烟囱和开窗EVAR技术治疗肾旁腹主动脉瘤的中期效果及术式选择策略分析

doi:10.3969/j.issn.1006-5725.2026.12.006

Abstract

Abstract:

Objective To compare the mid-term outcomes of chimney endovascular aneurysm repair （ch-EVAR） and fenestrated endovascular aneurysm repair （f-EVAR） in treating pararenal abdominal aortic aneurysm （PAAA）， and to explore the anatomical criteria for the selection of the procedure. Methods A retrospective analysis was carried out on the clinical data of 95 patients with PAAA who were treated at Tianjin Medical University General Hospital from January 2013 to December 2021. Among them， there were 52 patients in the ch-EVAR group and 43 in the f-EVAR group. The technical success rate， perioperative complications， and 36-month follow-up outcomes were compared between the two groups. Receiver operating characteristic （ROC） curve analysis was conducted to characterize the distribution of anatomical parameters， such as the tortuosity index and the number of planned reconstructed branches. Results The technical success rates were 98.08% in the ch-EVAR group and 97.67% in the f-EVAR group （P > 0.05）. The number of planned reconstructed visceral arteries was notably higher in the f-EVAR group compared to the ch-EVAR group （2.19 ± 1.22 vs. 1.23 ± 0.58， P < 0.001）. ROC curve analysis indicated a tortuosity index threshold of 1.08 （AUC = 0.925） and a reconstructed branch number threshold of 1.5 （AUC = 0.726） that could distinguish the two groups. The incidence of immediate type Ⅲ endoleak was greater in the f-EVAR group than in the ch-EVAR group （16.28% vs. 0.00%， P = 0.003）， while the overall endoleak rate did not show a significant difference between the groups. During a mean follow-up period of （35.4 ± 24.2） months， no significant differences were found in the cumulative survival rate， freedom from non-PAAA-related mortality， or freedom from secondary intervention between the two groups （P > 0.05）. Conclusions Ch-EVAR and f-EVAR exhibit comparable mid-term efficacy in the treatment of PAAA. According to the retrospective data from our center， f-EVAR might be the preferred choice for patients with a tortuosity index < 1.08 who need to reconstruct ≥ 2 visceral arteries. In contrast， ch-EVAR serves as a safe and effective surgical alternative for elderly patients with a tortuosity index > 1.08 who only require single-branch reconstruction.

Key words: abdominal aortic aneurysm, endovascular aneurysm repair, chimney technique, fenestrated technique, tortuosity index

CLC Number:

R654.3

Xiaoxing ZHANG,Jingyao HE,Xiangchen DAI. Mid-term outcomes and surgical strategy analysis of chimney EVAR and fenestrated EVAR in the treatment of pararenal abdominal aortic aneurysm[J]. The Journal of Practical Medicine, 2026, 42(12): 2128-2135.

