January 2021 | Educational Supplement

ChEVAR A practical guide to chimney

technique
endovascular aneurysm repair
(ChEVAR)
essentials

vascularnews.com This educational supplement has been sponsored by Medtronic

Foreword

Dear colleagues, dear readers of Vascular News,

The clinical evidence on the chimney/snorkel technique has flourished
in the last decade, with increasing numbers of key publications and
the release of new data. However, the role of the chimney technique
at different meetings has been secondary and is very often part of
a debate on other therapeutic options. During the COVID-19 period, it has been
possible to focus on evidence and standardisation of the procedure. In this Vascular
News supplement, we will highlight clinical and scientific aspects that will provide
relevant, practical advice for readers in order to optimise results and to help in the
decision-making process of potential patients with inadequate neck anatomies
suitable for chimney endovascular aneurysm repair (ChEVAR).
I am delighted to present to you a supplement in which we include input from various
experts on the chimney technique from all over Europe. I hope you enjoy reading this
supplement and that you find this information will help to optimise the performance of
the chimney technique in your practice.
Konstantinos P Donas is professor of vascular surgery,
Yours, head of the Department of Vascular Surgery, and
director of the Research Centre at Asklepios Clinic
Konstantinos P Donas Langen, Göthe-University Frankfurt, Langen, Germany.

Contents:
3: From a bailout procedure to a 8: H
 ow ChEVAR changed my practice
standardised therapeutic option: with inadequate infrarenal
Ten-year anniversary of the first publication sealing zones, Antonio Giménez Gaibar
of abdominal use of ChEVAR in
 ase report: Complex symptomatic
8-9: C
symptomatic patients, Giovanni Torsello
aortoiliac aneurysm: ChEVAR is the
4-5: Patient selection: Insights from the solution, Sébastien Déglise &
PROTAGORAS 2.0 study regarding Celine Deslarzes-Debuis
adequate preoperative sizing and
10-11: L
 atest clinical evidence
planning, Stefano Fazzini
on ChEVAR:
6: The procedure step by step: Which are What is next? Gergana T Taneva
the critical moments and what should be
avoided? Konstantinos Donas
7: How ChEVAR changed our approach in
hostile AAA necks,
Cornelis JJM Sikkink & Lee H Bouwman

All rights reserved. Published by BIBA Publishing, London T:+44 (0)20 7736 8788, publishing@bibamedical.com.
The opinions expressed in this supplement are solely those of Medtronic and the featured physicians and may not reflect the views of Vascular News.

