Endovascular Aortic Arch Repair with Chimney Technique for Pseudoaneurysm

Endovascular Aortic Arch Repair with Chimney Technique for Pseudoaneurysm | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Endovascular Aortic Arch Repair with Chimney Technique for Pseudoaneurysm Ming-yao Luo, Xiong Zhang, Kun Fang, Yuan-yuan Guo, Dong Chen, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1794554/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Aortic pseudoaneurysm is a life-threatening clinical condition, and thoracic endovascular aortic repair (TEVAR) has been reported to have a relatively satisfactory effect in aortic pathologies. We summarized our single-centre experience using chimney TEVAR for aortic arch pseudoaneurysms with inadequate landing zones. Methods: A retrospective study was conducted from October 2015 to August 2020, 32 patients (64.1±15.0 years, range 28-81; 29 men) with aortic arch pseudoaneurysms underwent chimney TEVAR to exclude an aortic lesion and reconstruct the supra-aortic branches, including 3 innominate artery, 12 left common carotid arteries and 29 left subclavian arteries. Follow-up computed tomography was suggested before discharge; at 3, 6, and 12 months; and yearly thereafter. Results: Forty-four related supra-aortic branches were well preserved and the technical success rate was 100%. The Type Ia endoleaks occurred in 3 (9%) patients. Two patients were lost to follow-up and 4 patients died during the follow-up period. The median follow-up was 46.5±14.3 (range, 4.5-60) months. One patient died due to acute myocardial infarction just 10 days after chimney TEVAR and the other 3 patients passed away at 1.5 months, 20 months and 31 months with non-aortic reasons. The 4.5-year survival estimate was 84.4%. The primary patency rate of the target supra-arch branch vessels was 97.7% (43/44), and no other aorta-related reinterventions and severe complications occurred. Conclusion: For aortic arch pseudoaneurysms with inadequate landing zones for TEVAR, the chimney technique seems to be feasible, with acceptable mid-term outcomes, and it could serve as an alternative minimally invasive approach to extend the landing zone. Slow flow type Ia endoleak could be treated conservatively after chimney TEVAR. Additional experience is needed, and the long-term durability of chimney TEVAR requires further follow-up. aortic arch pseudoaneurysm chimney graft/technique thoracic endovascular aortic repair type Ia endoleak trauma innominate artery left common carotid artery left subclavian artery Figures Figure 1 Figure 2 Background Aortic pseudoaneurysm is a life-threatening clinical condition and the causes include penetrating aortic ulcer (PAU), trauma, iatrogenic aetiologies, Bechet’s disease, aortic infections (mycotic aneurysms), etc. 1 . The development of endovascular treatment in the past decades has already provided a new treatment option for open surgery 2 ,3 . Currently, as chimney or fenestration techniques are used as assistive techniques, the indications for TEVAR have obviously expanded 4 . Since 2002, chimney TEVAR has been reported to be used successfully for different types of aortic arch diseases 5,6 . However, for the treatment of aortic arch pseudoaneurysms, the current literature on chimney TEVAR is limited 7-18 . The aim of this retrospective study is to report the mid-term results of chimney TEVAR for aortic arch pseudoaneurysms in our centre. Methods Patients From October 2015 to August 2020, 32 patients (64.1±15.0 years, range 28-81; 29 men) with aortic arch pseudoaneurysms underwent chimney TEVAR. All the patients in this group received preoperative computed tomography angiography (CTA) of the aorta for diagnosis and measurement. The effective diameter, the average of aortic anteroposterior and lateral diameters, was independently measured by two radiologists using 1-mm–collimation double-oblique reconstructions. The images sizing was conducted with Syngo fastView software (version VX57133,Siemens Healthineers,Germany). The decision regarding whether chimney TEVAR could be used was made on the basis of the anatomic features of the pseudoaneurysm and the arch. The inclusion criteria were as follows: patients with thoracic aortic pseudoaneurysms without a sufficient proximal landing zone for standard endovascular repair, which meant that the pseudoaneurysms were close to (<15 mm) or already involved the orifice of the left subclavian artery, the chimney technique for left subclavian artery (LSA) was performed; occasionally, even the left common carotid artery and innominate artery were involved. Double or triple chimney techniques were only used for patients who had contraindications to open surgery or who refused open surgery. The exclusion criteria were as follows: patients with (a) pseudoaneurysms involving the ascending aorta; (b) concomitant cardiac diseases that required open surgery; (c) anatomic features not suitable for TEVAR, such as severe stenosis of the access route arteries or a very large landing zone (>40mm) that limited device use; (d) severe cardiopulmonary, renal, or hepatic diseases and thus could not tolerate general anaesthesia. In total, 32 patients underwent chimney TEVAR according to the inclusion and exclusion criteria. The patients’ characteristics and comorbidities are listed in Table 1. Treatment procedure For all 32 patients, blood pressure and heart rate were strictly controlled after admission (target blood pressure <110/70 mmHg, heart rate<70 beats/min). For the symptomatic patients, the systolic blood pressure was controlled to approximately 90/60 mmHg, and the heart rate 55～65 beats/min. The chimney TEVAR procedure was performed in a hybrid operating room under fluoroscopic guidance. General anaesthesia with tracheal intubation was performed in all patients. The common femoral artery was exposed via surgical cut-down (26/29) and percutaneous puncture (3/29) using a Perclose ProGlide suture device (Abbott Laboratories Co., Ltd., USA), and if necessary, the brachial and carotid arteries were exposed surgically. Firstly, the chimney stent-graft was preloaded into the orifice of the target branch with the proximal side in the aortic lumen and the distal side maintained in the branch. Covered stents (Fluency; C.R. Bard, Inc., NJ, USA, or Viabahn; Gore & Associates, AZ, USA) were used as chimneys in all patients. Secondly, the aortic stent-graft [Hercules (MicroPort Medical Co., Ltd., Shanghai, China); Zenith (Cook, Inc., Bloomington, IN, USA); Ankura (Lifetech Scientific Co., Ltd., Shenzhen, China); or Valiant (Medtronic, Inc., Minneapolis, MN, USA)] was inserted via femoral access and deployed in the pre-established position of the aortic arch. The relative position of the chimney and aortic stent-graft was adjusted to keep the chimney away from the lesion in order to avoid blood flow from the gutter to the pseudoaneurysm. Thirdly, the chimney was deployed with an approximately 10 mm proximal segment over the proximal fabric ending of the aortic stent-graft into the aortic lumen and the distal segment in the branch artery (figure1). The chimneys in the innominate and carotid arteries were released immediately after deployment of the aortic stent-graft to shorten the cerebral ischaemia time (often less than 1 minute). For the purpose of improving long-term patency, chimneys were routinely dilated with a comparable balloon after deployment (10-12atm, 5-10 seconds). After chimney TEVAR, digital subtraction angiography (DSA）was performed to confirm the final results. The aortic stent-graft and chimney stent-graft(s) were selected with 15~20% and 0~5% oversizing, respectively. Additional details of the operation process have already been reported previously by our colleagues 19, 20 . After chimney TEVAR, low-molecular-weight heparin (4,000 IU per 12 hours) was administered for 3~7 days, followed by aspirin (100 mg/day) for at least 1 month. For patients without endoleaks, aspirin (100 mg/d) could be taken longer or even lifelong after chimney TEVAR, especially for those with a chimney less than 8 mm in diameter 4 or those with coexisting arteriosclerotic diseases that required antiplatelet therapy. For patients with type Ia endoleaks, aspirin was stopped until CTA showed satisfactory thrombosis of the gutter. The timing for the cessation of aspirin was decided comprehensively based on the order of severity of the endoleak, the chimney diameter and the coexisting diseases. Follow-up All patients underwent CTA and duplex ultrasound scans 1 week after chimney TEVAR or before discharge to evaluate the exclusion results of pseudoaneurysm and supra-aortic branch patency. Subsequent follow-up with physical examination and CTA was scheduled at 3, 6, and 12 months and annually thereafter, and telephone follow-up was performed semi-annually. The patients were asked to record all complaints and complications. Statistical Analysis All the data were enrolled and retrospectively