Treatment of complex aortic aneurysms with fenestrated endografts and chimney stent repair: Systematic review and meta-analysis

Abstract

Objective

We reviewed data pertaining to fenestrated endograft technique and chimney stent repair of complex aortic aneurysm for comparative analysis of the outcomes.

Methods

A comprehensive search of relevant databases was conducted to identify articles in English, related to the treatment of complex aortic aneurysm with fenestrated endovascular aneurysm repair and chimney stent repair, published until January 2015.

Results

A total of 42 relevant studies and 2264 patients with aortic aneurysm undergoing fenestrated endovascular aneurysm repair and chimney stent repair were included in our review. A total of 4413 vessels were involved in these processes. The cumulative 30-day mortality was 2.4% and 3.2% (p = 0.459). The follow-up aneurysm-related mortality was 1.4% and 3.2% (p = 0.018), and target organ dysfunction was 5.0% and 4.0% in fenestrated endovascular aneurysm repair and chimney stent repair, respectively (p = 0.27). A total of 156 vessels showed restenosis or occlusion after primary intervention (3.6% and 3.4% in fenestrated endovascular aneurysm repair and chimney stent repair, respectively, p = 0.792). The cumulative type I endoleak was 2.0% (38/1884) after fenestrated endovascular aneurysm repair compared with 3.4% (13/380) after chimney stent repair (p = 0.092), and the type II endoleak was 5.4% (102/1884) and 5.3% (20/380), respectively (p = 0.905). Approximately, 1.1% and 1.6% increase in aneurysm was observed following fenestrated endovascular aneurysm repair and chimney stent repair, respectively (p = 0.437). The re-intervention frequency was 205 and 19 cases after fenestrated endovascular aneurysm repair and chimney stent repair, respectively (11.7%, 5.6%, p = 0.001).

Conclusions

Fenestrated endovascular aneurysm repair and chimney stent repair are safe and effective in treating patients with complex aortic aneurysm. A higher aneurysm-related mortality was observed in chimney stent repair while fenestrated endovascular aneurysm repair was associated with a higher re-intervention rate.

Keywords

Vascular intervention vascular aorta grafts meta-analysis

Introduction

Endovascular aneurysm repair (EVAR) was first published in 1994 by Parodi¹ and has since been recognized as a standard method for treatment of infra-renal abdominal aortic aneurysms (AAA). Complex aortic aneurysm (CAA) is a type of aortic aneurysm affecting visceral arteries, including the renal, the celiac trunk and the superior and inferior mesenteric arteries. Newer techniques such as fenestrated EVAR (F-EVAR) and chimney stent repair (Ch-EVAR) raise the possibility of successful treatment of juxta-, para- and supra-renal aneurysms.^2,3 We reviewed the literature reporting F-EVAR and Ch-EVAR of CAA for comparative analysis of the outcomes.

Methods

Eligibility criteria

A feasible protocol was established for the meta-analysis in advance, and the review was developed, accordingly. We formulated the inclusion criteria on the basis of participants, interventions, comparisons, outcomes, study design and time principle⁴: (1) trials with patients afflicted with CAA involve renal, celiac trunk, superior or inferior mesenteric arteries; (2) interventions included F-EVAR or Ch-EVAR; (3) trials with outcomes of technical success, death, patency, complications and re-intervention and (4) published in English before January 2015.

Trials containing one of the following conditions were excluded: (1) concomitant aneurysms of other arteries; (2) non-endovascular intervention; (3) less than five patients or average follow-up less than six months; (4) inability to extract intact data and (5) trials involving the brachiocephalic artery.

Search strategy and study selection

We performed a systematic search according to the PRISMA statement,⁵ including PubMed, Embase, CENTRAL, Ovid and other pertinent databases. We also searched the relevant systematic reviews published previously as supplements. We used aortic aneurysm and chimney or aortic aneurysm and fenestration as keywords, searching in English and Chinese, until January 2015. A single author screened the studies by title and abstract for inclusion. Identified articles were assessed independently by another author to confirm their eligibility. Studies eligible for full-text review were reviewed by two independent reviewers for inclusion in the analysis.