2 UC202113392EE January 2021

Evolution
From a bailout procedure
to a standardised therapeutic
option: Ten-year anniversary
from the first publication of the
abdominal use of ChEVAR in
symptomatic patients
In this article, Giovanni Torsello tracks the evolution of the chimney endovascular
aneurysm repair (ChEVAR) procedure, and how it has developed from a “mere
bailout solution” to a “standardised complimentary approach” in the treatment of
juxtarenal abdominal aortic aneurysm (AAA).
IN 2003, ROY GREENBERG AND
colleagues reported their first ChEVAR
experience in the Journal of Vascular
Surgery.1 This technique, originally born as a
bailout solution for emergent situations, has
grown in popularity in recent years. Different
parallel graft methods (chimney/snorkel,
periscope, sandwich) have been developed
for the treatment of complex infrarenal,
juxtarenal, suprarenal, thoracoabdominal,
and aortic arch pathologies.2 These off-the-
shelf solutions have been adopted in many
centres worldwide. However, the preliminary
reported results were heterogeneous.
While Ohrlander, Hiramoto, and Donas3–5
reported excellent outcomes in terms of
30-day mortality and type I endoleak, higher
morbidity and mortality have been described
by other authors.6 The reasons for diverging
results were the small number of patients
included in single-centre cohorts, the wide
variety of treated entities, and the varying
device combinations used.
In order to better understand the value of
the technique in different aortic pathologies,
and also for standardisation of the procedure,
thirteen European and American investigators
pooled their experience with 517 cases
treated by ChEVAR in the PERICLES
registry.
An initial point of concern was the high
rate of intraoperative type Ia endoleak.
In PERICLES,7 the type Ia endoleak rate
was 7.9% on completion angiography and
decreased to 2.9% by the first postoperative
computed tomography angiography (CTA),
demonstrating that the majority of ChEVAR
gutter endoleaks can be expected to resolve
spontaneously. The evaluation of the
remaining persistent endoleaks were detected
in patients with an insufficient length of
the new proximal seal zone. Another key
factor associated with a high risk of type
Ia endoleak was stent graft oversizing of
less than 20%.8 The type Ia endoleak rate
January 2021
in this patient group was 14.3%
compared to 2.1% in cases with
30% oversizing. A higher rate
of gutter-related endoleaks and
low oversizing was found also
in patients treated in low volume
centres (<20 patients treated per
year), showing that experience Giovanni Torsello
plays an important role in the
outcome of this procedure.8
Another important merit of the PERICLES
study is the demonstration that the materials
play a paramount role when avoiding gutters.9
Unpublished data presented at the LINC
Mount Sinai 2017 Endovascular Symposium
(13–14 June, New York, USA) show that
the frequency of this complication was 3.4
times greater in patients treated with stainless
steel endoskeleton compared to nitinol
devices. This finding was confirmed by the
PROTAGORAS study,10 showing excellent
results if the flexible Endurant™ endograft
(Medtronic) is combined with high-radial
force balloon-expandable chimney stent
grafts (Advanta™ V12, Getinge). The data
have demonstrated the importance of specific
device combinations to achieve good results,
not only in terms of endoleak reduction, but
also in chimney occlusion-free survival. Both
The ENCHANT
registry will
provide reliable
data on ChEVAR
performance.”
complications are rare when nitinol-polyester
endografts are used. The choice of bridging
stent is also important in order to reduce
additional use of relining stents, which is
associated with significantly worse stent
patency (p=0.014).
ChEVAR essentials
In this context, PERICLES also
demonstrated that the risk of stent instability
rises as the number of chimney stent grafts
used increases. However, recent data
show comparable good results in multiple
chimneys when technical details are
observed.11
Another point of discussion is the stroke
risk after ChEVAR. This complication is
related to the antegrade cannulation of the
renal and visceral vessels. The use of bilateral
upper extremity access was found to be an
independent predictor factor associated with
a 2.8-fold increased risk for postoperative
stroke.12 Using a single-arm access point
(e.g. left upper extremity) can reduce the
stroke risk after ChEVAR procedures. In case
of multiple chimneys, retrograde
cannulation and periscope
implantation of one or two
chimneys can be an alternative,
avoiding catheter manipulation at
the level of the aortic arch. Further
studies are necessary to validate
the technique.
References
1. Greenberg RK, et al. Should patients with challenging
anatomy be offered endovascular aneurysm repair? J Vasc
Surg 2003; 38: 990–996.
2. Kansagra K, Kang J, Taon MC, et al. Advanced endografting
techniques: snorkels, chimneys, periscopes, fenestrations,
and branched endografts. Cardiovasc Diagn Ther 2018;
8(Suppl 1): S175–S83.
3. Ohrlander T, Sonesson B, Ivancev K, et al. The chimney graft:
a technique for preserving or rescuing aortic branch vessels
in stent-graft sealing zones. Endovasc Ther 2008 Aug; 15(4):
427–32. doi: 10.1583/07-2315.1
4. Hiramoto JS. Commentary: Multiple chimney grafts for
total endovascular revascularization of the visceral arteries
in the setting of ruptured TAAA: Inventive but let’s wait for
the smoke to clear on this one. J Endovasc Ther 2010; 17:
222–223.
5. Donas KP, Pecoraro F, Torsello G, et al. Use of covered
chimney stents for pararenal aortic pathologies is safe
and feasible with excellent patency and low incidence of
endoleaks. J Vasc Surg 2012; 55(3): 659–65.
6. Coscas R, Kobeiter H, Desgranges P, Becquemin JP.
Technical aspects, current indications, and results of chimney
grafts for juxtarenal aortic aneurysms. J Vasc Surg 2011 Jun;
53(6): 1520–7. doi: 10.1016/j.jvs.2011.01.067. Epub 2011
Apr 22.
7. Donas KP, Lee JT, Lachat M, et al. Collected world experience
about the performance of the snorkel/chimney endovascular
technique in the treatment of complex aortic pathologies:
the PERICLES registry. Ann Surg 2015; 262(3): 546–53;
discussion 52–3.
8. Donas KP, Usai MV, Taneva GT, et al. Impact of aortic stent-
graft oversizing on outcomes of the chimney endovascular
technique based on a new analysis of the PERICLES registry.
Vascular 2019; 27: 175–180.
9. Scali ST, Beck AW, Torsello G, et al. Identification of optimal
device combinations for the chimney endovascular aneurysm
