Early experience with the snorkel technique for juxtarenal aneurysms

Abstract

Objective: The lack of readily available branched and fenestrated endovascular aneurysm repair (EVAR) options has created an opportunity for creative deployment of endograft components to treat juxtarenal aneurysms. We present our early experience with "snorkel" or "chimney" techniques in the endovascular management of complex aortic aneurysms. Methods: We retrospectively reviewed planned snorkel procedures for juxtarenal aneurysms performed from September 2009 to August 2011. Our standardized technique included axillary or brachial cutdown for delivery of covered snorkel stents and mostly percutaneous femoral access for the main body endograft. Results: Fifty-six snorkel grafts were successfully placed in 28 consecutive patients (mean age, 75 years) with juxtarenal aneurysms. Mean aneurysm size was 64.8 mm (range, 53-87 mm). The snorkel configuration extended the proximal seal zone from an unsuitable infrarenal neck for standard EVAR (median diameter, 33.5 mm; length, 0.0 mm) to a median neck diameter of 24.5 mm and length of 18.0 mm. Five patients had unilateral renal snorkels, 17 had bilateral renal snorkels, and six had celiac/superior mesenteric artery/renal combinations. Technical success of snorkel placements was 98.2%, with loss of wire access leading to one renal stent deployment failure. Thirty-day mortality was 7.1%: one patient was readmitted 1 week postoperatively with pneumonia and died of sepsis; one patient died at 1 week of a right hemispheric stroke. Other major complications included perinephric hematomas, 7.1%; permanent hemodialysis, 3.6%; iliac artery injury requiring endoconduit placement, 3.6%; and brachial plexus nerve injury, 3.6%. Cardiac complications included self-limited arrhythmias (14.3%) and one non-Q-wave myocardial infarction (3.6%), with all recovering without coronary intervention. Mean follow-up was 10.7 months (range, 3-25 months). One patient died of nonaneurysmalrelated causes at 3 months (89.3% survival). Postoperative imaging revealed one renal snorkel graft occlusion occurring at 3 months (98.2% overall primary patency). Seven (25%) early endoleaks were noted on the first follow-up computed tomography angiography: two type I, three type II, and two type III (25%), leading to one secondary intervention (3.6%) with bridging cuff placement (type III). The small type Ia endoleaks and other type III endoleak resolved at the 6-month scan. Mean sac regression at the latest follow-up was 7.3 mm. No aneurysm has enlarged on postoperative imaging. Conclusions: Early success with the snorkel technique for juxtarenal aneurysms has made it our procedure of choice for complex short-neck to no-neck EVAR. Although long-term follow-up is needed, the flexibility of the snorkel technique and lack of requirement for custom-built devices may make this approach more attractive than branched or fenestrated stent grafts. ( J Vasc Surg 2012;55:935-46.)

Fenestrated stent grafts for the treatment of complex aortic aneurysm disease: A mature treatment paradigm

“…80 The high rate of complications like persistent dialysis and type I or III endoleak were also confirmed in other single-center studies for the chimney procedure (7.1% dialysis and 14% endoleak rate, respectively). 81 …”

Early Experience with the Endowedge Technique and Snorkel Technique for Endovascular Aneurysm Repair with Challenging Neck Anatomy

“…Furthermore, most of previous reports of the SnT used covered stents. 15) Even though we used bare stent for SnT because of availability to insurance in Japan; however, we achieved the good results for exclusion of AAAs without ELs using bare stents. These issues have challenged vascular surgeons to attempt the same approaches for the management of AAAs with challenging neck anatomy in the absence of available devices for FBE.…”

Chimney and Periscope Grafts Observed Over 2 Years After Their Use to Revascularize 169 Renovisceral Branches in 77 Patients With Complex Aortic Aneurysms

“…15,16 On the other hand, CPGs are an alternative way of treating these complex aneurysms and allow the use of offthe-shelf devices to treat emergency cases, patients unfit for thoracoabdominal open surgery, or patients who are not suitable for branched or fenestrated stent-grafts due to anatomical restrictions. 10,[16][17][18][19][20] CPGs have some major advantages over the branched graft techniques. For each aortic branch, the best branch design, chimney or periscope, can be chosen specifically based on the target vessel, the remote access vessel, and the aortic anatomy so that the procedure can be performed without delay.…”