analysed. Clinical data analysis was conducted with SPSS software (version 21, SPSS Inc., Chicago, IL), and GraphPad Prism (version8; GraphPad Software, San Diego, CA, USA) was used to construct graphical representations of the data.Continuous variables were expressed as the mean ± standard deviation, Kaplan-Meier analysis was used to establish the rate of survival. Ethical approval Results Procedures From October 2015 to August 2020, 32 patients (mean age 64.1±15.0 years, range 28-81; 29 men) with pseudoaneurysm performed cTEVAR. The etiologies were as follows: trauma or had a clear history of trauma in 10 (31.3%) patients, Bechet’s disease in 1 (3%) patient, and penetrating aortic ulcers or uncertain in 21 (65.6%) patients (table 1). Three (9%) patients underwent emergent surgery, which was defined as chimney TEVAR performed within 24 hours after admission. The mean fluoroscopy time, which had been defined as the period from the first to the last angiography, was 35.3±7.7 minutes. The mean volume of contrast agent was 63.9±7.0 ml. The mean length of intensive care unit (ICU) stay and postoperative stay was 2.2±3.0 days and 8.3±5.0 days (table2). In total, 47 chimney stent-grafts were implanted to preserve 44 target supra-arch branch vessels (table 3). Which included the LSA (n=29), left common carotid artery (LCCA) (n=12) and innominate artery (IA) (n=3), and for 8 patients, the chimney technique for the LSA was performed in a reverse manner as a periscope. Moreover, in case 9 the patient simultaneously underwent endovascular repair of an abdominal aortic aneurysm with a maximum sac diameter of 60 mm, with special consideration that the patient had abdominal pain symptoms. Perioperative outcomes Type Ia, Ib, II, III, and IV endoleaks occurred in 3 (9%), 0, 0, 0, and 0 patients, respectively. All type Ia endoleaks were slow flow and under close surveillance without reintervention. The detailed data related to the surgical procedure are shown in table2. In our study, symptoms of hoarseness (n=7) and chest and back pain (n=12) were all relieved. All patients were given low-molecular-weight heparin and then a standard antiplatelet agent (100 mg/day aspirin) after chimney TEVAR, except for 3 patients who had type Ia endoleaks (case 1, case 10 and case 11). For them, antiplatelet therapy was cancelled 1 week (cases 1 & 10) and 1 month (case 11) after chimney TEVAR. After follow-up CTA showed no remaining endoleaks, antiplatelet therapy was given to them again thereafter. In case 10, the patient had Bechet’s disease and also received standard immunotherapy postoperatively. For patients with hypertension, anti-hypertension medication therapy was continued perioperatively. The 30-day mortality rate was 3% (n = 1). In case 5, the 77-year-old male patient had a large symptomatic aortic arch pseudoaneurysm with a maximum diameter of 78 mm that involved the whole arch. Because he was considered at very high risk for open chest surgery due to multiple severe coexisting diseases, TEVAR with the chimney technique for the IA and LCCA and a periscope for the LSA was performed. He had a history of exertional angina and was confirmed via CTA to have severe left main coronary artery stenosis, which was planned to be treated after endovascular aortic arch repair. Unfortunately, he died suddenly from acute myocardial infarction 10 days after the chimney TEVAR operation. Another 67-year-old male patient, case 11, lived in the plateau area with an altitude over 3500 metres for 30 years and suffered from a variety of diseases, including chronic obstructive pulmonary disease, pulmonary heart disease, pulmonary hypertension, multiple pulmonary nodules, hypertension, gout and a history of bloody phlegm. The patient was transferred out of the ICU 2 days after the operation and was transferred to the ICU again for rescue due to massive haemoptysis associated with bronchiectasis on the 7th postoperative day. After conservative treatment, he recovered and was discharged 26 days postoperatively. Till now he lived uneventfully for another 5 years. The case 15 patient had lower hemoglobin index (67g/L) and left upper limb hematoma after operation, and he received brachial artery repair on the 15th postoperative day due to pseudoaneurysm at the puncture point. Midterm follow-up Two patients were lost to follow-up and the median follow-up was 46.5±14.3 (range, 4.5-60) months, and 3 other patients died during the midterm follow-up period, and the Kaplan-Meier survival curve is presented in Figure 2. The overall 4.5-year survival rate was 84.4%. Patient 32 suffered from chronical renal insufficiency before admission, and he received regular dialysis treatment before discharge but died 1.5 months postoperatively. Patient 16 died in the 31st month after TEVAR because of lung cancer, and patient 24 died in the 20th postoperative month because of uncertain reasons. With conservative treatment, including ceasing the use of antiplatelet agents and controlling the systolic pressure at 90–110 mm Hg and heart rate at 55–70 beats/min with antihypertensive agents and β-blockers, the 3 slow-flow type Ia endoleaks sealed spontaneously 3 months (case 1 & case 11) and 1 year (case 10), respectively, after chimney TEVAR. However, Chimney stent-graft of case 10 was occluded which might have been associated with the cessation of antiplatelet agents, and 70% stenosis of the chimney occurred in case 18. Discussion Aortic pseudoaneurysm is defined as a dilation of the aorta due to the disruption of all wall layers; it is only contained by periaortic connective tissue and can become a lethal situation, and the selection between endovascular and open surgical treatment depends on anatomic features, clinical presentations and comorbidities 1 . Some articles have reported the effectiveness of TEVAR in the treatment of pseudoaneurysms caused by tuberculosis 21, 22 , trauma 3, 23 and Bechet’s disease 24 . TEVAR enabled minimization of the intraoperative risk, particularly in unstable multi-trauma patients with a severe clinical status. Traumatic aortic pseudoaneurysms occur in 2% of patients with blunt thoracic trauma 27 ,28 . Endovascular treatment was early used successfully in 1997 by Semba 29 . A recent meta-analysis by Amer Harky et al 3 indicated that TEVAR carries lower in-hospital mortality and provides satisfactory perioperative outcomes compared with open repair in traumatic ruptured thoracic aortic pseudoaneurysms. Ten patients with possible traumatic reasons in this study had uneventful in-hospital and follow-up outcomes, and all of them had a history of traumatic accidents 5 to 20 years ago. The possible mechanism is, when the human body suffers deceleration injury, the arterial ligament may pull the wall of the small curvature of the aortic isthmus, which may lead to local injury, and over the years, the lesion progresses into a pseudoaneurysm as the blood flow impinges. Therefore, if the patient had unexplained pseudoaneurysms and had a history of severe trauma several years ago (such as a car accident), we also believed that the pseudoaneurysms might be related to the history of trauma. For patients without aortic injuries, infections, autoimmune diseases, PAU should be the most common aetiologies for aortic pseudoaneurysms. The pseudoaneurysms might have originated from a calcified plaque rupture, PAU could be the beginning form of pseudoaneurysms, they may lead to intramural haematoma, dissection, pseudoaneurysms, or even aortic rupture 30 . This pathologic condition is distinct from classic aortic dissection, which is more frequently seen in the natural history of PAUs with the propensity to evolve into aneurysms or pseudoaneurysms 31 . The chimney TEVAR technique was mostly used as a preferential choice in patients with inadequate proximal landing zones for standard TEVAR. The technique was early used by Criado et al 32 in arch-TEVAR with bare stents to rescue LSAs in the landing zones. Hiramoto et al 33 reported the administration of covered stents in the chimney technique assisted by TEVAR in 2006. According to our experience, covered chimney stents are very useful for decreasing the incidence of type Ia endoleaks. The majority of these patients in our study received a single chimney graft. Compared with carotid-subclavian transposition or carotid-subclavian bypass, in chimney TEVAR, the incidence of neurological events is not high due to the shorter operation time and more minimally invasive neck incision. Therefore, we routinely performed chimney TEVAR instead of carotid-subclavian transposition or carotid-subclavian bypass. Our team reported the outcomes of the LCCA chimney technique for the endovascular repair of acute non-A–non-B aortic dissections in 2011 4 , and 8 patients were included in the study, with no mortality and a 100% chimney patency rate during a mean follow-up of 11.4 months. In 2015, a larger retrospective study of 41 patients reported