repair technique within the PERICLES registry. J Vasc Surg
2018; 68(1): 24–35.
10. Donas KP, Torsello GB, Piccoli G, et al. The PROTAGORAS
study to evaluate the performance of the Endurant stent
graft for patients with pararenal pathologic processes
treated by the chimney/snorkel endovascular technique. J
Vasc Surg 2016; 63(1):1–7.
11. Taneva GT, Donas KP, et al. Results of chimney
endovascular aneurysm repair as used in the PERICLES
Registry to treat patients with suprarenal aortic pathologies.
J Vasc Surg 2020 May; 71(5): 1521–1527.e1.
12. Bosiers MJ, Tran K, Lee JT, et al. Incidence and prognostic
factors related to major adverse cerebrovascular events
in patients with complex aortic diseases treated by the
chimney technique. J Vasc Surg 2018; 67(5): 1372–9.
Giovanni Torsello is a vascular surgeon
at the Institute for Vascular Research, St
Franziskus Hospital in Münster, Germany.
UC202113392EE 3
Key data
Patient selection: Insights
from the PROTAGORAS 2.0
study regarding adequate
preoperative sizing and
planning
Stefano Fazzini highlights key findings of the recently-published PROTAGORAS
2.0 study, concluding “aortic stent graft oversizing should be considered the most
important parameter for optimal ChEVAR [chimney endovascular aneurysm repair]
planning”.
RECENTLY, THE CHEVAR
procedure was included in the European
Society for Vascular Surgery (ESVS) 2019
guidelines for the treatment of juxtarenal
abdominal aortic aneurysms (jAAA), as an
alternative to fenestrated EVAR (FEVAR) in
urgent settings and/or hostile anatomies (e.g.
angulated aortic neck, narrow and calcified
iliac access).
Despite the tremendous evolution of
ChEVAR in the last decade, in terms of
important publications (such as PERICLES
and PROTAGORAS) and worldwide
spread, the gutter-related endoleak (type Ia
endoleak) is still considered the Achilles’
heel of the technique by many authors.
One of the reasons for this perception is
the concerning results comparing ChEVAR
with FEVAR, showing that the former
has a higher rate of late type Ia endoleak.
Some authors have suggested that new
research should focus on improvements in
the preoperative planning, in order to avoid
significant divergent experiences with this
approach.
As a bailout and not-standardised
procedure, ChEVAR cannot be compared
with FEVAR in terms of preoperative
planning, because many challenging
anatomical aspects must be taken into
account with ChEVAR.
At the same time, physicians performing
ChEVAR should be dealing with urgent
cases and hostile anatomies.
The new era of the ChEVAR technique,
named ‘standardisation’, could be realised
by easy/customised planning and an ideal
chimney–graft combination.
Most of the published data have been
evaluated by in vitro experiences focusing
on gutter-related endoleaks and chimney
graft compression, which is supposed to
influence flow profile and may induce a risk
of stent thrombosis.
To overcome the technical bias of in vitro
4 UC202113392EE
studies (silicon models with one standard
chimney graft morphology), we decided to
analyse a homogeneous cohort of patients
with single/double chimney grafts involving
only one device combination: the Medtronic
Endurant stent graft combined with a
balloon-expandable stent graft (Advanta
V12, Getinge). This choice allowed us to
evaluate many challenging anatomies, such
as a hostile neck (reverse tapered, angulated)
and access (narrowed and calcified).
We performed a computed tomography
angiography (CTA)-based evaluation of a
10-year Münster experience with ChEVAR.
With PROTAGORAS 2.0 (European
Journal of Vascular and Endovascular
We advise an
oversizing of
30–40% to avoid
persistent type
Ia endoleaks and
likewise to ensure
chimney graft
patency.”
Surgery, article in press) for the first
time, a single parallel graft combination
was evaluated using late outcomes and
CTA-based pre/postoperative imaging in
order to identify significant predictors to
optimise sizing and prevent persistent type
Ia endoleaks and chimney grafts stenosis/
occlusion.
A recommended new range for main graft
sizing, a new composite parameter (L-OS),
and the concept of lost neck are the main
elements of novelty for ChEVAR planning.
A central finding of this study was that a
main graft oversizing between 30 and 40%
(Figure 1) was significantly associated with
a freedom from type Ia endoleak-related
reintervention, without compromising
primary chimney graft patency. Wide necks
(>29mm) were significantly related to type
Ia endoleaks having a mean oversizing of
less than 20%; inversely, narrow diameters
(<20mm) were significantly related to
chimney graft stenosis/occlusion caused by
excessive oversizing of more than 50%.
The mean diameter of sealing zone
(three aortic cross-sections of total neck
length) should be taken into consideration
in order to select the aortic stent graft
diameter (Figure 2). In contrast to the actual
recommendations of
20–30%, the optimal
main graft oversizing
seems to be higher, at
around 30%. In fact,
oversizing of at least
30–35% should be
used for single and
double chimneys,
respectively.
Stefano Fazzini The turbulence
of blood flow at
the level of the gutters should induce a
spontaneous resolution of flow, proportional
to the length and inversely proportional
to the gutter area. Despite this general
belief, a total neck length >20mm could
not guarantee the sealing of early and late
endoleaks in this study, if the oversizing was
not adequate.
In the present analysis, oversizing was the
only significant independent parameter to
prevent late type Ia endoleak. The presence
of infrarenal neck was the only factor
preventing type Ia endoleaks; in the case of
no infrarenal neck, an oversizing of more
than 35% would be needed to minimise the
risk of persistent gutters.
Another novelty of our research was the
presentation of a new composite parameter
(L-OS: total neck length [mm] + oversizing
[%]) in order to reflect more accurately the
successful preoperative planning. It could
be a useful tool for uncertain cases (the
choice of stent graft sizing leading to a wide
gap of oversizing, e.g. 32/36mm resulting
in 23/38% oversizing for a neck diameter
of 26mm) to find a compromise between
a short neck and aggressive oversizing,
single or double chimney grafts. An L-OS
range of 55–65 was significantly related to
freedom from persistent type Ia endoleak
and primary chimney graft patency.
Considering that we treated 86% of
hostile necks, the higher ranges (OS>35 and
L-OS>60) could be indicated for double
January 2021
 ChEVAR essentials