Data abstract

Data extraction form was designed according to the Cochrane handbook,⁶ and tested in one trial randomly, for improvement. Two authors extracted data independently, revised the data entry using EpiData software (ver. 3.1), checked for consistency and negotiated with the third party in case of ambiguity. The major data extracted included: (1) article information: first author, study types, year of publication, country, follow-up time, capacity and vessels involved; (2) participant profile: gender, age, comorbidities and classification of vessels and (3) outcomes: technical success, 30-day mortality, aneurysm-related mortality, target organ dysfunction, vascular restenosis or occlusion, endoleak, aneurysm growth and re-intervention.

Quality assessment and statistical analysis

Quality of the study was assessed with the Cochrane collaboration’s tool for assessing risk of bias.⁷ Seven aspects including the random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias were assessed and documented by two reviewers, independently. The data were negotiated with the third party in case of ambiguity. RevMan software (ver. 5.3) was used for risk of bias summary.

In the meta-analysis, we used the RevMan software (ver. 5.3) to complete heterogeneity test in pair-wise comparisons, and I² was selected as the quantitative test index.⁸ When I² was greater than 50%, a random effects model⁹ was used for data merging; otherwise, a fixed effect model was used. The odds risk ratios (OR) and 95% confidence intervals (CI) represented the effect magnitude. In the systematic review, characteristics and outcomes were pooled, respectively, and compared using the Pearson’s or Fisher’s exact test. Statistical significance was defined at the level of p < 0.05; all P values were two sided. Calculations were performed using SPSS software (version 18.0).

Results

Study selection

A total of 1474 studies were searched with matching keywords, duplicates were removed, records screened and full-text articles assessed. Finally, 42 studies matched the criteria and included in the review (Figure 1). The earliest study was published in 2001 and the latest in 2014.

Figure 1.

Study selecting flow diagram.

Study data

A total of 25 studies of F-EAVR, 13 studies of Ch-EVAR and 4 studies containing both were included in our review. Ten of these studies represent prospective trials (eight in F-EVAR studies, two in Ch-EVAR) and the rest were retrospective trials. Thirty-three single arm studies (F-EVAR 21, Ch-EVAR 12) with 2264 patients (F-EVAR 1884, Ch-EVAR 380) and 4413 vessels (F-EVAR 1884, Ch-EVAR 380) were included. The mean follow-up time was 18.07 months in F-EVAR and 16.12 months in Ch-EVAR. A meta-analysis of four trials comparing F-EVAR with Ch-EVAR was performed. The bias of these trials is shown in Figure 2. The basic data of the 42 studies are shown in Tables 1 and 2. Most of the trials included patients at high risk for open repair and contraindicated for conventional endovascular repair.

Figure 2.

Risk of bias summary.

Table 1.

Overview of the C-EVAR studies.