by our team revealed similar perioperative results 19 . In 2017, Wang T et al reported the results of 122 patients (no pseudoaneurysms) who underwent chimney TEVAR 20 , and the outcomes indicated that chimney TEVAR provided a safe, minimally invasive alternative with good chimney graft patency and low postoperative mortality for aortic arch pathologies. However, aortic arch pseudoaneurysms managed by chimney TEVAR have seldom been reported, and most previous studies in this area are case reports. This study significantly enriched the reported experience of chimney TEVAR for aortic arch pseudoaneurysms. The risk of type Ia endoleaks is the main problem of the chimney technique because of the “gutter” between the chimney and aortic stent-grafts. We recommend an overlap of at least 2 cm between the chimney and aortic stent-grafts if possible. A longer overlap, adequate oversizing of the thoracic stent-graft and appropriate ballooning of the chimneys could narrow the gutter and decrease the incidence of type Ia endoleaks. If a pseudoaneurysm is restricted to one side of the aortic arch, such as the anterior or postesrior wall, the relative position of the chimney and aortic stent-graft should be adjusted to keep the chimney away from the lesion in order to avoid blood flow from the gutter to the pseudoaneurysm. Aneurysms and pseudoaneurysms are mainly different in anatomy. In pseudoaneurysms, the majority of the aortic wall has been breached, but the extent of involvement is often focal, so the peudoaneurysms may have a lower incidence of type I endoleak. No cases of stroke occurred in our study. In our opinion, the most important factors for preventing stroke during and after chimney TEVAR include preoperatively analysing the target vessels with CTA and colour duplex ultrasound to see if there is any stenosis or calcified plaques, shortening the operation time via skilful manipulation, and open control instead of percutaneous puncture of the carotid or innominate artery, which may minimize vessel trauma and, accordingly, cerebral embolism risk. Antiplatelet therapy including aspirin (100 mg/d) was administered routinely for patients with no endoleak after chimney TEVAR. However, for patients with endoleaks, especially type Ia endoleaks, cessation of antiplatelet therapy was considered individually.The antiplatelet therapy may be linked to an increased risk for the development of endoleak 34 , and cessation of antiplatelet therapy may result in a risk of chimney occlusion and stroke. If the endoleak is slow flow, and the status of the pseudoaneurysm was stable peri-operatively, early use of antiplatelet agents for approximately one month without increasing the rupture risk of pseudoaneurysms might contribute to chimney patency, but this remains to be proven. For patients with pseudoaneurysms, reducing sac pressure and avoiding rupture are the fundamental and key objectives of treatment. If the pseudoaneurysm pressure cannot be relieved and the safety of patients cannot be ensured, antiplatelet therapy has to be cancelled to help thrombosis of the lesion. However, if severe type Ia endoleaks occur after the carotid or innominate chimney technique, or if a patient has to use antiplatelet agents continuously for some reason (e.g., after coronary stenting), the decision of how to administer antiplatelet therapy would be very controversial. Therefore, it is important to emphasize that in patients with a high risk of endoleak, such as in cases where the target vessel arises from the pseudoaneurysm, the use of hybrid or other techniques instead of chimney TEVAR is recommended, especially for patients who cannot stop using antiplatelet agents. Conclusion Aortic pseudoaneurysm is a lethal pathologic condition. For high selected aortic arch pseudoaneurysms with inadequate landing zones for TEVAR, the chimney technique seems to be feasible, with acceptable mid-term outcomes, and it could serve as an alternative minimally invasive approach to extend the landing zone. According to this small cohort, slow flow type Ia endoleaks after chimney TEVAR could be treated conservatively. Additional experience is needed, and the long-term durability of chimney TEVAR requires further follow-up. Abbreviations TEVAR: thoracic endovascular aortic repair; PAU: penetrating aortic ulcer; CTA: computed tomography angiography; LSA: left subclavian artery ; DSA: digital subtraction angiography; ICU: intensive care unit; LCCA: left common carotid artery; IA: innominate artery; CHD: coronary heart disease; CRF: chronic renal failure; DM: diabetes mellitus Declarations Ethics approval and consent to participate The procedures followed were in accordance with the ethical standards of the Institute Review Board of our Hospital (NO.2017-946) and Helsinki Declaration. Written informed consent was obtained from all the patients and their relatives. Consent for publication All the participants provided written informed consent for the publication of the results of this study. Availability of data and materials The data used in this study are available from the corresponding author if needed. Competing interests Author’s declare that they have no competing interests. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Natural Science Foundation, China (No. 81870345), the Beijing Science and Technology Project (No. D171100002917004), the Grant of CAMS Initiative for Innovative Medicine, China (NO. 2016-I2M-1-016), and the Yunnan Provincial Cardiovascular Disease Clinical Medical Center Project (NO. FZX2019-06-01). Authors' contributions MYL, XZ and CS analyzed the results and composed the manuscript. KF and YYG participated in the collection of clinical data. DC and JTL participated in editing the manuscript.All authors review and approved the final manuscript. Acknowledgements The authors would like to thank Yunfei Xue and Jiawei Zhao for their assistance. Authors' information (optional) 1 State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, Beilishi Road, Xicheng District, Beijing, 100037, China. 2 Department of Vascular Surgery, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, 650102, China. 3 Department of Surgery, Stanford University School of Medicine, Stanford, CA,94305, USA. 4 Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410013, China. References Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. Vrints CJ and Guidelines ESCCfP. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. 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Management of traumatic aortic rupture. Surgery Today. 2013;43:1339–46. Semba CP, Kato N, Kee ST, Lee GK, Mitchell RS, Miller DC, et al. Acute rupture of the descending thoracic aorta: repair with use of endovascular stent-grafts. J Vasc Interv Radiol. 1997;8:337–42. Nathan DP, Boonn W, Lai E, Wang GJ, Desai N, Woo EY, et al. Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease. J Vasc Surg. 2012;55:10–5. Vilacosta I, San Roman JA, Aragoncillo P, Ferreiros J, Mendez R, Graupner C, et al.Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography. J Am Coll Cardiol. 1998;32:83–9. Criado FJ, Barnatan MF, Rizk Y, Clark NS and Wang CF. Technical strategies to expand stent-graft applicability in the aortic arch and proximal descending thoracic aorta. J Endovasc Ther. 2002;9 Suppl 2:32–8. Hiramoto JS, Schneider DB, Reilly LM and Chuter TA. A double-barrel stent-graft for endovascular repair of the aortic arch. J Endovasc Ther. 2006;13:72–76. Joseph L. Bobadilla, John R. Hoch, Glen E. Leverson, Girma Tefera. The effect of warfarin therapy on endoleak development after endovascular aneurysm repair (EVAR) of the abdominal aorta. J Vasc Surg. 2010;52:267–71. Tables Table 1. Patient Characteristics Characteristics n (%) Age, years 25.9±2.6 Male 29 (91） Obese (BMI>30kg/m 2 ) 1 (3) Comorbidities Hypertension 22 (69) Hyperlipidemia 16 (50) CHD 10 (31) CRF 3 (9) DM 5 (16) Trauma 10 (31) Smoker 19 (59) Symptoms Chest and back pain 11 (34) Hoarseness 7 (22) None of symptom 14 (44) CHD, coronary heart disease. CRF, chronic renal failure. DM, diabetes mellitus. Continuous data are presented as the means ± standard deviation; categorical data are given as the counts (percentage). Table 2. Operative characteristics and outcomes Characteristics n (%) Emergency cTEVAR 3 (9) Aortic branches chimneys Left subclavian artery 29 Left common carotid artery 12 Innominate artery 3 Landing zones Zone 0 3 (9) Zone 1 9 (28) Zone 2 10 (31) Fluoroscopy time (min) 35.3 ± 7.7 Contrast volume (ml) 63.9 ± 7.0 Post-OP ICU stay (days） 2.2 ± 3.0 Post-OP stay (days) 8.3 ± 5.0 Postoperative complications Endoleak 3 (9) Chimney stenosis 1(3) Death 4 (13) Aortic related reoperation 0 Aortic related rehospitalization 0 TEVAR, thoracic endovascular aortic repair; OP, operation; ICU, intensive care unit. Continuous data are presented as the means ± standard deviation; categorical data are given as the counts (percentage). Table 3. Stent graft characteristics