chimney grafts and hostile parameters as

pararenal neck or infrarenal angulation >60
degrees (Figure 3).
An additional finding of the current
study was the estimation of the lost neck,
considering that the ideal and available total
neck length is not always achieved; even in
the case of very precise deployment, some
amount of neck (mean of 3mm) could be
lost during the procedure, caused by the
presence of the sheaths in place and/or very
angulated anatomy.
Finally, the association between these
two devices, the most used in the published
literature, seems to result in optimal clinical
outcomes, combining the flexibility of
Endurant stent grafts and high patency
rate of Advanta V12. Our imaging-based
analysis confirm the benefit of the high
conformability at the level of the transition
zone between the aortic neck and the
Figure 1. Key parameters for sizing of ChEVAR procedures with single/double chimney proximal portion of the aneurysm, thanks
grafts. to short M-shaped stents of Endurant stent
grafts.
Our experience suggests that aortic stent
graft oversizing should be considered the
most important parameter for optimal
ChEVAR planning. The total neck length
seems not effective to guarantee the
sealing without an adequate oversizing.
In conclusion, as far as the usage of the
Endurant stent graft and Advanta V12
is concerned, we advise an oversizing of 30–
40% to avoid persistent type Ia endoleaks
and likewise to ensure chimney graft
Figure 2. Aortic neck
patency. In case of double chimney grafts
diameter is measured as and/or hostile neck features, greater degrees
the mean of three aortic of oversizing should be planned. A 20–
cross-sections of the 25mm total neck length should be suggested
sealing zone (proximal, considering the amount of lost neck, higher
middle, distal segment). in angulated anatomies. The pararenal and
wide necks seem to be the main risk factors
for endoleaks.

Stefano Fazzini is a researcher and vascular

surgeon in the Department of Vascular and
Endovascular Surgery at “Tor Vergata”
University of Rome in Rome, Italy.