		Type	Arms	Cases	Vessels	Follow-up
1	Anderson et al.¹⁰	Retrospective	1	13	33	3–24
2	O’Neill et al.¹¹	Prospective	1	119	302	19
3	Semmens et al.¹²	Retrospective	1	58	116	16.8
4	Ziegler et al.¹³	Retrospective	1	60	119	23
5	Scurr et al.¹⁴	Retrospective	1	45	117	24
6	Greenberg et al.¹⁵	Prospective	1	30	77	24
7	Amiot et al.¹⁶	Retrospective	1	134	403	15
8	Verhoeven et al.¹⁷	Retrospective	1	100	275	24
9	Donas et al.¹⁸	Prospective	3	29	44	13.2
10	British Society for Endovascular Therapy and the Global Collaborators on Advanced Stent-Graft Techniques for Aneurysm Repair (GLOBALSTAR) Registry¹⁹	Retrospective	1	318	889	6
11	Canavati et al.²⁰	Retrospective	2	53	160	/
12	Perot et al.²¹	Retrospective	2	115	/	24
13	Guo et al.²²	Retrospective	1	9	26	7.6
14	Holden et al.²³	Prospective	1	15	/	24
15	Quinones-Baldrich et al.²⁴	Prospective	1	31	/	24
16	Kitagawa et al.²⁵	Prospective	1	16	64	4.3
17	Katsargyris et al.²⁶	Prospective	1	26	74	26.8
18	Suominen et al.²⁷	Prospective	2	21	60	24
19	Kristmundsson et al.²⁸	Retrospective	1	54	134	67
20	Grimme et al.²⁹	Retrospective	1	138	392	13
21	Unno et al.³⁰	Retrospective	1	5	17	8.6
22	Rolls et al.³¹	Prospective	1	13	35	8.1
23	Hertault et al.³²	Retrospective	2	288	/	25
24	Banno et al.³³	Retrospective	2	80	194	14
25	Silverberg et al.³⁴	Retrospective	1	9	34	16
26	Liao et al.³⁵	Retrospective	1	8	21	6
27	Dijkstra et al.³⁶	Retrospective	1	25	56	11
28	Vemuri et al.³⁷	Retrospective	2	57	120	1.76
29	Lee et al.³⁸	Retrospective	2	15	25	6
	Total/mean	–	–	1884	3787	18.07

Table 2.

Overview of the C-EVAR studies.

		Type	Arms	Cases	Vessels	Follow-up
1	Ohrlander et al.³⁹	Retrospective	1	6	11	2–24
2	Hiramoto et al.⁴⁰	Retrospective	1	29	31	19.6
3	Donas et al.⁴¹	Retrospective	1	15	15	6.8
4	Bruen et al.⁴²	Retrospective	2	21	37	12
5	Coscas et al.⁴³	Retrospective	1	16	26	10.5
6	Lee et al.⁴⁴	Retrospective	1	28	56	10.7
7	Donas et al.¹⁸	Prospective	3	30	38	15.2
8	Schiro et al.⁴⁵	Retrospective	1	9	9	12
9	Tolenaar et al.⁴⁶	Retrospective	1	13	22	10.8
10	Liu et al.⁴⁷	Retrospective	1	5	6	15.8
11	Suominen et al.²⁷	Prospective	2	7	11	22
12	Lachat et al.⁴⁸	Retrospective	1	77	169	25
13	Ducasse et al.⁴⁹	Retrospective	1	22	22	18
14	Banno et al.³³	Retrospective	2	38	60	12
15	Igari et al.⁵⁰	Retrospective	1	8	12	11
16	Lee et al.³⁸	Retrospective	2	15	25	6
17	Scali et al.⁵¹	Retrospective	1	41	76	18.2
	Total/mean	–	–	380	626	16.12

Characteristics

F-EVAR

The mean age was 73.56 years, including 707 males (37.5%, 1884). Of the 29 studies, 27 provided data pertaining to comorbidities including 52.17% (946/1813) with coronary artery disease (CAD), 15.89% (288/1813) with diabetes mellitus (DM), 69.50% (1260/1813) with hypertension, 18.59% (337/1813) with dyslipidemia, 24.16% (438/1813) with renal insufficiency (RI) and 31.50% (571/1813) with chronic obstructive pulmonary disease (COPD). Twenty-three studies provided details of vessels treated: Of the total 3583 vessels, 2248 renal arteries were treated, accounting for 62.7%. The celiac trunk artery (CTA) accounted for the proportion of 7.3%, and the superior mesenteric artery (SMA) accounted for 26.2% of the total vessels treated (3583), while no inferior mesenteric artery was treated in F-EVAR.