Case Aortic stent graft Landing zone IA LCCA LSA 1 34-30-160 (LA） 2 8-60 (BF) 2 28-24-160 (LA) 2 8-60 (BF) 3 26-22-160 (MH) 2 10-60 (BF) 4 36-28-180 (LA) 2 8-60 (BF) 5 36-36-200 (MV) 0 14-60 (BF) 6-80 (BF) 8-150 (GV) 6 36-36-150 (MV) 2 6-60 (BF) 7 34-28-180 (LA) 2 8-60 (BF) 8 34-34-150 (MV) 2 8-80 (BF) 9 34-34-150 (MV) 2 8-60 (BF) 10 28-28-150 (MV) 2 5-50 (GV) 11 32-32-200 (MV) 1 8-60 (BF) 12 32-32-200 (MV) 1 6-60 (BF) 13 42-42-150 (MV) 0 10-60 (BF) 6-80 (BF) 14 32-32-150 (MV) 2 8-60 (BF) 15 42-42-150 (MV) 2 6-60 (BF) 16 34-34-150 (MV) 0 8-60 (BF) 8-80 (BF) 6-80 (BF) 8-150 (GV) 17 32-32-150 (MV) 2 6-60 (BF) 18 28-22-180 (LA) 2 8-60 (BF) 19 34-30-160 (LA) 2 8-80 (BF) 20 34-30-160 (LA) 2 8-60 (BF) 21 36-32-160 (MH) 2 6-80 (BF) 22 34-34-150 (MV) 1 8-60 (BF) 8-80 (BF) 8-150 (GV) 23 34-30-160 , 32-38-160 (MH) 1 6-60 (BF) 8-80 (BF) 24 42-42-200, 28-28-80 (MV) 2 8-50 (GV) 25 34-34-150 (MV) 1 6-80 (BF) 10-150 (BF) 26 34-24-200 (LA) 1 8-60 (BF) 8-50 (GV) 8-150 (GV) 27 30-24-160 (LA) 2 8-60 (BF) 28 28-28-150 (GT) 2 8-50 (GV) 29 32-32-150 (MV) 2 7-50 (GV) 30 30-30-200 (MV) 1 6-60 (BF) 6-150 (GV) 31 36-36-150 (MV) 1 8-60 (BF) 9-50 (GV) 8-150 (GV) 32 Valiant 30-30-150 (MV) 1 8-60 (BF) 6-150 (GV) BF, Bard Fluency; GV, Gore Viabahn; LA, Lifetech Ankura; MH, MicroPort Hercules; MV, Medtronic Valiant; GT,Gore TAG; LSA, left subclavian artery. LCCA, left common carotid artery. IA, innominate artery. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 27 Jul, 2022 Reviews received at journal 23 Jul, 2022 Reviewers agreed at journal 18 Jul, 2022 Reviewers invited by journal 18 Jul, 2022 Editor assigned by journal 18 Jul, 2022 Editor invited by journal 25 Jun, 2022 Submission checks completed at journal 25 Jun, 2022 First submitted to journal 25 Jun, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1794554","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":116317857,"identity":"585086bb-1389-4260-9a47-f6f7efafcdd2","order_by":0,"name":"Ming-yao Luo","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Ming-yao","middleName":"","lastName":"Luo","suffix":""},{"id":116317858,"identity":"d2e632b7-1113-4ff1-9e42-7bf92de9cb38","order_by":1,"name":"Xiong Zhang","email":"","orcid":"","institution":"The Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Xiong","middleName":"","lastName":"Zhang","suffix":""},{"id":116317859,"identity":"c068ce7f-abd0-488b-95b5-4d9191525f59","order_by":2,"name":"Kun Fang","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Kun","middleName":"","lastName":"Fang","suffix":""},{"id":116317860,"identity":"2e83037c-5403-4bf4-86fa-6e2d1664aabe","order_by":3,"name":"Yuan-yuan Guo","email":"","orcid":"","institution":"Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuan-yuan","middleName":"","lastName":"Guo","suffix":""},{"id":116317861,"identity":"f4d046c2-9215-44d3-bc0a-9a72d47d799c","order_by":4,"name":"Dong Chen","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Dong","middleName":"","lastName":"Chen","suffix":""},{"id":116317862,"identity":"dcf459ea-34d5-40bf-a0df-ff4f0535d5b2","order_by":5,"name":"Jason T. Lee","email":"","orcid":"","institution":"Stanford University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jason","middleName":"T.","lastName":"Lee","suffix":""},{"id":116317863,"identity":"73ddf169-976f-4f9b-9612-68fe932a66cb","order_by":6,"name":"Chang Shu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYDACCTB5gIGfmfngAxiXOC2S7WzJBqRpMTjPYyZAlLv4Zzc/e/jlz53EzYcZzBgY2yzyGNgPH92A15I7x8yNZdueJW47zJD2gLFNopiBJy3tBj4tBhIJZtKSDYdBWo4bMJyRSGyQ4DEjoCX9m7TEn8OJm5uBVhCpJcdM8gPb4cQNzMxsEgwVRGiRuJFTJs3Ydth4xmE2ZoOEColiNkJ+4Z+Rvk3yx5/Dsv395z8++GBQl8fPfvgYXi0gwMwDYyUAERsh5SDA+AOJk0CMjlEwCkbBKBhZAAD5X0ptMvyX0AAAAABJRU5ErkJggg==","orcid":"","institution":"Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":true,"prefix":"","firstName":"Chang","middleName":"","lastName":"Shu","suffix":""}],"badges":[],"createdAt":"2022-06-25 12:29:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1794554/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1794554/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":23244267,"identity":"6b54484c-2315-4726-b2ef-f0a440a01e8e","added_by":"auto","created_at":"2022-06-29 17:26:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1125146,"visible":true,"origin":"","legend":"\u003cp\u003ea 55-year-old male had a pseudoaneurysm which involved the orifice of left subclavian artery. B, he underwent single chimney technique for the left subclavian artery. C, one year after operation, the chimney stent graft kept patent and the patient was in good condition.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-1794554/v1/4ca4e857ee031b9cd9f88a82.png"},{"id":23244266,"identity":"69770768-3c7c-4367-9e7b-3f537ccd6c0d","added_by":"auto","created_at":"2022-06-29 17:26:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":318139,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curve for overall patient survival. The 4.5-year survival estimate was 84.4% (95% confidence interval 71.3% to 100.0%).\u0026nbsp;\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-1794554/v1/cf7c4786e311018508ba8fdc.png"},{"id":23244284,"identity":"b5a1bcf6-d6ab-4642-b500-f3e073583580","added_by":"auto","created_at":"2022-06-29 17:26:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":257093,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1794554/v1/d4bdc7cb-3bbe-4668-adfa-5ab939b63144.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endovascular Aortic Arch Repair with Chimney Technique for Pseudoaneurysm","fulltext":[{"header":"Background","content":"\u003cp\u003eAortic pseudoaneurysm is a life-threatening clinical condition and the causes \u0026nbsp; include penetrating aortic ulcer (PAU), trauma, iatrogenic aetiologies, Bechet\u0026rsquo;s disease, aortic infections (mycotic aneurysms), etc.\u003csup\u003e1\u003c/sup\u003e. The development of endovascular treatment in the past decades has already provided a new treatment option for open surgery\u003csup\u003e2\u003c/sup\u003e\u003csup\u003e,3\u003c/sup\u003e. Currently, as chimney or fenestration\u0026nbsp;techniques\u0026nbsp;are used as\u0026nbsp;assistive techniques, the indications for TEVAR have obviously expanded\u003csup\u003e4\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eSince 2002, chimney TEVAR has been reported to be used successfully for different types of aortic arch diseases\u003csup\u003e5,6\u003c/sup\u003e. However, for the treatment of aortic arch pseudoaneurysms, the current literature on chimney TEVAR is limited\u003csup\u003e7-18\u003c/sup\u003e. The aim of this retrospective study is to report the mid-term results of chimney TEVAR for aortic arch pseudoaneurysms in our centre.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003ePatients\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;From October 2015 to August 2020, 32 patients (64.1\u0026plusmn;15.0\u0026nbsp;years, range 28-81; 29 men) with aortic arch pseudoaneurysms underwent chimney TEVAR.\u0026nbsp;All the patients in this group received preoperative computed tomography angiography (CTA) of the aorta for diagnosis and measurement. The effective diameter, the average of aortic anteroposterior and lateral diameters, was independently measured by two radiologists using 1-mm\u0026ndash;collimation double-oblique reconstructions. The images sizing was conducted with Syngo fastView software (version VX57133,Siemens Healthineers,Germany). The decision regarding whether chimney TEVAR could be used was made on the basis of the anatomic features of the pseudoaneurysm and the arch.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were as follows: patients with thoracic aortic pseudoaneurysms without a sufficient proximal landing zone for standard endovascular repair, which meant that the pseudoaneurysms were close to (\u0026lt;15 mm) or already involved the orifice of the left subclavian artery, the chimney technique for\u0026nbsp;left subclavian artery\u0026nbsp;(LSA)\u0026nbsp;was performed; occasionally, even the left common carotid artery and innominate artery were involved. Double or triple chimney techniques were only used for patients who had contraindications to open surgery or who refused open surgery.\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria were as follows: patients with (a) pseudoaneurysms involving the ascending aorta; (b) concomitant cardiac diseases that required open surgery; (c) anatomic features not suitable for TEVAR, such as severe stenosis of the access route arteries or a very large landing zone (\u0026gt;40mm) that limited device use; (d) severe cardiopulmonary, renal, or hepatic diseases and thus could not tolerate general anaesthesia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn total, 32 patients underwent chimney TEVAR according to the inclusion and exclusion criteria. The patients\u0026rsquo; characteristics and comorbidities are listed in Table 1.