In Vitro Quantification of Gutter Formation and Chimney Graft Compression in Chimney EVAR Stent-Graft Configurations Using Electrocardiography-Gated Computed Tomography

Abstract

Purpose: To assess the dynamic behavior of chimney grafts during the cardiac cycle. Methods: Three chimney endovascular aneurysm repair (EVAR) stent-graft configurations (Endurant and Advanta V12, Endurant and Viabahn, and Endurant and BeGraft) were placed in silicone aneurysm models and subjected to physiologic flow. Electrocardiography (ECG)-gated contrast-enhanced computed tomography was used to visualize geometric changes during the cardiac cycle. Endograft and chimney graft surface, gutter volume, chimney graft angulation over the center lumen line, and the D-ratio (the ratio between the lengths of the major and minor axes) were independently assessed by 2 observers at 10 time points in the cardiac cycle. Results: Both gutter volumes and chimney graft geometry changed significantly during the cardiac cycle in all 3 configurations (p<0.001). Gutters and endoleaks were observed in all configurations. The largest gutter volume (232.8 mm³) and change in volume (20.7 mm³) between systole and diastole were observed in the Endurant-Advanta configuration. These values were 2.7- and 3.0-fold higher, respectively, compared to the Endurant-Viabahn configuration and 1.7- and 1.6-fold higher as observed in the Endurant-BeGraft configuration. The Endurant-Viabahn configuration had the highest D-ratio (right, 1.26–1.35; left, 1.33–1.48), while the Endurant-BeGraft configuration had the lowest (right, 1.11–1.17; left, 1.08–1.15). Assessment of the interobserver variability showed a high correlation (intraclass correlation >0.935) between measurements. Conclusion: Gutter volumes and stent compression are dynamic phenomena that reshape during the cardiac cycle. Compelling differences were observed during the cardiac cycle in all configurations, with the self-expanding (Endurant–Viabahn) chimney EVAR configurations having smaller gutters and less variation in gutter volume during the cardiac cycle yet more stent compression without affecting the chimney graft surface.

Keywords

abdominal aortic aneurysm aneurysm diameter aneurysm model cardiac cycle chimney graft endograft dynamic computed tomography ECG-gated computed tomography endoleak endovascular aneurysm repair flow model gutter in vitro study self-expanding stent-graft stent compression stent-graft volume

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References

Jongkind

Yeung

Akkersdijk

GJM

et al . Juxtarenal aortic aneurysm repair. J Vasc Surg. 2010;52:760–767.

Bastos Gonçalves

Hoeks

Teijink

et al . Risk factors for proximal neck complications after endovascular aneurysm repair using the Endurant stentgraft. Eur J Vasc Endovasc Surg. 2015;49:156–162.

Zarins

Bloch

Crabtree

et al . Stent graft migration after endovascular aneurysm repair: importance of proximal fixation. J Vasc Surg. 2003;38:1264–1272.

Suominen

Pimenoff

Salenius

. Fenestrated and chimney endografts for juxtarenal aneurysms: early and midterm results. Scand J Surg. 2013;102:182–188.

Resch

Sonesson

Dias

et al . Chimney grafts: is there a need and will they work? Perspect Vasc Surg Endovasc Ther. 2011;23:149–153.

Katsargyris

Oikonomou

Klonaris

et al . Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift? J Endovasc Ther. 2013;20:159–169.

Moulakakis

Mylonas

Dalainas

et al . The chimney-graft technique for preserving supra-aortic branches: a review. Ann Cardiothorac Surg. 2013;2:339–346.

Zhang

Guo

et al . Endovascular chimney technique for juxtarenal abdominal aortic aneurysm: a systematic review using pooled analysis and meta-analysis. Ann Vasc Surg. 2015;29:1141–1150.

Overeem

Boersen

Schuurmann

RCL

et al . Classification of gutter type in parallel stenting during endovascular aortic aneurysm repair. J Vasc Surg. 2017;66:594–599.

10.

Scali

Feezor

Chang

et al . Critical analysis of results after chimney endovascular aortic aneurysm repair raises cause for concern. J Vasc Surg. 2014; 60:865–873.

