Initial Experience With Covered Endovascular Reconstruction of the Aortic Bifurcation in Conjunction With Chimney Grafts

Abstract

Purpose: To show feasibility of the covered endovascular repair of the aortic bifurcation (CERAB) technique in conjunction with chimney grafts in aortic side branches for complex aortoiliac occlusive disease. Methods: Two European centers and one facility located in New Zealand participated in a retrospective observational study that enrolled 14 consecutive patients (mean age 61.2±8.9 years; 11 men) treated with CERAB in conjunction with chimney graft(s) between December 2012 and May 2015. Indications for treatment included disabling claudication in 9 and critical limb ischemia in 5. Lesions were classified as TransAtlantic Inter-Society Consensus II B (n=1), C (n=1), or D (n=12). Results: A total of 15 chimney grafts were used to perfuse the inferior mesenteric artery (n=8), the right renal artery (n=4), and the left renal artery (n=3). Technical success was achieved in all cases. Procedural complications included 5 unintended dissections and 1 vessel thrombosis, all of which were successfully treated intraoperatively. Five patients developed access-site hematoma/ecchymosis (3 at the brachial access). Mean follow-up was 12 months (range 6–24) without death or loss to follow-up. One patient suffered occlusion of a CERAB limb and an IMA chimney graft; the former was recanalized, but the IMA graft was not; there were no signs of bowel ischemia. Ankle-brachial indices significantly increased from 0.54 (range 0.47–0.60) preoperatively to 0.97 (range 0.90–1.00) in 11 patients examined at 12 months, and all patients had an improvement in the Rutherford category. All CERAB limbs, including the one recanalized, were patent at the most recent follow-up, as were 14 of 15 chimney grafts. Conclusion: Chimney-CERAB is technically feasible and may offer an alternative to open surgery for complex aortoiliac occlusive disease. Further prospective studies are needed to confirm these findings.