\u003c/p\u003e\n\u003cp\u003eTreatment procedure\u003c/p\u003e\n\u003cp\u003eFor all 32 patients, blood pressure and heart rate were strictly controlled after admission (target blood pressure \u0026lt;110/70 mmHg, heart rate\u0026lt;70 beats/min). For the symptomatic patients, the systolic blood pressure was controlled to approximately 90/60 mmHg, and the heart rate 55～65 beats/min.\u003c/p\u003e\n\u003cp\u003eThe chimney TEVAR procedure was performed in a hybrid operating room under fluoroscopic guidance. General anaesthesia with tracheal intubation was performed in all patients.\u0026nbsp;The common femoral artery was exposed via surgical cut-down (26/29) and percutaneous puncture (3/29) using a Perclose ProGlide suture device (Abbott Laboratories Co., Ltd., USA), and if necessary, the brachial and carotid arteries were exposed surgically.\u003c/p\u003e\n\u003cp\u003eFirstly, the chimney stent-graft was preloaded into the orifice of the target branch with the proximal side in the aortic lumen and the distal side maintained in the branch. Covered stents (Fluency; C.R. Bard, Inc., NJ, USA, or Viabahn; Gore \u0026amp; Associates, AZ, USA) were used as chimneys in all patients. Secondly,\u0026nbsp;the aortic stent-graft [Hercules (MicroPort Medical Co., Ltd., Shanghai, China); Zenith (Cook, Inc., Bloomington, IN, USA); Ankura (Lifetech Scientific Co., Ltd., Shenzhen, China); or Valiant (Medtronic, Inc., Minneapolis, MN, USA)] was inserted via femoral access and deployed in the pre-established position of the aortic arch. The relative position of the chimney and aortic stent-graft was adjusted to keep the chimney away from the lesion in order to avoid blood flow from the gutter to the pseudoaneurysm. Thirdly, the chimney was deployed with an approximately 10 mm proximal segment over the proximal fabric ending of the aortic stent-graft into the aortic lumen and the distal segment in the branch artery (figure1). The chimneys in the innominate and carotid arteries were released immediately after deployment of the aortic stent-graft to shorten the cerebral ischaemia time (often less than 1 minute). For the purpose of improving long-term patency, chimneys were routinely dilated with a comparable balloon after deployment (10-12atm, 5-10 seconds). After chimney TEVAR, digital subtraction angiography (DSA）was performed to confirm the final results.\u0026nbsp;The aortic stent-graft and chimney stent-graft(s) were selected with 15~20% and 0~5% oversizing, respectively. Additional details of the operation process have already been reported previously by our colleagues\u003csup\u003e19, 20\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAfter chimney TEVAR, low-molecular-weight heparin (4,000 IU per 12 hours) was administered for 3~7 days, followed by aspirin (100 mg/day) for at least 1 month. For patients without endoleaks, aspirin (100 mg/d) could be taken longer or even lifelong after chimney TEVAR, especially for those with a chimney less than 8 mm in diameter\u003csup\u003e4\u003c/sup\u003e or those with coexisting arteriosclerotic diseases that required antiplatelet therapy. For patients with type Ia endoleaks, aspirin was stopped until CTA showed satisfactory thrombosis of the gutter. The timing for the cessation of aspirin was decided comprehensively based on the order of severity of the endoleak, the chimney diameter and the coexisting diseases.\u003c/p\u003e\n\u003cp\u003eFollow-up\u003c/p\u003e\n\u003cp\u003eAll patients underwent CTA and duplex ultrasound scans 1 week after chimney TEVAR or before discharge to evaluate the exclusion results of pseudoaneurysm and supra-aortic branch patency. Subsequent follow-up with physical examination and CTA was scheduled at 3, 6, and 12 months and annually thereafter, and telephone follow-up was performed semi-annually. The patients were asked to record all complaints and complications.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll the data were enrolled and retrospectively analysed. Clinical data analysis was conducted with SPSS software (version 21, SPSS Inc., Chicago, IL), and GraphPad Prism (version8; GraphPad Software, San Diego, CA, USA) was used to construct graphical representations of the data.Continuous variables were expressed as the mean \u0026plusmn; standard deviation, Kaplan-Meier analysis was used to establish the rate of survival.\u003c/p\u003e\n\u003cp\u003eEthical approval\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eProcedures\u003c/p\u003e\n\u003cp\u003eFrom October 2015 to August 2020, 32 patients (mean age 64.1\u0026plusmn;15.0 years, range 28-81; 29 men) with pseudoaneurysm performed cTEVAR. The etiologies were as follows: trauma or had a clear history of trauma in 10 (31.3%) patients, Bechet\u0026rsquo;s disease in 1 (3%) patient, and penetrating aortic ulcers or uncertain in 21 (65.6%) patients (table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThree\u0026nbsp;(9%) patients underwent emergent surgery, which was defined as chimney TEVAR performed within 24 hours after admission. The mean fluoroscopy time, which had been defined as the period from the first to the last angiography, was 35.3\u0026plusmn;7.7 minutes. The mean volume of contrast agent was 63.9\u0026plusmn;7.0 ml. The mean length of intensive care unit (ICU) stay and postoperative stay was 2.2\u0026plusmn;3.0 days and 8.3\u0026plusmn;5.0 days (table2).\u003c/p\u003e\n\u003cp\u003eIn total, 47 chimney stent-grafts were implanted to preserve 44 target supra-arch branch vessels (table 3). Which included the LSA (n=29), left common carotid artery (LCCA) (n=12) and innominate artery (IA) (n=3), and for 8 patients, the chimney technique for the LSA was performed in a reverse manner as a periscope. Moreover, in case 9 the patient simultaneously underwent endovascular repair of an abdominal aortic aneurysm with a maximum sac diameter of 60 mm, with special consideration that the patient had abdominal pain symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePerioperative outcomes\u003c/p\u003e\n\u003cp\u003eType Ia, Ib, II, III, and IV endoleaks occurred in 3 (9%), 0, 0, 0, and 0 patients, respectively. All type Ia endoleaks were slow flow and under close surveillance without reintervention. The detailed data related to the surgical procedure are shown in table2.\u003c/p\u003e\n\u003cp\u003eIn our study, symptoms of hoarseness (n=7) and chest and back pain (n=12) were\u0026nbsp;all\u0026nbsp;relieved. All patients were given low-molecular-weight heparin and then a standard antiplatelet agent (100 mg/day aspirin) after chimney TEVAR, except for 3 patients who had type Ia endoleaks (case 1, case 10 and case 11). For them, antiplatelet therapy was cancelled 1 week (cases 1 \u0026amp; 10) and 1 month (case 11) after chimney TEVAR.\u0026nbsp;After follow-up CTA showed no remaining endoleaks, antiplatelet therapy was given to\u0026nbsp;them\u0026nbsp;again thereafter. In case 10, the patient had Bechet\u0026rsquo;s disease and also received standard immunotherapy postoperatively. For patients with hypertension, anti-hypertension medication therapy was continued perioperatively.\u003c/p\u003e\n\u003cp\u003eThe 30-day mortality rate was 3% (n = 1). In case 5, the 77-year-old male patient had a large symptomatic aortic arch pseudoaneurysm with a maximum diameter of 78 mm that involved the whole arch. Because he was considered at very high risk for open chest surgery due to multiple severe coexisting diseases, TEVAR with the chimney technique for the IA and LCCA and a periscope for the LSA was performed. He had a history of exertional angina and was confirmed via CTA to have severe left main coronary artery stenosis, which was planned to be treated after endovascular aortic arch repair. Unfortunately, he died suddenly from acute myocardial infarction 10 days after the chimney TEVAR operation.\u003c/p\u003e\n\u003cp\u003eAnother 67-year-old male patient, case 11, lived in the plateau area with an altitude over 3500 metres for 30 years and suffered from a variety of diseases, including chronic obstructive pulmonary disease, pulmonary heart disease, pulmonary hypertension, multiple pulmonary nodules, hypertension, gout and a history of bloody\u0026nbsp;phlegm. The patient was transferred out of the ICU 2 days after the operation and was transferred to the ICU again for rescue due to massive haemoptysis associated with bronchiectasis on the 7th postoperative day. After conservative treatment, he recovered and was discharged 26 days postoperatively. Till now he lived uneventfully for another 5 years.\u003c/p\u003e\n\u003cp\u003eThe case 15 patient had lower hemoglobin index (67g/L) and left upper limb hematoma after operation, and he received brachial artery repair on the 15th\u0026nbsp;postoperative\u0026nbsp;day due to\u0026nbsp;pseudoaneurysm at the puncture point.