami, MD, Michael J. Singh, MD, Michel S. Makaroun, MD, Rabih A. Chaer, MD.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
OBJECTIVES: Chimneys and periscopes are often used to treat pararenal or thoracoabdominal aneurysms de novo or after failed open or endovascular repair. We sought to describe our institutional experience given their limited success and questionable long-term outcomes. METHODS: We retrospectively reviewed the electronic record for patients treated with chimneys/periscopes from 1997-2020. Baseline characteristics, procedural details, periprocedural complications, re-interventions and long-term outcomes were collected.
RESULTS: 58 patients (86 vessels) were treated; median follow-up was 32 months. There were 36% (n=21) juxta-renal, 2% (n=1) para-visceral, 21% (n=12) thoracoabdominal aneurysms, and 41% (n=24) had pararenal failure of prior EVAR (n=17) or open repair (n=7). Of the 86 vessels treated, 93% were (n=80/86) chimneys and 7% (n=6/86) periscopes, [8.1% (n=7) were reinforced with a bare metal stent] (Table 1), and the most common stent graft utilized was Viabahn™. Cases were urgent/emergent in 36.2% (n=21). At the conclusion of the initial procedure, 16/58 of patients had an endoleak [50% (8/16) Gutter, 25% (4/16) Type Ia, 25% (4/16) Type II]. On follow-up,14/58 patients developed ≥1 endoleaks [35% (7/20) Gutter, 15% (3/20) Type Ia, 15% (3/20) Type Ib, 5% (1/20) Type II and 30% (6/20) Type III]. 11/58 patients underwent interventions for one or more endoleaks [33% (5/15) Gutter, 20% (3/15) Type Ib, 7% (1/15) Type II and 40% (6/15) Type III]. 12/58 patients returned to the operating room for one or more procedures during the index hospitalization (5 laparotomies, 3 dialysis access, 3 acute limb ischemia, and 4 chimney/periscope interventions). 10/58 underwent angioplasty/stenting for chimney/periscope compression or occlusion during the follow-up period. Survival was 61.3% at 1 year by KM analysis (75% for elective, 37% for urgent/emergent)(aneurysm related death 22%) (Table 1). Cox hazard modelling showed that aneurysm diameter (HR 1.03,[1.004,1.05],p=0.02) and urgent/emergent interventions (HR 3.6,[1.33,9.74],p=0.01) were predictors of mortality.
CONCLUSIONS: Endovascular repair of aortic aneurysms with chimneys/periscopes is associated with poor outcomes, including limited technical success and aneurysm exclusion, as well as high morbidity and mortality, with a high rate of re-interventions both in the immediate post-operative period and on follow-up. They should be used only when other surgical or endovascular options are not possible.
| Patient demographics (n=58) | N (%) | Branch vessels (n=86) | N (%) | 4 vessels treated | 1(1.7%) |
| Age, y, mean (SD) | 76.8±7.8 | Renal chimney | 50(58.1%) | Outcomes (n=58) | Mean (SD) |
| Male gender | 47(81%) | Renal periscope | 5(5.8%) | Sac expansion, mm | 9.2±10 |
| Hypertension | 42(82.8%) | SMA chimney | 23(26.7%) | Cause of death (n=36) | N (%) |
| Coronary artery disease | 28(48.3%) | Celiac chimney | 7(8.1%) | Infection | 5(13.8%) |
| Hyperlipidemia | 29(50%) | Celiac periscope | 1(1.1%) | AAA | 4(11.1%) |
| Obese | 20(34.5%) | Number of vessels treated | N (%) | Cardiac | 4(11.1%) |
| Procedural characteristics | Mean (SD) | 1 vessel treated | 38(65.5%) | Respiratory arrest | 3(8.3%) |
| Operating time, hr | 3.5±1.5 | 2 vessels treated | 13(22.4%) | CMO (withdrawal of dialysis) | 2(5.5%) |
| Aortic diameter, cm | 7.1±2 | 3 vessels treated | 6(10.3%) | Unknown | 18(50%) |
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