Figures/Tables 7

Fig.1

Fig.2

Tab.1

Fig.3

Tab.2

Fig.4

Tab.3

References 23

[1]	ISSELBACHER E M， PREVENTZA O， HAMILTON BLACK J R， et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease： A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines ［J］. Circulation， 2022， 146（24）： e334-e482.doi： 10.1161/cir.0000000000001106 . doi: 10.1161/cir.0000000000001106
[2]	ANAGNOSTAKOS J， LAL B K. Abdominal aortic aneurysms ［J］. Prog Cardiovasc Dis， 2021， 65： 34-43.doi： 10.1016/j.pcad.2021.03.009 . doi: 10.1016/j.pcad.2021.03.009
[3]	ZHANG P， LIU C， LI J， et al. Risk factors for abdominal aortic aneurysm in general populations： A systematic review and meta-analysis ［J］. PLoS One， 2025， 20（9）： e0329500.doi： 10.1371/journal.pone.0329500 . doi: 10.1371/journal.pone.0329500
[4]	KONTOPODIS N， GALANAKIS N， CHARALAMBOUS S， et al. Editor's Choice-Endovascular Aneurysm Repair in High Risk Patients： A Systematic Review and Meta-Analysis ［J］. Eur J Vasc Endovasc Surg， 2022， 64（5）： 461-474.doi： 10.1016/j.ejvs.2022.07.009 . doi: 10.1016/j.ejvs.2022.07.009
[5]	WANHAINEN A， VAN HERZEELE I， BASTOS GONCALVES F， et al. Editor's Choice-European Society for Vascular Surgery （ESVS） 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms ［J］. Eur J Vasc Endovasc Surg， 2024， 67（2）.doi： 10.1016/j.ejvs.2023.11.002 . doi: 10.1016/j.ejvs.2023.11.002
[6]	WANG C， GAO J， ZHANG H， et al. Early Outcome of WeFlow-JAAA Off-the-Shelf Endograft in the Treatment of Juxtarenal/Pararenal Abdominal Aortic Aneurysms ［J］. Ann Vasc Surg， 2025， 122（0）： 187-193.doi： 10.1016/j.avsg.2025.06.007 . doi: 10.1016/j.avsg.2025.06.007
[7]	GAO J P， WANG C A， ZHANG H P， et al. Anatomic feasibility of the WeFlow-JAAA endograft system for treating juxtarenal and pararenal abdominal aortic aneurysms ［J］. Sci Rep， 2025， 15（1）： 39818.doi： 10.1038/s41598-025-23485-y . doi: 10.1038/s41598-025-23485-y
[8]	FARUQI R M， CHUTER T A， REILLY L M， et al. Endovascular repair of abdominal aortic aneurysm using a pararenal fenestrated stent-graft ［J］. J Endovasc Surg， 1999， 6（4）： 354-358.doi： 10.1177/152660289900600411 . doi: 10.1177/152660289900600411
[9]	GREENBERG R K， CLAIR D， SRIVASTAVA S， et al. Should patients with challenging anatomy be offered endovascular aneurysm repair？［J］. J Vasc Surg， 2003， 38（5）： 990-996.doi： 10.1016/s0741-5214（03）00896-6 . doi: 10.1016/s0741-5214（03）00896-6
[10]	DIBARTOLOMEO A D， PYUN A J， DING L， et al. Comparative outcomes of physician-modified fenestrated-branched endovascular repair of post-dissection and degenerative complex abdominal or thoracoabdominal aortic aneurysms ［J］. J Vasc Surg， 2023， 78（3）： 565-574.e562.doi： 10.1016/j.jvs.2023.05.005 . doi: 10.1016/j.jvs.2023.05.005
[11]	ZLATANOVIC P， JOVANOVIC A， TRIPODI P， et al. Chimney Versus Fenestrated Endovascular Versus Open Repair for Juxta/Pararenal Abdominal Aortic Aneurysms： Systematic Review and Network Meta-analysis of the Short-term Results ［J］. World J Surg， 2022， 47（3）： 803-823.doi： 10.1007/s00268-022-06829-x . doi: 10.1007/s00268-022-06829-x
[12]	WILSON E M， YAO K， KOSTIUK V， et al. Adherence to SVS Abdominal Aortic Aneurysm Guidelines Among Patients Detected by AI-Based Algorithm ［J］. Ann Vasc Surg， 2025， 120： 108-114. doi： 10.1016/j.avsg.2025.05.007 . doi: 10.1016/j.avsg.2025.05.007
[13]	LIU T， HU T， LU W， et al. Morphology and biomechanical index predict the rupture location and rupture risk of abdominal aortic aneurysm ［J］. Sci Rep， 2025， 15（1）：9604.doi： 10.1038/s41598-025-94828-y . doi: 10.1038/s41598-025-94828-y
[14]	LI S， WANG W， SUN X， et al. Monocentric Evaluation of Physician-Modified Fenestrations or Parallel Endografts for Complex Aortic Diseases ［J］. J Endovasc Ther， 2023， 31（5）： 936-948.doi： 10.1177/15266028221149918 . doi: 10.1177/15266028221149918
[15]	CHUN J Y， HAAN M D， MALEUX G， et al. CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair ［J］. Cardiovasc Intervent Radiol， 2024， 47（2）： 161-176.doi： 10.1007/s00270-023-03629-1 . doi: 10.1007/s00270-023-03629-1
[16]	CHARISIS N， BOURIS V， CONWAY A M， et al. A Systematic Review and Pooled Meta-Analysis on the Incidence and Temporal Occurrence of Type II Endoleak Following an Abdominal Aortic Aneurysm Repair ［J］. Ann Vasc Surg， 2021， 75： 406-419.doi： 10.1016/j.avsg.2021.01.083 . doi: 10.1016/j.avsg.2021.01.083
[17]	REYES VALDIVIA A， MILNER R， HEIJMEN R， et al. Mid-term outcomes of the use of endoanchors during thoracic endovascular aortic repair in multicentre analysis ［J］. Vascular， 2022， 31（3）： 455-462.doi： 10.1177/17085381221076320 . doi: 10.1177/17085381221076320
[18]	TANEVA G T， LEE J T， TRAN K， et al. Long-term chimney/snorkel endovascular aortic aneurysm repair experience for complex abdominal aortic pathologies within the PERICLES registry ［J］. J Vasc Surg， 2020， 73（6）： 1942-1949.doi： 10.1016/j.jvs.2020.10.086 . doi: 10.1016/j.jvs.2020.10.086
[19]	PITOULIAS G A， FAZZINI S， DONAS K P， et al. Multicenter Mid-Term Outcomes of the Chimney Technique in the Elective Treatment of Degenerative Pararenal Aortic Aneurysms ［J］. J Endovasc Ther， 2021， 29（2）： 226-239.doi： 10.1177/15266028211047940 . doi: 10.1177/15266028211047940
[20]	PEI Y， WANG Z， HAO S， et al. Analysis of independent risk factors for aneurysm rupture based on carotid tortuosity index and morphological parameters of single intracranial aneurysms in anterior circulation ［J］. Clin Neurol Neurosurg， 2023， 234： 107993.doi： 10.1016/j.clineuro.2023.107993 . doi: 10.1016/j.clineuro.2023.107993
[21]	OLSON S L， PANTHOFER A M， BLACKWELDER W， et al. Role of volume in small abdominal aortic aneurysm surveillance ［J］. J Vasc Surg， 2021， 75（4）： 1260-1267.doi： 10.1016/j.jvs.2021.09.046 . doi: 10.1016/j.jvs.2021.09.046
[22]	BATH J， FAZZINI S， IPPOLITI A， et al. Chimney endovascular aneurysm repair （ChEVAR） for hostile neck complex aneurysm ［J］. Vascular， 2022， 30（6）： 1058-1068.doi： 10.1177/17085381211043951 . doi: 10.1177/17085381211043951
[23]	ZOTTOLA Z R， KRUGER J L， KONG D S， et al. Locoregional anesthesia is associated with reduced hospital stay and need for intensive care unit care of elective endovascular aneurysm repair patients in the Vascular Quality Initiative ［J］. J Vasc Surg， 2022， 77（4）：1061-1069.doi： 10.1016/j.jvs.2022.11.043 . doi: 10.1016/j.jvs.2022.11.043