\u003c/p\u003e\n\u003cp\u003eMidterm follow-up\u003c/p\u003e\n\u003cp\u003eTwo patients were lost to follow-up and the median follow-up was 46.5\u0026plusmn;14.3 (range, 4.5-60) months, and 3 other patients died during the midterm follow-up period, and the Kaplan-Meier survival curve is presented\u0026nbsp;in Figure 2. The overall 4.5-year survival rate was 84.4%. Patient 32 suffered from chronical renal insufficiency before admission, and he received regular dialysis treatment before discharge but died 1.5 months postoperatively. Patient 16 died in the 31st month after TEVAR because of lung cancer, and patient 24 died in the 20th postoperative month because of uncertain reasons.\u003c/p\u003e\n\u003cp\u003eWith conservative treatment, including ceasing the use of antiplatelet agents and controlling the systolic pressure at 90\u0026ndash;110 mm Hg and heart rate at 55\u0026ndash;70 beats/min with antihypertensive agents and \u0026beta;-blockers, the 3 slow-flow type Ia endoleaks sealed spontaneously 3 months (case 1 \u0026amp; case 11) and 1 year (case 10), respectively, after chimney TEVAR. However, Chimney stent-graft of case 10 was occluded which might have been associated with the cessation of antiplatelet agents, and 70% stenosis of the chimney occurred in case 18.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAortic pseudoaneurysm is defined as a dilation of the aorta due to the disruption of all wall layers; it is only contained by periaortic connective tissue and can become a lethal situation, and the selection between endovascular and open surgical treatment depends on anatomic features, clinical presentations and comorbidities\u003csup\u003e1\u003c/sup\u003e. Some articles have reported the effectiveness of TEVAR in the treatment of pseudoaneurysms caused by tuberculosis\u003csup\u003e21, 22\u003c/sup\u003e, trauma\u003csup\u003e3, 23\u003c/sup\u003e and Bechet\u0026rsquo;s disease\u003csup\u003e24\u003c/sup\u003e. TEVAR enabled minimization of the intraoperative risk, particularly in unstable multi-trauma patients with a severe clinical status.\u003c/p\u003e\n\u003cp\u003eTraumatic aortic pseudoaneurysms occur in 2% of patients with blunt thoracic trauma\u003csup\u003e27\u003c/sup\u003e\u003csup\u003e,28\u003c/sup\u003e. Endovascular treatment was early used successfully in 1997 by Semba\u003csup\u003e29\u003c/sup\u003e. A recent meta-analysis by Amer Harky et al\u003csup\u003e3\u003c/sup\u003e indicated that TEVAR carries lower in-hospital mortality and provides satisfactory perioperative outcomes compared with open repair in traumatic ruptured thoracic aortic pseudoaneurysms. Ten patients with possible traumatic reasons in this study had uneventful in-hospital and follow-up outcomes, and all of them had a history of traumatic accidents 5 to 20 years ago. The possible mechanism is, when the human body suffers deceleration injury, the arterial ligament may pull the wall of the small curvature of the aortic isthmus, which may lead to local injury, and over the years, the lesion progresses into a pseudoaneurysm as the blood flow impinges. Therefore, if the patient had unexplained pseudoaneurysms and had a history of severe trauma several years ago (such as a car accident), we also believed that the pseudoaneurysms might be related to the history of trauma.\u003c/p\u003e\n\u003cp\u003eFor patients without\u0026nbsp;aortic injuries, infections, autoimmune diseases,\u0026nbsp;PAU\u0026nbsp;should be the most common aetiologies for aortic pseudoaneurysms. The pseudoaneurysms might have originated from a calcified plaque rupture, PAU could be the beginning form of pseudoaneurysms, they may lead to intramural haematoma, dissection, pseudoaneurysms, or even aortic\u0026nbsp;rupture\u003csup\u003e30\u003c/sup\u003e. This pathologic condition is distinct from classic aortic dissection, which is more frequently seen in the natural history of PAUs with the propensity to evolve into aneurysms or pseudoaneurysms\u003csup\u003e31\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe chimney TEVAR technique\u0026nbsp;was\u0026nbsp;mostly\u0026nbsp;used as a preferential choice in patients with inadequate proximal landing zones for standard TEVAR. The technique was early used by Criado et\u0026nbsp;al\u003csup\u003e32\u003c/sup\u003e in arch-TEVAR with bare stents to rescue LSAs in the landing zones. Hiramoto et al\u003csup\u003e33\u003c/sup\u003e reported the administration of covered stents in the chimney technique assisted by TEVAR in 2006. According to our experience, covered chimney stents are very useful for decreasing the incidence of type Ia endoleaks.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority of these patients in our study received a single chimney graft. Compared with carotid-subclavian transposition or carotid-subclavian bypass, in chimney TEVAR, the incidence of neurological events is not high due to the shorter operation time and more minimally invasive neck incision. Therefore, we routinely performed chimney TEVAR instead of carotid-subclavian transposition or carotid-subclavian bypass. Our team reported the outcomes of the LCCA chimney technique for the endovascular repair of acute non-A\u0026ndash;non-B aortic dissections in 2011\u003csup\u003e4\u003c/sup\u003e, and 8 patients were included in the study, with no mortality and a 100% chimney patency rate during a mean follow-up of 11.4 months. In 2015, a larger retrospective study of 41 patients reported by our team revealed similar perioperative results\u003csup\u003e19\u003c/sup\u003e. In 2017, Wang T et al reported the results of 122 patients (no pseudoaneurysms) who underwent chimney TEVAR\u003csup\u003e20\u003c/sup\u003e, and the outcomes indicated that chimney TEVAR provided a safe, minimally invasive alternative with good chimney graft patency and low postoperative mortality for aortic arch pathologies. However, aortic arch pseudoaneurysms managed by chimney TEVAR have seldom been reported, and most previous studies in this area are case reports. This study significantly enriched the reported experience of chimney TEVAR for aortic arch pseudoaneurysms.\u003c/p\u003e\n\u003cp\u003eThe risk of type Ia endoleaks is the main problem of the chimney technique because of the \u0026ldquo;gutter\u0026rdquo; between the chimney and aortic stent-grafts. We recommend an overlap of at least 2 cm between the chimney and aortic stent-grafts if possible. A longer overlap, adequate oversizing of the thoracic stent-graft and appropriate ballooning of the chimneys could narrow the gutter and decrease the incidence of type Ia endoleaks. If a pseudoaneurysm is restricted to one side of the aortic arch, such as the anterior or postesrior wall, the relative position of the chimney and aortic stent-graft should be adjusted to keep the chimney away from the lesion in order to avoid blood flow from the gutter to the pseudoaneurysm. Aneurysms and pseudoaneurysms are mainly different in anatomy. In pseudoaneurysms, the majority of the aortic wall has been breached, but the extent of involvement is often focal, so the peudoaneurysms may have a lower incidence of type I endoleak.\u003c/p\u003e\n\u003cp\u003eNo cases of stroke occurred in our study. In our opinion, the most important factors for preventing stroke during and after chimney TEVAR include preoperatively analysing the target vessels with CTA and colour duplex ultrasound to see if there is any stenosis or calcified plaques, shortening the operation time via skilful manipulation, and open control instead of percutaneous puncture of the carotid or innominate artery, which may minimize vessel trauma and, accordingly, cerebral embolism risk.\u003c/p\u003e\n\u003cp\u003eAntiplatelet therapy including aspirin (100 mg/d) was administered routinely for patients with no endoleak after chimney TEVAR. However, for patients with endoleaks, especially type Ia endoleaks, cessation of antiplatelet therapy was considered individually.The antiplatelet therapy may be linked to an increased risk for the development of endoleak\u003csup\u003e34\u003c/sup\u003e, and cessation of antiplatelet therapy may result in a risk of chimney occlusion and stroke. If the endoleak is slow flow, and the status of the pseudoaneurysm was stable peri-operatively, early use of antiplatelet agents for approximately one month without increasing the rupture risk of pseudoaneurysms might contribute to chimney patency, but this remains to be proven. For patients with pseudoaneurysms, reducing sac pressure and avoiding rupture are the fundamental and key objectives of treatment. If the pseudoaneurysm pressure cannot be relieved and the safety of patients cannot be ensured, antiplatelet therapy has to be cancelled to help thrombosis of the lesion. However, if severe type Ia endoleaks occur after the carotid or innominate chimney technique, or if a patient has to use antiplatelet agents continuously for some reason (e.g., after coronary stenting), the decision of how to administer antiplatelet therapy would be very controversial. Therefore, it is important to emphasize that in patients with a high risk of endoleak, such as in cases where the target vessel arises from the pseudoaneurysm, the use of hybrid or other techniques instead of chimney TEVAR is recommended, especially for patients who cannot stop using antiplatelet agents.