Ch-EVAR

The mean age was 74.34 years, and 80.3% (305/380) were males. Only one study failed to provide the data pertaining to comorbidities. Among the 374 patients included in this study, 64.97% (243) afflicted with CAD, 8.29% (31) with DM, 52.40% (196) with hypertension, 35.29% (132) with dyslipidemia, 21.12% (79) with RI and 39.30% (147) with COPD. All studies contained intact data of the treated vessel. The renal artery accounted for 81.6% (511/626), the CTA accounted for 4.8% (30/626) and the SMA for 13.4% (84/626). A single inferior mesenteric artery was involved in Ch-EVAR.

All the characteristics showed significant differences between F-EVAR and Ch-EVAR, except for RI (p = 0.208) and inferior mesenteric artery (p = 0.149) (Table 3).

Table 3.

Characteristics of patients in each groups.

	F-EVAR	C-EVAR	P value
Age (year-old)	73.56	74.34
Male	37.5% (707/1884)	80.3% (305/380)	<0.001
Comorbidities
CAD	52.17% (946/1813)	64.97% (243/374)	<0.001
DM	15.89% (288/1813)	8.29% (31/374)	<0.001
Hypertension	69.50% (1260/1813)	52.40% (196/374)	<0.001
Dyslipidemia	18.59% (337/1813)	35.29% (132/374)	<0.001
RI	24.16% (438/1813)	21.12% (79/374)	0.208
COPD	31.50% (571/1813)	39.30% (147/374)	0.003
Vessels involved
RA	62.7% (2248/3583)	81.6% (511/626)	<0.001
CTA	7.3% (262/3583)	4.8% (30/626)	0.022
SMA	26.2% (940/3583)	13.4% (84/626)	<0.001
IMA	0% (0/3583)	0.2% (1/626)	0.149

F-EVAR: fenestrated EVAR; Ch-EVAR: chimney stent repair; CAD: coronary artery disease; DM: diabetes mellitus; RI: renal insufficiency; COPD: chronic obstructive pulmonary disease; RA: renal artery; CTA: celiac trunk artery; SMA: superior mesenteric artery; IMA: inferior mesenteric artery.

Outcomes

F-EVAR

The technical success rate was 98.2% for target vessels, with 68 vessels resulting in failure. The cumulative 30-day mortality was 2.4%, with 47 death during this period. Twenty-nine deaths included seven multi-organ failures, nine cases of myocardial infarction, six cases of intestinal ischemia, three cases of septic shock, two cases of arteriorrhexis (renal and iliac artery) and two major strokes. During the follow-up, 27 patients (1.4%) died from aneurysm, including four from ruptured aneurysm, eight from intestinal ischemia, one from aortoduodenal fistula, one from iliac in stent thrombosis, one from infection of the prosthesis and one from mycotic aneurysm. There were 38 cases (2.0%) of type I and 102 cases (5.4%) of type II endoleak. Five percent (185/3658) of patients showed target organ dysfunction including kidney, spleen and intestine; 3.6% (135/3787) of vascular restenosis or occlusion and 1.1% (20/1811) of patients with aneurysms showed increased vessel diameter. With these complications, 205 (11.7%) patients underwent secondary intervention. Twenty studies reported common complications including 63 cardiac, 16 cerebral and 33 respiratory.

Ch-EVAR

Except for a higher technical success rate of 99.5% (623/626) compared with F-EVAR, Ch-EVAR was associated with a higher 30-day mortality and aneurysm-related mortality. Thirty-three cases of endoleak included 13 (3.4%) type I and 20 (5.3%) type II. Twenty-five patients showed target organ dysfunctions with 21 vessels occluded. Nineteen (5.6%) patients underwent secondary procedure. In addition to the major complications, four cardiac, one respiratory and six cerebral complications were observed. Compared with the F-EVAR group, significant differences in technical success, aneurysm-related mortality and re-intervention rate were observed between the two interventions (Table 4).

Table 4.

Outcomes of patients in each groups.

