Chimney Thoracic Endovascular Technique

Lesions in the aortic arch or descending aorta can be treated using open or endovascular methods. When the lesion is located close to or involves the supra-aortic branches, treatment becomes more difficult, and hybrid approaches may be necessary. In such cases, debranching must be performed to create an adequate landing zone for the thoracic endograft. The requirement for more than one procedure in hybrid cases makes them less attractive than total endovascular repair with, for example, custom-made branched or fenestrated endografts. The obligatory delay between stages of a hybrid treatment comes with a high cost. With these limitations in mind, the chimney technique was developed as a total, one-stage endovascular solution to treat urgent and acute pathologies with off-the-shelf devices. (See also Chapter 6, Chapter 7, Chapter 8 .)

Procedure

Case Presentation

A 77-year-old woman presented with a contained rupture of an aortic arch aneurysm. A total endovascular repair using the chimney technique was elected. Fig. 16.1 shows the ruptured aortic arch, as well as a lusoria artery (aberrant subclavian artery).

Exposure of left axillary/proximal brachial artery

The patient’s arm was abducted to 90 degrees. The proximal brachial artery was exposed through a 3- to 4-cm longitudinal incision in the groove between biceps and triceps, distally to the attachment of the pectoralis major muscle. The axillary (or proximal brachial) artery was carefully exposed, taking care to avoid injury of the median nerve, and prepared for puncture along its ventral surface. This approach facilitates the use of 7-French (7F) or 8F sheaths. Alternatively, when a single chimney graft is required, a percutaneous approach to the brachial artery in the antecubital fossa can also be performed. We recommend this only with planned placement of bare-metal stents as chimney grafts, since they are compatible with sheaths less than 7F in size.

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