Pararenal Aortic Thrombus in Patients Undergoing Aortic Aneurysm Repair With Chimney Technique

Introduction: Chimney technique (chimney graft in abdominal aortic aneurysm repair [ChEVAR]) can be used to treat patients with pararenal aortic aneurysm unfit for open surgery and not suitable for custom-made fenestrated endograft. Since almost 1 in 5 patients undergo a reintervention within 3 years, features associated with higher risk of complications need to be investigated to tailor the follow-up schedule to each patient. The aim of our study was to assess the impact of mural thrombus in the pararenal aorta on perioperative and follow-up complications after ChEVAR.Methods: All consecutive patients undergoing ChEVAR at our center from 2015 to 2022 were included in this retrospective study. Collected variables included number of target vessels, stent graft size, presence, and severity of mural thrombus in pararenal aorta, which was reported with a scoring system from 0 to 10 based on thrombus type, thickness area, and circumference Analyzed outcomes included perioperative and follow-up complications.Methods: All consecutive patients undergoing ChEVAR at our center from 2015 to 2022 were included in this retrospective study. Collected variables included number of target vessels, stent graft size, presence, and severity of mural thrombus in pararenal aorta, which was reported with a scoring system from 0 to 10 based on thrombus type, thickness area, and circumference Analyzed outcomes included perioperative and follow-up complications.Results: Thirty-one patients underwent ChEVAR during the study period. In 4 patients the indication for ChEVAR was type 1A endoleak after a previous endovascular aneurysm repair (EVAR). The number of target vessels was 1 in 17 patients (55%), 2 in 12 (39%), 3 in 1 (3%), and 4 in 1 (%). The mean mural thrombus score was 5.9. Complications were the following: type 1A endoleak in 4 cases (13%), chimney stent complications in 7 cases (23%) (including partial or total thrombosis, intrastent stenosis, displacement), renal function worsening during follow-up in 8 cases (26%). Overall survival was 90% at 2 years. Patients with severe mural thrombus showed lower freedom from ChEVAR-related complications (28% vs 59% at 2 years, p=0.023).Conclusions: The presence of severe pararenal aortic mural thrombus was associated with lower freedom from ChEVAR-related complications in patients undergoing ChEVAR for pararenal aortic aneurysm repair. Further research with a larger number of patients is required to confirm these results.Clinical Impact The analysis of severity of mural thrombus in pararenal aorta, which was reported with a scoring system from 0 to 10 based on thrombus type, thickness area and circumference, can be useful and can be represent an important predictor element for complications in patient submitted to Chimney tecnique; in fact the presence of severe pararenal aortic mural thrombus was associated with lower freedom from ChEVAR-related complications in patients undergoing ChEVAR for pararenal aortic aneurysm repair. Then, in patient with pararenal aortic aneurysm, a preoperative evaluation could be focused on severity of mural thrombus to minimize the complications in ChEVAR tecnique or to change the surgical strategy. Visual Abstract