	F-EVAR	Ch-EVAR	P value
Technical success	98.2% (3810/3878)	99.5% (623/626)	0.028
30-day mortality	2.4% (47/1884)	3.2% (12/380)	0.459
Aneurysm-related mortality	1.4% (27/1884)	3.2% (12/380)	0.018
Type I endoleak	2.0% (38/1884)	3.4% (13/380)	0.092
Type II endoleak	5.4% (102/1884)	5.3% (20/380)	0.905
Target organ function impaired	5.0% (185/3658)	4.0% (25/626)	0.27
Vessels restenosis/ occluded	3.6% (135/3787)	3.4% (21/339)	0.792
Aneurysm growth	1.1% (20/1811)	1.6% (6/380)	0.437
Re-intervention	11.7% (205/1746)	5.6% (19/380)	0.001

Meta-analysis

Four trials^18,27,33,38 were included in the meta-analysis. The outcomes of technical success, 30-day mortality, types I and II endoleaks, target organ dysfunction, vascular restenosis/occlusion and re-intervention were analyzed (Figure 3). The results showed no significant differences between F-EVAR and Ch-EVAR (P > 0.05). The heterogeneity test indicated no discordance between the trials except for target organ dysfunction. The results support F-EVAR in 30-day mortality and type I endoleak, with an OR of 0.94 [0.25, 3.55] and 0.62 [0.10, 3.93], respectively. The results favored Ch-EVAR in technical success, type II endoleak, target organ dysfunction, vascular restenosis/occlusion and re-intervention, with an OR of 0.39 [0.07, 2.26], 1.25 [0.48, 3.28], 2.21 [0.11, 44.40], 1.02 [0.29, 3.52] and 1.51 [0.74, 3.10], respectively.

Figure 3.

Forest plot of F-EVAR vs. Ch-EVAR. (a) Forest plot for technical success; (b) forest plot for 30-day mortality; (c) forest plot for type I endoleak; (d) forest plot for type II endoleak; (e) forest plot for target organ function impaired; (f) forest plot for vessels restenosis/occluded and (g) forest plot for re-intervention.

Discussion

Standard EVAR represented an alternative to AAA for years,⁵² with proven success.⁵³ However, it was only appropriate for infra-renal AAA with a long neck. The option for para-renal, thoracic or juxta-renal AAA was unclear. For patients with complex AAA contraindicated for open surgery, F-EVAR and Ch-EVAR offer fewer invasive options.⁵⁴ F-EVAR uses fenestrations (holes) in the graft to access visceral arteries to enable extension of the graft sealing zone to an adequate, more proximal, landing zone incorporating the visceral vessels. Fenestrations are sealed with a covered stent into the target vessels. Newer techniques include the use of preloaded cannulating wires, double reducing ties and an enlarged proximal scallop. Ch-EVAR uses a covered stent parallel to the proximal graft to preserve the flow to visceral vessels without specially designed holes in the graft, which are stented to obtain an adequate seal. Studies have already compared the outcome of these two types of technique. Our review updated the comparative CAA data.

No randomized controlled trials (RCTs) compared F-EVAR and Ch-EVAR. We included 15 studies published in 2014, and 82.6% articles published in the last five years. Several prospective studies were reviewed, and population-based studies conducted. The characteristics of two groups differ from each other, with the mean vessels number treated by F-EVAR and Ch-EVAR at 1.9 and 1.6. The F-EVAR group treated more vessels per patient, and more number of patients accepted CTA and SMA fenestration (7.3% vs. 4.8% and 26.2% vs. 13.4%). The results suggest that the condition of aneurysm in F-EVAR group is more complex than in Ch-EVAR group, which may increase the difficulty in stent placement and impact the technical success rate.