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAortic pseudoaneurysm is a lethal pathologic condition. For high selected aortic arch pseudoaneurysms with inadequate landing zones for TEVAR, the chimney technique seems to be feasible, with acceptable mid-term outcomes, and it could serve as an alternative minimally invasive approach to extend the landing zone.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;According to this small cohort, slow flow type Ia endoleaks after chimney TEVAR could be treated conservatively. Additional experience is needed, and the long-term durability of chimney TEVAR requires further follow-up.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTEVAR: thoracic endovascular aortic repair; PAU: penetrating aortic ulcer; CTA: computed tomography angiography; LSA: left subclavian artery ; DSA: digital subtraction angiography; ICU: intensive care unit; LCCA: left common carotid artery; IA: innominate artery; CHD: coronary heart disease; CRF: chronic renal failure; DM: diabetes mellitus\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe procedures followed were in accordance with the ethical standards of the Institute Review Board of\u0026nbsp;our\u0026nbsp;Hospital (NO.2017-946) and Helsinki Declaration. Written informed consent was obtained from all the patients and their relatives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the participants provided written informed consent for the publication of\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ethe results of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used in this study are available from the corresponding author if\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eneeded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor\u0026rsquo;s declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Natural Science Foundation, China (No. 81870345), the Beijing Science and Technology Project (No. D171100002917004), the Grant of CAMS Initiative for Innovative Medicine, China (NO. 2016-I2M-1-016), and the\u0026nbsp;Yunnan Provincial Cardiovascular Disease Clinical Medical Center Project\u0026nbsp;(NO. FZX2019-06-01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMYL, XZ and CS analyzed the results and composed the manuscript. KF and YYG participated in the collection of clinical data. DC and JTL participated in editing the manuscript.All authors review and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank\u0026nbsp;Yunfei\u0026nbsp;Xue\u0026nbsp;and Jiawei Zhao for their assistance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eState Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, Beilishi Road, Xicheng District, Beijing, 100037, China. \u003csup\u003e2\u003c/sup\u003eDepartment of Vascular Surgery, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, 650102, China.\u0026nbsp;\u003csup\u003e3\u003c/sup\u003eDepartment of Surgery, Stanford University School of Medicine, Stanford, CA,94305, USA. \u003csup\u003e4\u003c/sup\u003eDepartment of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410013, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eErbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 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Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease. J Vasc Surg. 2012;55:10\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eVilacosta I, San Roman JA, Aragoncillo P, Ferreiros J, Mendez R, Graupner C, et al.Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography. J Am Coll Cardiol. 1998;32:83\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCriado FJ, Barnatan MF, Rizk Y, Clark NS and Wang CF. Technical strategies to expand stent-graft applicability in the aortic arch and proximal descending thoracic aorta. J Endovasc Ther. 2002;9 Suppl 2:32\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHiramoto JS, Schneider DB, Reilly LM and Chuter TA. A double-barrel stent-graft for endovascular repair of the aortic arch. J Endovasc Ther. 2006;13:72\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eJoseph L. Bobadilla, John R. Hoch, Glen E. Leverson, Girma Tefera. The effect of warfarin therapy on endoleak development after endovascular aneurysm repair (EVAR) of the abdominal aorta. J Vasc Surg. 2010;52:267\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003eTable 1. Patient Characteristics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e25.9\u0026plusmn;2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e29 (91）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eObese (BMI\u0026gt;30kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eComorbidities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e22 (69)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eHyperlipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e16 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eCHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e10 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eCRF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e3 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e5 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e10 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e19 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eChest and back pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e11 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eHoarseness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e7 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"53.55029585798817%\"\u003e\n \u003cp\u003eNone of symptom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.44970414201183%\"\u003e\n \u003cp\u003e14 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" width=\"100%\"\u003e\n \u003cp\u003eCHD, coronary heart disease. CRF, chronic renal failure. DM, diabetes mellitus.\u003c/p\u003e\n \u003cp\u003eContinuous data are presented as the means \u0026plusmn; standard deviation; categorical data are given as the counts (percentage).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003eTable 2. Operative characteristics and outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eEmergency cTEVAR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e3 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eAortic branches chimneys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eLeft subclavian artery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eLeft common carotid artery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eInnominate artery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eLanding zones\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eZone 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e3 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eZone 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e9 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eZone 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e10 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eFluoroscopy time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e35.3 \u0026plusmn; 7.7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eContrast volume (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e63.9 \u0026plusmn; 7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003ePost-OP ICU stay (days）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e2.2\u0026nbsp;\u0026plusmn;\u0026nbsp;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003ePost-OP stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e8.3\u0026nbsp;\u0026plusmn;\u0026nbsp;5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003ePostoperative complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eEndoleak\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e3 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eChimney stenosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e1(3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e4 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eAortic related reoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"70.95808383233533%\"\u003e\n \u003cp\u003eAortic related rehospitalization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.04191616766467%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" width=\"100%\"\u003e\n \u003cp\u003eTEVAR, thoracic endovascular aortic repair; OP, operation; ICU, intensive care unit.\u003c/p\u003e\n \u003cp\u003eContinuous data are presented as the means \u0026plusmn; standard deviation; categorical data are given as the counts (percentage).