Figure 3. The easy customisation for ChEVAR sizing. The main hostile neck parameters are
considered pararenal, angulated (>60°), hostile shape (reverse tapered), and calcified (>50%)
neck.

January 2021 UC202113392EE 5

Procedure guide
The procedure step by
step: Which are the critical
moments and what should
be avoided?
In this step-by-step guide, Konstantinos P Donas outlines the chimney
endovascular aneurysm repair (ChEVAR) technique from access to further
treatment considerations, detailing various crucial moments and offering a range of
tips and tricks to ensure a successful procedure.
THE CHEVAR TECHNIQUE
is demanding and requires
advanced endovascular skills.
It involves a minimum of two
access points: femoral and
an upper extremity. Femoral
access can be completed in a
percutaneous fashion. One or both
upper extremities, preferably the
left side, are accessed dependent
on the number of chimney grafts Konstantinos P
planned. A preoperative computed Donas
tomography angiography (CTA)
of the thoracic aorta and the subclavian
arteries is paramount in order to exclude
the presence of soft plaques and thrombotic
lesions, which can lead to stroke or
embolisation of the visceral arteries.
An open approach to the axillary artery
is utilised in the majority of cases. We gain
proximal and distal control of the axillary
artery, and single or double puncture of the
vessel can be performed at a distance of
1–2cm. After changing the short 5F sheaths
for 90cm 7F sheaths, we perform a selective
catheterisation of the involved target vessels.
Here is the first critical periprocedural
moment; the sheath followed by the chimney
graft should be advanced in the target vessels
only over a stiff wire with an atraumatic
curved tip. Particularly where there is
friction or stenosis of the orifice of the target
vessels, there is a risk of injury to the kidney
parenchyma when using stiff wires with stiff
tips.
Once the selected branches have wires in
place, the aortic endograft is deployed and,
subsequently, each chimney graft should
have the proximal edge in the middle of
the suprarenal stent of the aortic endograft,
extending at least 10–15mm inside the target
vessel. Angulated renal arteries are at risk of
severe stenosis and kinking of the chimney
grafts, in the case of deep placement and
involvement of the angulated segment of
the renal arteries. Additional deployment
of flexible nitinol stents or covered stents
6 UC202113392EE
increases the risk of occlusions
due to the placement of more
material in a small (6mm or less)
target vessel.
The second critical moment is
to deploy the chimney graft in
the middle of the suprarenal stent
of the abdominal device (Figures
1–3). The chimney graft should
be protected and not be in contact
with the pins of the suprarenal
stent. In the removal of the
balloon of the chimney graft after
deployment in particular, the sheath should
be below or just at the level of the pins of the
suprarenal stent, protecting the balloon of
the chimney graft from the pins in order to
avoid the risk of trapping the balloon with the
suprarenal pins of the abdominal device.
The next crucial moment is to perform
The ChEVAR
technique is
demanding and
requires advanced
endovascular skills.”
kissing ballooning between the aortic stent
graft and the chimney graft at the end of the
procedure. This manoeuvre is very important
because it improves the conformability of the
abdominal device and the chimney grafts.
Here it is crucial to deflate the balloon of
the chimney graft only after the complete
deflation of the balloon in the aortic stent
graft. Otherwise, there is a risk of creating a
stenosis of the chimney graft, which is not
per se crush resistent from the balloon of the
aortic stent graft if the balloon of the chimney
graft is deflated first.
The next crucial moment during the
procedure is the reaction of the physician in
case of type Ia endoleak at the completion
Figure 1. There is a risk of complication
from trapping the sheath with the pins of the
suprarenal stent.
Figure 2. There is a risk of capturing the
balloon of the chimney graft with the pins.
Figure 3. The ideal position of the sheath,
protecting the balloon from the pins, for
when we decide to remove the balloon.
angiography. How aggressive should further
treatment be; should we deploy a cuff;
should we use endoanchors or not? The main
rationale for the decision is to admit that type
Ia endoleaks caused by the gutters is common
during the procedure. The question is, which
case will need additional treatment and which
case will undergo radiological surveillance?
Preoperative planning is key to the
eradication of potential gutter-related
endoleaks. As clarified in the previous article
from Fazzini, aggressive oversizing of
30% in single chimneys and 35% in double
chimneys, and a new seal zone of at least
20mm in length, are important considerations
in preoperative planning. Within these
parameters, any gutter-related endoleak at the
completion angiography will dissapear in the
in-hospital CTA.
Konstantinos P Donas is professor of
vascular surgery, head of the Department
of Vascular Surgery, and director of the
Research Centre at Asklepios Clinic Langen,
Göthe-University Frankfurt, Langen,
Germany.
January 2021
Experience ChEVAR essentials

How ChEVAR changed our approach in

hostile AAA necks
Cornelis JJM Sikkink and Lee H Bouwman detail how chimney endovascular aneurysm repair (ChEVAR) has changed
their approach in hostile abdominal aortic aneurysm (AAA) neck management, summarising that a standardised approach
has been a key factor to ensure procedural success.