The Ch-EVAR showed a better technical success rate than F-EVAR (99.5%, 98.2%, p = 0.028), with the difference probably related to technological challenges, operator skill, condition of the aneurysm and the target vessel. Based on the success rate, the outcome of re-intervention rate was 11.7% and 5.6%, respectively (p = 0.001), with F-EVAR associated with a higher re-intervention rate due to the more complex condition of aneurysms and difficulties with the fenestration techniques. Further, Ch-EVAR showed a higher aneurysm-related mortality than F-EVAR (3.2%, 1.4%, p = 0.018), with a similar mortality reported in previous single systematic reviews.^17,55,56 Ch-EVAR is indicated for emergent intervention involving ruptured AAA, due to its higher technical success and lower re-intervention rate.

In F-EVAR, customized fenestrated grafts were inappropriate due to the long wait times. Home-made grafts were characterized by their off-the-shelf properties. However, no trials or analyses compared the advantages and disadvantages. In the F-EVAR trials included, we found that 26 out of 29 trials used the customized graft and three trials used off-the-shelf graft. Most of the trials used company-manufactured grafts, such as Zenith Cook device, and few home-made grafts were reported. For comparison of these two grafts, more trials with larger sample capacity were needed to highlight any statistically significant differences in outcomes.

The results of meta-analysis support Ch-EVAR in terms of technical success and re-intervention rates, consistent with the systematic review, although without any significant differences.

The limitations: (1) the outcome acquired under inconsistent base line; (2) no subgroup analysis; (3) failed to estimate the increased of bias even though the techniques used in the trials were not compared or analyzed and (4) higher levels of evidence such as RCTs are needed to corroborate our findings.

Conclusions

F-EVAR and Ch-EVAR are safe and effective in treating patients with CAA. No significant differences were seen between F-EVAR and Ch-EVAR in 30-day mortality, target organ dysfunction, target vessel occlusion or development of aneurysms. A higher aneurysm-related mortality in Ch-EVAR was observed. The F-EVAR was associated with a higher re-intervention rate than Ch-EVAR. Further evidence based on controlled clinical trials with a longer follow-up is needed to analyze the different outcomes.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Our review is supported by National Nature Science Foundation of China (81070256, 81100226).

References

Parodi

. Endovascular repair of abdominal aortic aneurysms and other arterial lesions. Surg Technol Int 1994; 3: 431–436.

Lachat

Frauenfelder

Mayer

. Complete endovascular renal and visceral artery revascularization and exclusion of a ruptured type IV thoracoabdominal aortic aneurysm. J Endovasc Ther 2010; 17: 216–220.

Brechtel

Ketelsen

Endisch

. Endovascular repair of acute symptomatic pararenal aortic aneurysm with three chimney and one periscope graft for complete visceral artery revascularization. Cardiovasc Intervent Radiol 2012; 35: 413–417.

Liu

. On-site quality control of acupuncture randomized controlled trial: design of content and checklist of quality control based on PICOST. Zhongguo Zhen Jiu 2014; 34: 183–185.

Moher

Altman

Liberati

. PRISMA statement. Epidemiology 2011; 22: 128–128.

Higgins J and Green S (eds). Cochrane handbook for systematic reviews of interventions Version 5.1.0 [updated March 2011] [EB/OL]. The Cochrane Collaboration, www.cochrane-handbook.org (2011, accessed 8 January 2016).

Higgins

Altman

Gotzsche

. The Cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928–d5928.

Higgins

Thompson

. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21: 1539–1558.

Dersimonian

Laird

. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177–188.

10.

Anderson

Berce

Hartley

. Endoluminal aortic grafting with renal and superior mesenteric artery incorporation by graft fenestration. J Endovasc Ther 2001; 8: 3–15.

11.

O’Neill

Greenberg

Haddad

. A prospective analysis of fenestrated endovascular grafting: intermediate-term outcomes. Eur J Vasc Endovasc Surg 2006; 32: 115–123.

12.

Semmens

Lawrence-Brown

Hartley

. Outcomes of fenestrated endografts in the treatment of abdominal aortic aneurysm in Western Australia (1997–2004). J Endovasc Ther 2006; 13: 320–329.

13.

Ziegler

Avgerinos

Umscheid

. Fenestrated endografting for aortic aneurysm repair: a 7-year experience. J Endovasc Ther 2007; 14: 609–618.

