Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift?

ABSTRACT

PURPOSE: To review the literature reporting open surgical and endovascular treatment of juxtarenal aortic aneurysm (JAA). METHODS: A systematic search of the PubMed database was carried out to identify English-language articles published between January 2001 and July 2012 on the management of JAA with open surgery, fenestrated endovascular aneurysm repair (F-EVAR), and the chimney graft technique (Ch-EVAR). The search found 20 studies with a total of 1725 patients (76% men; age range 66-74 years) undergoing open surgery, 10 studies detailing 931 patients (87.6% men; age range 72-75 years) receiving F-EVAR, and 5 studies comprising 94 patients (75% men; age range 68-82) reporting Ch-EVAR. RESULTS: A total of 2465 vessels were targeted with fenestrations and 151 with chimney grafts (CG); intraoperative target vessel preservation was 98.6% and 98.0%, respectively. Cumulative 30-day mortality was 3.4%, 2.4%, and 5.3% for open surgery, F-EVAR and Ch-EVAR, respectively (p=NS). Impaired renal function was noted in 18.5%, 9.8%, and 12% following open surgery, F-EVAR, and Ch-EVAR, respectively (open vs. F-EVAR p<0.001). New-onset dialysis was required postoperatively in 3.9%, 1.5%, and 2.1%, respectively (open vs. F-EVAR p<0.001). Postoperative cardiac complications were noted in 11.3%, 3.7%, and 7.4%, respectively (open vs. F-EVAR p<0.001). The incidence of ischemic stroke was 0.1% and 0.3% following open surgery and F-EVAR, but 3.2% after Ch-EVAR (open vs. Ch-EVAR p=0.002; F-EVAR vs. Ch-EVAR p=0.012). Early proximal type I endoleak was lower after F-EVAR compared to Ch-EVAR (4.3% vs. 10%, respectively, p=0.002). CONCLUSION: Open surgery remains a safe and effective treatment option for good risk patients with JAA. F-EVAR is associated with low operative mortality, compares favorably to open surgery in terms of morbidity, and current midterm data indicate that it can be a valid treatment option in both low- and high-risk patients. Early results of Ch-EVAR demonstrate feasibility only. In view of the limited number of reports and the lack of long-term data, the technique should be considered only in acute poor surgical risk patients, as a bailout in case of unintentional renal artery coverage, or in elective poor surgical cases that are not suitable for F-EVAR.