项目	ch-EVAR（n = 52）	f-EVAR（n = 43）	t/χ² 值	P值
年龄（x ± s）/岁	71.87 ± 8.83	67.84 ± 8.56	2.244	0.027
男性	36（69.23）	35（81.40）	1.845	0.174
吸烟史	24（46.15）	25（58.14）	1.354	0.245
高血压	41（78.85）	36（83.72）	0.364	0.546
2型糖尿病	2（3.85）	6（13.95）	3.118	0.077
冠心病	22（42.31）	15（34.88）	0.546	0.460
慢阻肺	4（7.69）	2（4.65）	0.368	0.544
肾功能不全	1（1.92）	5（11.62）	3.747	0.053
肾旁腹主动脉瘤形态学特征
腹主动脉瘤最大直径（x ± s）/mm	60.78 ± 15.30	58.96 ± 16.70	0.522	0.606
腹主动脉瘤中线长度（x ± s）/mm	131.54 ± 23.59	124.83 ± 22.91	1.400	0.165
扭曲指数（x ± s）	1.17 ± 0.08	1.07 ± 0.03	8.138	< 0.001
计划重建分支动脉（x ± s）/条	1.23 ± 0.58	2.19 ± 1.22	-5.005	< 0.001
腹腔干动脉	3（5.77）	12（27.91）	8.675	0.008
肠系膜上动脉	8（15.38）	23（53.49）	15.545	< 0.001
左肾动脉	29（55.77）	32（74.42）	3.562	0.059
右肾动脉	23（44.23）	27（62.79）	3.252	0.071