CHEVAR HAS BEEN PRESENT IN in urgent cases and possibility of gaining

endovascular specialists’ armamentarium for when fenestrated a long suprarenal
many years, but has always been relegated to repair is unfeasible or sealing zone with
a bailout option due to lack of a standardised contraindicated. a relatively easy
approach reflected in contradicting published In our institution, approach compared
evidence. Further resistance to the technique we started to adopt to use of a four-
was due to concerns regarding gutters and ChEVAR because fenestrated stent
intraoperative endoleaks. we were regularly graft. We feel that
The PERICLES study helped to confronted with this technique is
clarify multiple aspects, such as the patients with short Cornelis JJM Sikkink Lee H Bouwman of particular value
spontaneous resolution of gutter endoleaks and hostile necks, in patients with
when oversizing and new sealing zone who were not ideal candidates for open infrarenal aortic necks between 3–8mm in
requirements are correctly applied. surgical repair. We wanted an easy off-the- length.
Additionally, multiple benchmodel studies shelf alternative in cases with inadequate In conclusion, in our experience the
have reported Endurant (Medtronic) and infrarenal sealing zones where EVAR was chimney technique remains an effective
Advanta V12 (Getinge) to morphologically not feasible and fenestrated EVAR (FEVAR) complementary alternative modality in
adapt well to each other, reducing gutter areas was excluded due to anatomical or logistical inadequate infrarenal sealing zones and a
and minimising stent compression.1–3 factors, for instance in semi-emergency standardised approach has been a key factor
Further contribution to a standardised cases. Although not determinative, economic to ensure ChEVAR success.
approach was achieved in 2016, when factors are also evident. The main advantages
Medtronic received CE mark for the we see, compared to custom-made solutions, References
1. Donas KP, Usai MV, Taneva GT, et al. Impact of aortic stent-
Endurant II/IIs stent graft system to treat are the immediate availability, fewer access graft oversizing on outcomes of the chimney endovascular
patients with AAA using ChEVAR, based on problems due to the smaller profile, and the technique based on a new analysis of the PERICLES registry.
Vascular 2019; 27: 175–180.
the clinical findings of the PROTAGORAS 2. Donas KP, Lee JT, Lacaht M, et al. Collected world

trial.4 The ongoing ENCHANT multicentre
prospective trial is set to add further robust
evidence that might support future therapy
guidelines.
At our hospital, we are participating in the
We feel that
experience about the performance of the snorkel/chimney
endovascular technique in the treatment of complex aortic
this technique
pathologies: the PERICLES registry. Ann Surg 2015; 262:
546–553.
3. Mestres G, Uribe JP, Garcia-Madrid C, et al. The best
is of particular value conditions for parallel stenting during EVAR: an in vitro study.
Eur J Vasc Endovasc Surg 2012; 44: 468–473.

in the patients with

ENCHANT trial and have enrolled several
patients over the last three years. Early results
of these patients are promising but more
4. Donas KP, Torsello GB, Piccoli G, et al. The PROTAGORAS
study to evaluate the performance of the Endurant stent graft
for patients with pararenal pathologic processes treated by
infrarenal aortic the chimney/snorkel endovascular technique. J Vasc Surg
2016; 63: 1–7.

long-term outcomes are desired. necks between

3–8mm in length.”
To be noted, 2019 AAA treatment Cornelis JJM Sikkink and Lee H Bouwman
guidelines from the European Society for are vascular surgeons at the Zuyderland
Vascular Surgery now recommend ChEVAR Medical Center in Heerlen, The Netherlands.

Figure 1. CT angiogram of a patient with a Figure 2. Final intraoperative angiogram, Figure 3. 3D reconstruction, four weeks after
hostile neck 7mm long. with patent renal stents and the stent graft the procedure; patent vessels/stents, no
just below the SMA. endoleak.

January 2021 UC202113392EE 7

Experience

How ChEVAR changed my and/or visceral vessels require coverage, and

thus the number of snorkel grafts needed.

practice with inadequate

A sealing ring below the chimney grafts
would be desirable for technical success. Our
hypothesis is that owing to this sealing ring,

infrarenal sealing zones the gutters run blind and produce thrombosis.
Furthermore, a discrepant origin of the two
renal arteries would be advisable to indicate
Antonio Giménez Gaibar discusses his team’s positive experience with chimney ChEVAR.
endovascular aneurysm repair (ChEVAR), and highlights future research that might Published results confirm that ChEVAR
introduce further evidence in support of the technique. can be applied in a variety of clinical
situations with a high degree of technical
success. It has been established as a useful,
EVAR IS A MINIMALLY INVASIVE challenging iliac artery access. safe, and effective technique for cases
method for treating infrarenal abdominal Our team started using ChEVAR in not suitable for the current commercially
aortic aneurysms (AAAs), especially for high-risk patients for open surgery with available branched or fenestrated devices
patients with severe comorbidities. However, short neck and inadequate sealing zone for and it provides an immediate off-the-shelf
between 30–40% of patients are unsuitable standard EVAR. As a rule of thumb, we solution. We believe that the ongoing
anatomic candidates for conventional EVAR, applied 20–30% oversizing in all cases, ENCHANT trial may introduce further
mostly due to a challenging proximal aortic with a tendency to oversize closer to 30%, evidence to support this technique.
neck anatomy. as suggested by the most recent evidence,
Several endovascular techniques have in cases requiring more than one chimney. Antonio Giménez Gaibar is director of
been proposed to ensure a secure proximal Balloon-expandable covered stents have been the Department of Vascular Surgery at
landing zone in AAA with hostile necks. The used as chimney grafts. The length of the the Hospital Universitari Parc Tauli in
conceptual basis for these complex cases proximal landing zone dictates which renal Barcelona, Spain.
involves cranial extension of the proximal
seal zone with preservation of branch vessel
patency. ChEVAR and fenestrated (FEVAR)
or branched EVAR (BEVAR) are most
commonly used.
One advantage of ChEVAR is its
immediate availability. Before the approval
of custom fenestrated devices by the US
Food and Drug Administration (FDA) in
2012, homemade fenestrated and chimney
techniques were developed to treat urgent
or bailout-type interventions with an all-
endovascular procedure. This technique can
currently be used to treat AAAs with short
necks, type Ia endoleaks after EVAR, as well
as juxtarenal and pararenal endovascular
repairs. It is also recommended when
FEVAR/BEVAR would entail unacceptable
cost, manufacturing delays, or for patients
deemed unsuitable for custom-made devices, Figure 1. a, b: Preoperative CT-scan AAA with hostile neck anatomy; c, d: Postoperative one-
especially in tortuous aortic anatomy or in month CT-scan.