14.

Scurr

Brennan

Gilling-Smith

. Fenestrated endovascular repair for juxtarenal aortic aneurysm. Br J Surg 2008; 95: 326–332.

15.

Greenberg

Sternbergh

Makaroun

. Intermediate results of a United States multicenter trial of fenestrated endograft repair for juxtarenal abdominal aortic aneurysms. J Vasc Surg 2009; 50: 730–737.

16.

Amiot

Haulon

Becquemin

. Fenestrated endovascular grafting: the French multicentre experience. Eur J Vasc Endovasc Surg 2010; 39: 537–544.

17.

Verhoeven

Vourliotakis

Bos

. Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: an 8-year single-centre experience. Eur J Vasc Endovasc Surg 2010; 39: 529–536.

18.

Donas

Eisenack

Panuccio

. The role of open and endovascular treatment with fenestrated and chimney endografts for patients with juxtarenal aortic aneurysms. J Vasc Surg 2012; 56: 285–290.

19.

British Society for Endovascular Therapy and the Global Collaborators on Advanced Stent-Graft Techniques for Aneurysm Repair (GLOBALSTAR) Registry. Early results of fenestrated endovascular repair of juxtarenal aortic aneurysms in the United Kingdom. Circulation 2012; 125: 2707–2715.

20.

Canavati

Millen

Brennan

. Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair. J Vasc Surg 2013; 57: 362–367.

21.

Perot

Sobocinski

Maurel

. Comparison of short- and mid-term follow-up between standard and fenestrated endografts. Ann Vasc Surg 2013; 27: 562–570.

22.

Guo

Zhang

Liu

. Fenestrated endovascular aortic repair for juxtarenal abdominal aortic aneurysm. Chin Med J (Engl) 2013; 126: 409–414.

23.

Holden

Mertens

Hill

. Initial experience with the Ventana fenestrated system for endovascular repair of juxtarenal and pararenal aortic aneurysms. J Vasc Surg 2013; 57: 1235–1245.

24.

Quinones-Baldrich

Holden

Mertens

. Prospective, multicenter experience with the Ventana Fenestrated System for juxtarenal and pararenal aortic aneurysm endovascular repair. J Vasc Surg 2013; 58: 1–9.

25.

Kitagawa

Greenberg

Eagleton

. Zenith p-branch standard fenestrated endovascular graft for juxtarenal abdominal aortic aneurysms. J Vasc Surg 2013; 58: 291–300.

26.

Katsargyris

Yazar

Oikonomou

. Fenestrated stent-grafts for salvage of prior endovascular abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2013; 46: 49–56.

27.

Suominen

Pimenoff

Salenius

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

28.

Kristmundsson

Sonesson

Dias

. Outcomes of fenestrated endovascular repair of juxtarenal aortic aneurysm. J Vasc Surg 2014; 59: 115–120.

29.

Grimme

Zeebregts

Verhoeven

. Visceral stent patency in fenestrated stent grafting for abdominal aortic aneurysm repair. J Vasc Surg 2014; 59: 298–306.

30.

Unno

Yamamoto

Higashiura

. Early experience with fenestrated stent grafts for treatment of juxtarenal aortic aneurysm. Ann Vasc Dis 2013; 6: 642–650.

31.

Rolls

Jenkins

Bicknell

. Experience with a novel custom-made fenestrated stent graft in the repair of juxtarenal and type IV thoracoabdominal aneurysms. J Vasc Surg 2014; 59: 615–622.

32.

Hertault

Sobocinski

Kristmundsson

. Results of F-EVAR in octogenarians. Ann Vasc Surg 2014; 28: 1396–1401.

33.

Banno

Cochennec

Marzelle

. Comparison of fenestrated endovascular aneurysm repair and chimney graft techniques for pararenal aortic aneurysm. J Vasc Surg 2014; 60: 31–39.

34.