项目	ch-EVAR（n = 52）	f-EVAR（n = 43）	t/χ² 值	P值
麻醉方式
全麻	25（48.08）	37（86.05）	14.968	< 0.001
局麻+监护	27（51.92）	6（13.96）	14.968	< 0.001
术中即刻并发症
内漏	12（23.08）	14（32.56）	1.064	0.302
Ⅰa型	9（17.31）	4（9.30）	1.277	0.204
Ⅰb型	2（3.85）	0（0.00）	1.689	0.297
Ⅱ型	1（1.92）	3（6.98）	1.490	0.240
Ⅲ型	0（0.00）	7（16.28）	9.138	0.003
分支动脉闭塞	1（1.92）	0（0.00）	1.000	0.361
手术时间（x ± s）/min	154.38 ± 95.77	160.91 ± 96.95	-0.329	0.743
手术成功率	51（98.08）	43（100.00）	0.836	0.361
技术成功率	51（98.08）	42（97.67）	0.892	0.703

时间	组别	累计生存率			非PAAA相关死亡率			免于二次手术干预率
时间	组别	百分比/%	对数秩检验	P值	百分比/%	对数秩检验	P值	百分比/%	对数秩检验	P值
6月	ch-EVAR	84.5	2.874	0.090	96.0	1.702	0.192	95.9	1.661	0.197
6月	f-EVAR	95.3	2.874	0.090	100.0	1.702	0.192	88.3	1.661	0.197
12月	ch-EVAR	82.5	3.658	0.056	93.7	2.652	0.103	95.9	1.661	0.197
12月	f-EVAR	95.3	3.658	0.056	100.0	2.652	0.103	88.3	1.661	0.197
36月	ch-EVAR	74.6	1.009	0.315	93.7	2.652	0.103	91.5	1.412	0.235
36月	f-EVAR	82.0	1.009	0.315	100.0	2.652	0.103	85.5	1.412	0.235

Mid-term outcomes and surgical strategy analysis of chimney EVAR and fenestrated EVAR in the treatment of pararenal abdominal aortic aneurysm

RichHTML

PDF (PC)

Knowledge

Abstract

Cite this article

share this article

Figures/Tables 7

References 23

Related Articles 4

Recommended Articles

Metrics

Comments

[1]	Jun LÜ,Tang DENG,Jin PENG,Xunkai WANG,Jiangpeng WU,Guiyun JIN. Mechanism of maresin1 in alleviating lower limb ischemia-reperfusion injury by inhibiting pyroptosis via the TLR4/NF-κB/NLRP3 pathway [J]. The Journal of Practical Medicine, 2026, 42(10): 1849-1857.
[2]	Shulian GAO,Lingxiu ZHONG,Yamin SONG,Lixia LIN,Senpei ZHUANG,Jian TAO. Risk factors of tracheal reintubation after total aortic arch replacement [J]. The Journal of Practical Medicine, 2025, 41(11): 1681-1686.
[3]	Peiyao MA,Shenke KONG,Qiang ZHAO,Kun WANG,Xin WANG,Wenzhi WANG,Fayun ZHAO,Yanxin LI,Pengfei WANG,Ruishan LIU,Gejun ZHANG,Zhongying XU,Liang XU,Huijun SONG,Yihang. LI. Impact of bicuspid aortic valve or tricuspid aortic valve on left ventricular reverse remodeling after transcatheter percutaneous intervention for coarctation of aorta complicated by bicuspid or tricuspid aortic valve [J]. The Journal of Practical Medicine, 2024, 40(10): 1396-1401.
[4]	Cui JI,Qinying WANG,Lei WANG,Yuan. WANG. Effect of cognitive⁃behavioral intervention under the family⁃based care model on continuing care of patients after aortic dissection surgery [J]. The Journal of Practical Medicine, 2024, 40(4): 566-570.