Case report: Sébastien Déglise and Celine

Deslarzes-Dubuis outline a case
Case
A 68-year-old man known for cardiac
Complex study involving the successful use of
chimney endovascular aneurysm repair
insufficiency, atrial fibrillation, hypertension,
strokes, and active smoking, presented to the
symptomatic (ChEVAR). In the discussion of their
experience, Déglise and Deslarzes-
Emergency Department with abdominal and
back pain.
aortoiliac Dubuis note that, despite many
advantages, ChEVAR continues to
The computed tomography angiography
(CTA) scan revealed signs of perianeurysmal
aneurysm: face “high resistance,” and argue that
“choice of the technique should be
fat infiltration and fast growth of a known
juxtarenal abdominal aortic aneurysm from
ChEVAR is the dictated more by the patient, the clinical
circumstances, and the anatomical
32 to 50mm. Due to his frailty related to
severe comorbidities, open surgery was
solution characteristics rather than by personal
beliefs”.
contraindicated. However, the presence of
a short conical neck with circumferential
thrombus (Figure 1) precluded any standard

8 UC202113392EE January 2021


endovascular aneurysm repair (EVAR). The
suprarenal aorta was healthy and could offer
a good proximal sealing zone. Moreover,
the distal landing zone was complex, with
occlusion of the left internal iliac artery and a
25mm distal common right iliac artery. Both
accesses were suitable for EVAR. Given the
thrombotic and conical neck anatomy, it was
decided to seal above the renal arteries by
doing a ChEVAR. Indeed, fenestrated EVAR
(FEVAR) could not be considered due to
the acute symptoms of a pre-rupture state
in this patient. We opted for an iliac branch
device on the right side due to an ectatic
iliac artery and the risk of further dilatation
due to a bell-bottom stent graft. Regarding
the chimneys, two BeGraft covered balloon-
expandable stents of 6 and 7mm in diameter
(Bentley InnoMed) were placed in each renal
artery from a left axillary approach using two
separate 7F Destino™ Twist long deflectable
steerable guiding sheaths (Oscor) parallel
to the 32mm Endurant IIs (Medtronic)
mainbody. An iliac branch device (IBD) was
then placed on the right side and another
BeGraft covered stent was deployed in the
right hypogastric artery form the left upper
access. One Endurant II (Medtronic) limb
extension was used as a bridge between the
main body and the IBD and another was
placed on the left side in order to seal in the
external iliac artery. Completion angiogram
showed neither any gutter nor any other
endoleaks. The chimneys were widely open,
as well as the iliac branch device (Figure
2). Patient had an uneventful recovery and
follow-up CTA confirmed the good initial
results with an excluded aneurysm, no
endoleaks, and patent chimneys (Figure 3).
January 2021
Discussion
The chimney technique made itself known as
a bailout procedure to save covered arterial
branches during EVAR. With growing
experience, the ChEVAR technique made
a name for itself among the years thanks to
various advantages. In 2015, the PERICLES
registry offered the first world evidence of
excellent and robust results of this technique
in patients with complex aneurysm anatomy.
However, the durability of this technique
remained a matter of debate mainly because
of gutter endoleaks. The PERICLES
investigators, however, found that those
gutters were benign and disappeared on the
first postoperative CTA in the majority of the
patients with the respect of a 30% oversizing
and a >20mm new sealing zone. The next
step in the development of this strategy was
the CE mark that Medtronic obtained in 2016
with its Endurant II/IIs system combined
with balloon-expandable covered stents.
Despite numerous well-known advantages,
like its off-the-shelf availability and the
fact that it does not require many resources,
ChEVAR continues to face high resistance,
especially among FEVAR supporters.
However, these two strategies have to be
considered as complementary rather than
in opposition. The choice of the technique
should be dictated more by the patient, the
clinical circumstances, and the anatomical
characteristics rather than by personal beliefs.
In our case, many parameters spoke in favour
of ChEVAR. The first point to take into
consideration was the presence of symptoms
leading to an emergent intervention
precluding the use of any custom-made
device. One could argue that an off-the-
ChEVAR essentials
Figure 1. a: Infrarenal conical neck
with circumferential thrombus; b: 3D
reconstruction showing infrarenal angulation
and downward left renal artery.
Figure 2. Intraoperative images showing the
two chimneys with the Endurant IIs device
(a) and completion angiogram (b).
Figure 3. a: Postoperative 3D-CTA showing
ChEVAR and IBD on the right with patent
chimneys; b. absence of any gutter
endoleaks.
shelf multibranch stent graft could solve
this problem, but with an increased zone of
aortic coverage and therefore a higher risk
of spinal cord ischaemia and its potential
devastating consequences. Indeed, ChEVAR
allows for sealing in a healthy zone of aorta
but with as minimal coverage as possible.
Another point was the relatively steep
trajectory of the left renal artery associated
with some degree of angulation of the aorta.
In these circumstances, precise deployment
of a fenestrated stent graft and cannulation
of the target vessel from below through
the fenestration could be very challenging.
This was not the case from above for the
left chimney, especially when using a
deflectable, steerable sheath. Finally, the
technical configuration of the Endurant II/
IIs system allows for an easy combination
with others components, such as an IBD, to
ensure an optimal final result. All of these
advantages led the European Society for
Vascular Surgery (ESVS) to recommend the
ChEVAR technique in urgent cases when
a fenestrated procedure is contraindicated
in their recently published abdominal
aortic aneurysm treatment guidelines. The
ongoing international multicentre prospective
ENCHANT trial will add knowledge and
further evidence to consolidate the role of the
ChEVAR technique in complex aneurysms
management.
Sébastien Déglise and Celine Deslarzes-
Dubuis are vascular surgeons at the
University Hospital of Lausanne (CHUV) in
Lausanne, Switzerland.
UC202113392EE 9
E-learning
Latest clinical
evidence on
ChEVAR: What
is next?
Writing that clinical evidence on
chimney endovascular aneurysm repair
(ChEVAR) has “flourished” in the last
decade, Gergana T Taneva highlights
key elements of the most recent
research on the technique.
CHEVAR HAS SHOWN comparable
results to fenestrated EVAR (FEVAR) for
the treatment of juxtarenal abdominal aortic
aneurysms (jAAA).1–3 The clinical evidence
on ChEVAR has flourished in the last
decade, with an increasing number of key
publications released within recent years.4–8
ChEVAR has gained popularity to the
point that its role within the AAA treatment
algorithm is considered complementary
depending on a patient’s characteristics
and aortoiliac anatomy.9 However, cost-
10 UC202113392EE
effectiveness issues, long-term outcomes,
and procedural tips such as the deal with
angulated renal arteries remain unknown.
In this context, we present an overview of
the latest evidence and publications on these
appealing topics (Table 1).
1. Widely spoken of and much needed, a
cost analysis and comparison of both
techniques, ChEVAR and FEVAR,
was performed, evaluating all elective
and symptomatic patients treated at
St Franziskus Hospital in Münster,
Germany, for jAAA by single or double
chimney (n=111) or by FEVAR with three
fenestrations (n=37) between 2013 and
January 2017.10 The cost-effectiveness
analysis was defined as the summary
of material costs, in-hospital costs,
and additional costs due to procedure-
related reinterventions. Index procedure
and hospitalisation median costs were
higher for FEVAR (€42,116 vs. €22,171,
p<0.001). The median overall costs,
including costs after reinterventions during
follow-up, remain higher for FEVAR
(€42,128 vs. €22,872, p<0.001) for a
follow-up period of almost four years.10
Six patients (5.4%) in the ChEVAR group
required readmission compared to three
patients (8.1%) who required readmission
for reinterventions in the FEVAR group
(p=0.69). Both FEVAR and ChEVAR
proved to be expensive and technically-
demanding interventions for the
treatment of juxtarenal aortic pathologies.
However, ChEVAR was significantly
more cost-effective compared to FEVAR
at comparable readmission rates for
reinterventions.11
2. Also highly-anticipated, and extension of
the follow-up and long-term evaluation
of the multicentric PERICLES Registry
was performed analysing clinical and
radiographic data from patients treated
with ChEVAR between 2008 and 2014.12 A
subgroup of 244 patients with 387 chimney
grafts placed and follow-up of at least
30 months was used to analyse specific
anatomic and device predictors of adverse
events. In the subgroup, the technical
success was 88.9%, while primary patency
was 94%, 92.8%, 92%, and 90.5% at
two-and-a-half years, three years, four
years, and five years, respectively. Mean
aneurysm sac regression was 7.8±11.4mm,
p<0.0001. Chimney graft occlusion
occurred in 24 target vessels (6.2%).
Late open conversion was required in
January 2021
Future research ChEVAR essentials