Silverberg

Glauber

Rimon

. Endovascular repair of complex aortic aneurysms. Isr Med Assoc J 2014; 16: 5–10.

35.

Liao

Watson

Mansour

. Preliminary results of Zenith fenestrated abdominal aortic aneurysm endovascular grafts. Am J Surg 2014; 207. 417–421, 421.

36.

Dijkstra

Tielliu

Meerwaldt

. Dutch experience with the fenestrated Anaconda endograft for short-neck infrarenal and juxtarenal abdominal aortic aneurysm repair. J Vasc Surg 2014; 60: 301–307.

37.

Vemuri

Oderich

Lee

. Postapproval outcomes of juxtarenal aortic aneurysms treated with the Zenith fenestrated endovascular graft. J Vasc Surg 2014; 60: 295–300.

38.

Lee

Chandra

. Comparison of fenestrated endografts and the snorkel/chimney technique. J Vasc Surg 2014; 60. 849–856, 856–857.

39.

Ohrlander

Sonesson

Ivancev

. The chimney graft: a technique for preserving or rescuing aortic branch vessels in stent-graft sealing zones. J Endovasc Ther 2008; 15: 427–432.

40.

Hiramoto

Chang

Reilly

. Outcome of renal stenting for renal artery coverage during endovascular aortic aneurysm repair. J Vasc Surg 2009; 49: 1100–1106.

41.

Donas

Torsello

Austermann

. Use of abdominal chimney grafts is feasible and safe: short-term results. J Endovasc Ther 2010; 17: 589–593.

42.

Bruen

Feezor

Daniels

. Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms. J Vasc Surg 2011; 53. 895–904, 904–905.

43.

Coscas

Kobeiter

Desgranges

. Technical aspects, current indications, and results of chimney grafts for juxtarenal aortic aneurysms. J Vasc Surg 2011; 53: 1520–1527.

44.

Lee

Greenberg

Dalman

. Early experience with the snorkel technique for juxtarenal aneurysms. J Vasc Surg 2012; 55. : 935–946, 945–946.

45.

Schiro

Antoniou

Ormesher

. The chimney technique in endovascular aortic aneurysm repair: late ruptures after successful single renal chimney stent grafts. Ann Vasc Surg 2013; 27: 835–843.

46.

Tolenaar

Zandvoort

Moll

. Technical considerations and results of chimney grafts for the treatment of juxtarenal aneursyms. J Vasc Surg 2013; 58: 607–615.

47.

Liu

Pan

Song

. Chimney stents for endovascular repair of juxtarenal aortic aneurysms with unfavourable anatomy. Int Angiol 2013; 32: 307–311.

48.

Lachat

Veith

Pfammatter

. 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.

49.

Ducasse

Lepidi

Brochier

. The “open” chimney graft technique for juxtarenal aortic aneurysms with discrepant renal arteries. Eur J Vasc Endovasc Surg 2014; 47: 124–130.

50.

Igari

Kudo

Uchiyama

. Early experience with the endowedge technique and snorkel technique for endovascular aneurysm repair with challenging neck anatomy. Ann Vasc Dis 2014; 7: 46–51.

51.

Scali

Feezor

Chang

. Critical analysis of results after chimney endovascular aortic aneurysm repair raises cause for concern. J Vasc Surg 2014; 60. 865–873, 873–875.

52.

Takagi

Umemoto

. Endovascular repair of abdominal aortic aneurysm. Lancet 2005; 366: 890–891.

53.

Prinssen

Verhoeven

Buth

. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351: 1607–1618.

54.

Katsargyris

Oikonomou

Klonaris

. 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.

55.

Yang

Xiong

Liu

. Endovascular chimney technique of aortic arch pathologies: a systematic review. Ann Vasc Surg 2012; 26: 1014–1021.

56.

Cross

Gurusamy

Gadhvi

. Fenestrated endovascular aneurysm repair. Br J Surg 2012; 99: 152–159.