11.

Donas

Torsello

Piccoli

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;63:1–7.

12.

Iezzi

Di Stasi

Dattesi

et al . Proximal aneurysmal neck: angiography conformational pulsatile changes with possible consequences for endograft sizing. Radiology. 2011;260:591–598.

13.

van Keulen

Moll

Barwegen

et al . Pulsatile distension of the proximal aneurysm neck is larger in patients with stent graft migration. Eur J Vasc Endovasc Surg. 2010;40:326–331.

14.

de Bruin

Yeung

Niepoth

et al . Geometric study of various chimney graft configurations in an in vitro juxtarenal aneurysm model. J Endovasc Ther. 2013;20:184–189.

15.

Parodi

Berguer

Ferreira

et al . Intra-aneurysmal pressure after incomplete endovascular exclusion. J Vasc Surg. 2001;34:909–914.

16.

Lehmkuhl

Andres

Lücke

et al . Dynamic CT angiography after abdominal aortic endovascular aneurysm repair: influence of enhancement patterns and optimal bolus timing on endoleak detection. Radiology. 2013;268:1–7.

17.

Iezzi

Cotroneo

Filippone

et al . Multidetector-row computed tomography angiography in abdominal aortic aneurysm treated with endovascular repair : evaluation of optimal timing of delayed phase imaging for the detection of low-flow endoleaks. J Comput Assist Tomogr. 2008;32:609–615.

18.

Groot Jebbink

Mathai

Boersen

et al . Hemodynamic comparison of stent configurations used for aortoiliac occlusive disease. J Vasc Surg. 2017;66:251.e1–260.e1.

19.

Yousif

Holdsworth

Poepping

. A blood-mimicking fluid for particle image velocimetry with silicone vascular models. Exp Fluids. 2011;50:769–774.

20.

Lanne

Bergqvist

Bengtsson

et al . Diameter and compliance in the male human abdominal aorta: influence of age and aortic aneurysm. Eur J Vasc Surg. 1992;6:178–184.

21.

van Herwaarden

Bartels

Muhs

et al . Dynamic magnetic resonance angiography of the aneurysm neck: conformational changes during the cardiac cycle with possible consequences for endograft sizing and future design. J Vasc Surg. 2006;44:22–28.

22.

Patel

Katsargyris

Verhoeven

et al . Endovascular aortic aneurysm repair with chimney and snorkel grafts: indications, techniques and results. Cardiovasc Intervent Radiol. 2013;36:1443–1451.

23.

Bosiers

Donas

Mangialardi

et al . European multicenter registry for the performance of the chimney/snorkel technique in the treatment of aortic arch pathologic conditions. Ann Thorac Surg. 2016;101:2224–2230.

24.

Ullery

Itoga

Tran

et al . Natural history of type Ia gutter endoleaks after snorkel/chimney EVAR. J Vasc Surg. 2017;65:981–990.

25.

Moll

Powell

Fraedrich

et al . Management of abdominal aortic aneurysms clinical practice guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg. 2011;41(suppl 1):S1–S58.

26.

Bastos Gonçalves

Verhagen

Vasanthananthan

et al . Spontaneous delayed sealing in selected patients with a primary type-Ia endoleak after endovascular aneurysm repair. Eur J Vasc Endovasc Surg. 2014;48:53–59.

27.

Lachat

Veith

Pfammatter

et al . Chimney and periscope grafts observed over 2 years after their use to revascularize 169 renovisceral branches in 77 patients with complex aortic aneurysms. J Endovasc Ther. 2013;20:597–605.

28.

Mestres

Uribe

García-Madrid

et al . The best conditions for parallel stenting during EVAR: an in vitro study. Eur J Vasc Endovasc Surg. 2012;44:468–473.

29.

Tessarek

. BeGraft peripheral stent design and technical aspects. Paper presented at: LINC Congress 2016; January 27, 2016; Leipzig, Germany. https://linc2016.cncptdlx.com/media/1235_Joerg_Tessarek_27_01_2016_Room_5___Global_Expert_Exchange.pdf. Accessed February 6, 2018.

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