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" width=\"100%\"\u003e\n \u003cp\u003eTable 3. Stent graft characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.371681415929203%\"\u003e\n \u003cp\u003eAortic stent graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003eLanding zone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003eIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003eLCCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003eLSA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e34-30-160 (LA）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e28-24-160 (LA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e26-22-160 (MH)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e10-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e36-28-180 (LA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e36-36-200 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e14-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e6-80 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-150 (GV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e36-36-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e6-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e34-28-180 (LA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e34-34-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-80 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e34-34-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e28-28-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e5-50 (GV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.371681415929203%\"\u003e\n \u003cp\u003e32-32-200 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.371681415929203%\"\u003e\n \u003cp\u003e32-32-200 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e6-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e42-42-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e10-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e6-80 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e32-32-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e42-42-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e6-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.371681415929203%\"\u003e\n \u003cp\u003e34-34-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e8-60 (BF) \u0026nbsp; \u0026nbsp; 8-80 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e6-80 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-150 (GV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e32-32-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e6-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e28-22-180 (LA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e34-30-160 (LA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-80 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e34-30-160 (LA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e36-32-160 (MH)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e6-80 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.371681415929203%\"\u003e\n \u003cp\u003e34-34-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e8-60 (BF) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;8-80 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-150 (GV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.371681415929203%\"\u003e\n \u003cp\u003e34-30-160 , 32-38-160 (MH)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e6-60 (BF)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-80 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e42-42-200, 28-28-80 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-50 (GV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e34-34-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e6-80 (BF)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e10-150 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e34-24-200 (LA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-50 (GV) \u0026nbsp; \u0026nbsp; \u0026nbsp;8-150 (GV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e30-24-160 (LA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e28-28-150 (GT)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e8-50 (GV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e32-32-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e7-50 (GV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e30-30-200 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e6-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e6-150 (GV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003e36-36-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e9-50 (GV) \u0026nbsp; \u0026nbsp; \u0026nbsp;8-150 (GV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.026548672566372%\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.371681415929203%\"\u003e\n \u003cp\u003eValiant 30-30-150 (MV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.053097345132745%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.274336283185841%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.920353982300885%\"\u003e\n \u003cp\u003e8-60 (BF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.353982300884955%\"\u003e\n \u003cp\u003e6-150 (GV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" width=\"100%\"\u003e\n \u003cp\u003eBF, Bard Fluency; GV, Gore Viabahn; LA, Lifetech Ankura; MH, MicroPort Hercules; MV, Medtronic Valiant; GT,Gore TAG; LSA, left subclavian artery. LCCA, left common carotid artery. IA, innominate artery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"aortic arch pseudoaneurysm, chimney graft/technique, thoracic endovascular aortic repair, type Ia endoleak, trauma, innominate artery, left common carotid artery, left subclavian artery","lastPublishedDoi":"10.21203/rs.3.rs-1794554/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1794554/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eAortic pseudoaneurysm is a life-threatening clinical\u0026nbsp;condition, and\u0026nbsp;thoracic endovascular aortic repair (TEVAR) has been reported to have a relatively satisfactory effect in aortic pathologies. We summarized our single-centre experience using chimney TEVAR for aortic arch pseudoaneurysms with inadequate landing zones.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA retrospective study was conducted\u0026nbsp;from October 2015 to August 2020, 32 patients (64.1±15.0 years, range 28-81; 29 men) with aortic arch pseudoaneurysms underwent chimney TEVAR to exclude an aortic lesion and reconstruct the supra-aortic branches, including 3 innominate artery, 12 left common carotid arteries and 29 left subclavian arteries. Follow-up computed tomography was suggested before discharge; at 3, 6, and 12 months; and yearly thereafter.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eForty-four related supra-aortic branches were well preserved and the technical success rate was 100%. The Type Ia endoleaks occurred in 3 (9%) patients. Two patients were lost to follow-up and 4 patients died during the follow-up period. The median follow-up was 46.5±14.3 (range, 4.5-60) months. One patient died due to acute myocardial infarction just 10 days after chimney TEVAR and the other 3 patients passed away at 1.5 months, 20 months and 31 months with non-aortic reasons. The 4.5-year survival estimate was 84.4%. The primary patency rate of the target supra-arch branch vessels was 97.7% (43/44), and no other aorta-related reinterventions and severe complications occurred.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eFor aortic arch pseudoaneurysms with inadequate landing zones for TEVAR, the chimney technique seems to be feasible, with acceptable mid-term outcomes, and it could serve as an alternative minimally invasive approach to extend the landing zone. Slow flow type Ia endoleak could be treated conservatively after chimney TEVAR. Additional experience is needed, and the long-term durability of chimney TEVAR requires further follow-up.\u003c/p\u003e","manuscriptTitle":"Endovascular Aortic Arch Repair with Chimney Technique for Pseudoaneurysm","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-29 17:26:06","doi":"10.21203/rs.3.rs-1794554/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-07-27T06:48:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-07-23T09:22:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6d77cb75-a54a-4910-b686-8fe509446f45","date":"2022-07-19T01:18:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-07-18T15:24:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-07-18T15:11:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-06-25T13:09:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-06-25T13:07:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2022-06-25T12:24:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"91760e35-f3dc-4e5a-8500-0397851ac80a","owner":[],"postedDate":"June 29th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2023-01-24T07:59:33+00:00","versionOfRecord":[],"versionCreatedAt":"2022-06-29 17:26:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1794554","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1794554","identity":"rs-1794554","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}