five patients for endograft
infection (n=2), persistent
type 1a endoleak (n=2), and
endotension (n=1). This
analysis of the PERICLES
Registry provided the missing
long-term experience on the
ChEVAR technique. It showed
favourable results with over
half of the patients surviving
for more than five years. Up Gergana T Taneva
to 48 months’ follow-up, the
stented vessels remained patent in over
92% of the cases. The absence of infrarenal
neck and a proximal sealing zone diameter
>30mm were significantly associated with
long-term device-related complications and
with poorer outcomes in terms of persistent
type 1a endoleak. The evidence advocated
the anatomical limits of the technique,
demanding adequate preoperative planning
and indication.
3. The cause of much speculation, chimney
graft lining in the case of highly angulated
renal arteries was evaluated as a risk factor
for occlusion. Lining for deployment of
an additional stent and smoothening the
transition in a branched vessel are normally
performed when the distal part of the
chimney graft is seen within an angulated
segment of the target vessel. Typically,
an additional bare metal nitinol stent is
placed to improve the flexibility and even
the transition. In order to minimise the
reduction of the patent lumen by deploying long-term performance evidence of the
an additional device, we preferred the use
of bare metal instead of covered stents.
Cost-effectiveness
analysis of
Topic chimney/snorkel
versus fenestrated
endovascular repair
J Cardiovasc Surg
Journal
(Torino)
Year of publication 2020
To investigate the outcomes, we research is paramount to expand and confirm
evaluated all elective patients the cited findings.
treated at St Franziskus Hospital
in Münster, Germany, over nine References
1. Taneva GT, Criado FJ, Torsello G, Veith F. Results of chimney
years (January 2009–December endovascular aneurysm repair as used in the PERICLES
2017) with placement of Advanta Registry to treat patients with suprarenal aortic pathologies
2014: 1–8. Doi: 10.1016/j.jvs.2019.08.228.
V12 (Getinge) as chimney 2. Donas KP, Lee JT, Lachat M, et al. Collected world experience
about the performance of the snorkel/chimney endovascular
graft in combination with the technique in the treatment of complex aortic pathologies:
Endurant stent graft (Medtronic) The PERICLES registry. Ann Surg 2015; 262(3): 546–52. Doi:
10.1097/SLA.0000000000001405.
as abdominal endograft.13 A total 3. Ronchey S, Fazzini S, Scali S, et al. Collected transatlantic
of 116 patients were included, experience from the PERICLES Registry: Use of chimney
grafts to treat post-EVAR type Ia endoleaks shows good
with lining performed in 43 midterm results 2018. Doi: 10.1177/1526602818782941.
vessels for 32 patients. Lining was not 4. Ballesteros-Pomar M, Taneva GT, Austermann M, et al.
Successful management of a type B gutter related endoleak
performed to increase the radial force of after chimney EVAR by coil assisted onyx embolisation.
EJVES Short Reports 2019; 42: 38–42. Doi: 10.1016/j.
the covered stents. The subgroup analysis ejvssr.2018.12.002.
revealed significantly higher primary 5. Bosiers MJ, Tran K, Lee JT, et al. Incidence and prognostic
factors related to major adverse cerebrovascular events in
patency within the non-lined group patients with complex aortic diseases treated by the chimney
(96.9%) at one year versus the lined group technique. J Vasc Surg 2018; 67(5): 1372–9. Doi: 10.1016/j.
jvs.2017.08.079.
(77.1%; p=0.001).13 Lining represented 6. Donas KP, Criado FJ, Torsello G, et al. Classification
a risk factor for chimney graft occlusion of chimney EVAR-related endoleaks: Insights from the
PERICLES Registry. J Endovasc Ther 2017; 24(1): 72–4. Doi:
(odds ratio 9.9; p=0.006).13 This single- 10.1177/1526602816678994.
7. Torsello G, Usai MV, Scali S, et al. Gender-related outcomes
centre nine-year ChEVAR experience of chimney EVAR within the PERICLES Registry. Vascular
with more than 110 Advanta V12 chimney 2018; 26(6): 641–6. Doi: 10.1177/1708538118797448.
8. Donas KP, Usai MV, Taneva GT, et al. Impact of aortic
stents showed durable results. However, stent-graft oversizing on outcomes of the chimney
lining in angulated renal arteries showed endovascular technique based on a new analysis of the
PERICLES Registry. Vascular 2019; 27(2): 175–80. Doi:
a significantly higher risk for chimney 10.1177/1708538118811212.
graft occlusion.13 These data highlight the 9. Donas KP, Eisenack M, Panuccio G, et al. The role of
open and endovascular treatment with fenestrated and
importance of finding new ways to achieve chimney endografts for patients with juxtarenal aortic
aneurysms. J Vasc Surg 2012; 56(2): 285–90. Doi: 10.1016/j.
better conformability of the stent grafts jvs.2012.01.043.
within the target vessel. 10. Taneva GT, Donas KP, Pitoulias GA, et al. Cost-effectiveness
analysis of chimney/snorkel versus fenestrated endovascular
The presented clinical evidence contributes repair for high-risk patients with complex abdominal aortic
to broaden the global knowledge on the pathologies. J Cardiovasc Surg 2019. Doi: 10.23736/S0021-
9509.19.11146-9.
chimney technique, clarifying several major 11. Taneva GT, Donas KP, Pitoulias GA, et al. Cost-effectiveness
issues such as cost comparison with FEVAR, analysis of chimney/snorkel versus fenestrated endovascular
repair for high-risk patients with complex abdominal aortic
pathologies. J Cardiovasc Surg (Torino) 2019; 60(0): 1–6.
Doi: 10.23736/S0021-9509.19.11146-9.
largest related registry, and the issue of lining 12. Taneva GT, Lee JT, Tran K, et al. Long-term chimney/snorkel
contributing to stent graft occlusion. Further EVAR experience for complex abdominal aortic pathologies
within the PERICLES Registry. J Vasc Surg 2020;(S0741-
5214(20)32496-4). Doi: 10.1016/j.jvs.2020.10.086.
13. Taneva GT, Fazzini S, Pipitone MD, et al. Use of stainless-
Use of balloon- steel , balloon-expandable chimney grafts is durable
expandable chimney though caution is required when lining angulated renal
Long-term chimney arteries. J Endovasc Ther 2020; 27(6): 902–9. Doi:
grafts is durable,
EVAR experience 10.1177/1526602820948260.
though caution is
within the
required when lining Gergana T Taneva is a vascular surgeon at
PERICLES registry
angulated renal
arteries
the University Hospital Puerta de Hierro in
Madrid, Spain, and research leader of the
Research Centre at Asklepios Clinic Langen,
J Vasc Surg J Endovasc Ther Göthe-University Frankfurt,
Langen, Germany.
2020 2020

ChEVAR was ChEVAR showed

significantly more favourable long- Lining represented a
Main findings cost-effective term patency and risk factor for chimney
at comparable patient survival graft occlusion
reintervention rates rates

Table 1. Overview of the latest evidence and publications on cost-effectiveness issues,

long-term outcomes, and lining of chimney stent grafts.

The content of these articles is meant for general information purposes only and should not be construed as a promotion or solicitation for any product or for an indication for any product which
is not authorized by the laws and regulations of the country where the reader resides. The views and opinions expressed therein should be interpreted as personal views. They are completely
independent and do not necessarily reflect the opinions of Medtronic. As a health care provider, you should use your own professional judgment in evaluating the information provided and rendering
any medical opinion or advice. Your use of and any reliance on such information is solely at your own risk and responsibility. Medtronic makes no representation or warranty, express or implied,
including any warranty of accuracy, completeness, or usefulness of any information described in these articles and Medtronic assumes no liability for the use of the information in any manner
whatsoever.
See the device manual for information regarding the instructions for use, indications, contraindications, warnings, precautions, and potential adverse events.

January 2021 UC202113392EE 11