Lessons learned from Ch-EVAR for the treatment of pararenal AAAs Miltos Matsagkas MD, PhD, FEBVS Professor of Vascular Surgery University of Thessaly
Ch-EVAR Ch-EVAR = Chimney-EVAR Placement of single or multiple stents parallel to main aortic stentgraft to extend the sealing zone over one or multiple side branches while maintaining patency to those branches 2
ChEVAR with the Endurant Stentgraft system Current Endurant indication has been for Infrarenal AAA New Endurant Indication is additionally for Juxtarenal AAA 10 mm Infrarenal AAA Juxtarenal AAA
Endovascular repair of pararenal AAAs Two solutions nowadays F-EVAR Ch-EVAR
Is there an endovascular conflict? Why Ch-EVAR if suitable for F-EVAR? o Cost o Manufacturing delays When patient not suitable for F-EVAR? There are many situations where Ch-EVAR is still an option o Acute setting o Anatomical reasons o Existing set-up
Ch-EVAR for pararenal AAAs Quite often in the everyday practice, we need.. Off the shelf solution Efficient Durable Cost effective
Pericles global registry 517 pts 119 from US and 398 Europe 898 chimney grafts 692 renal arteries 156 SMA 50 celiac arteries Donas et al, Ann Surg 2015
Ch-EVAR documentation 128 patients with pararenal pathologies and the intention to treat by Endurant and Atrium Advanta V12 as chimney graft Follow up: 3 year Kaplan Mayer analysis K. Donas et. al, J Vasc Surg. 2016 Jan;63(1):1-7
Failed EVAR treated with chimneys Donas et al, J Vasc Surg 2015
Chimney EVAS (Ch-EVAS) for Challenging Neck Anatomy The compliant endobags promised to optimize the seal around parallel grafts and minimize the risk of type 1a gutter endoleak
Post-market registry of the Nellix System with Chimney Stents Open-label, single-arm, no prospective screening 200 patients, up to 10 international centers with 5y F/U 187 patients (154 primary, 9 raaa, 25 Revision EVAR, 5 Revision EVAS) Endpoints typical of EVAR therapy in complex AAA M Thompson et al, J Endovasc Ther 2018
Ch-EVAR challenges Type I endoleak (up to 10%) Mechanical interaction / Target vessel grafts position Questions remaining: long-term durability Lack of strong evidence basis
Ch-EVAR: Reasons for good results Devices selection Length of the new neck Oversizing Meticulous planning
Larissa University Hospital, Greece From 5/2016-4/2018 (24 months) 22 Ch-EVAR (out of 226 EVARs, 9.7%) 41 target vessels 4 x3 Ch-EVAR, 11 x2 Ch-EVAR, 7 single Ch-EVAR 4 pts had previous aortic surgery (3 pts type I endoleak and 1 pt pararenal anastomotic aneurysm after previous OR) 11 Endurant (Medtronic), 9 Nellix (Endologix), 2 Incraft (Cordis)
Larissa University Hospital, Greece Technical success 100% 30 day mortality: 13.6% - 3 pts 1 stroke (4.5%) At FU (mean 9.2 months) 1 target vessel occlusion at 6 month FUP (RA) 2 reinterventions (all endo) o 1 limb relining (type III endoleak) o 1 TV stenosis (1 SMA treated successfully)
Access Device selection Length of the new neck Oversizing Target vessel patency
Access X Long hydrophilic sheath 7-8Fr
Gutters and graft compression are the main problems De Bruin et al, J Endovasc Ther 2013
Bad choices lead to worse results freedom from MAEs : 57% ± 10% at 3 years but 41 patients treated by 10 different combinations of abdominal and chimney grafts Scali et al, J Vasc Surg 2014
Device selection Best performance regarding Freedom from chimney graft compression and gutters area Endurant + Advanta V12 or Excluder + Viabahn Mestres et al, Eur J Vasc Endovasc Surg 2012
Device selection Our experience 10 Endurant + Lifestream (Bard) 9 Nellix + Lifestream (Bard) 0% gutter endoleak
Device selection Our experience 2 InCraft + Lifestream (Bard) Both presenting gutter endoleak postoperatively Both resolved after 1 month
New neck length PROTAGORAS study Seal zone from 4.7mm to 18.7mm Donas et al, J Vasc Surg 2016
New neck length Our experience Cel Tr sevar 2xCh 3xCh Median pre-op proximal neck length: 3mm (range, 1-8 mm) Median neck length after chimney: 21.5 mm (range, 18-38 mm)
Un-avoidable gutters Gutter low flow Endoleaks = Benign Endoleaks? Neck seal length >2 cm seems to help
Graft oversizing Chou et al, J Thorac Cardiovasc Surg 2014
Graft oversizing Generally we prefer 20-30% oversizing Mestres et al, Eur J Vasc Endovasc Surg 2012
Target vessel patency When using Chimneys, you can not really determine the proper graft apposition
Target vessel patency
Target vessel patency Parallel graft compression may be always a serious problem
Target vessel patency For the last 6 months, we always reline with a Sx stent in almost every chimney
Renal cannulation angles Chimneys: more downward renal artery angulation Fenestrations: less downward angulation to the renal arteries Ullery et al, J Endovasc Ther 2015
How many Chimneys? More parallel grafts higher complication rate?
Meticulous planning is mandatory
Meticulous planning is mandatory
Measurements (angulation) Detailed measurements are essential
Detailed measurements are essential Measurements (lenght)
Detailed measurements are essential Separate measurements for TV (LRA)
Optimal C-arm position for every TV
Planning Endurant IIs stent graft (Medtronic) o Main body: o Rt extension: o Lt extension: 36-14 x 103mm 16-10 x 156mm 16-13 x 156mm Life-Stream Peripheral balloon-expandable covered stents (Bard) o 7 x 57 mm (SMA) o 6 x 57 mm (LRA) o 6 x 57 mm (RRA)
All information available in the OR
Great help during the procedure
Great help during the procedure
Great help during the procedure
To get an optimal result
In Conclusion The lessons we learned so far.. Keep vascular access as simple as possible Choose a Bx stent-graft and reline with a Sx Always maintain an adequate proximal neck length Oversize always 20-30% Be patient about gutter endoleaks Have a meticulous planning and back-up solutions
ChEVAR future looks promissing