Cleaning Up the Chimney: Early Renal Stent Graft Thrombosis Following Endovascular Treatment of a Juxtarenal Aortic Aneurysm With the Chimney Technique.

The endovascular management of juxtarenal aortic aneurysms with the chimney technique (ch-EVAR) has gained popularity in recent years. It provides an alternative to open repair, allowing treatment of challenging anatomies with devices readily available in any vascular suite. The primary drawback persists as the occurrence of type-Ia endoleak from gutters and renal stent thrombosis. We present two cases of early renal stent graft thrombosis following chimney endovascular aneurysm repair. The first patient was an 80-year-old man who underwent single ch-EVAR and came back on the fifth post-op day with renal stent graft thrombosis. He was re-operated for recanalization and additional stenting of his chimney graft. The patient recovered well with no complications. The second case involved a 72-year-old man with a juxtarenal aneurysm, treated with ch-EVAR on both renal arteries. Unfortunately, on the 10th post-op day, he was referred to our department due to lumbar pain and acute renal failure due to chimney graft thrombosis bilaterally. The left renal chimney graft was recanalized by endovascular means. On the contrary, despite efforts of the endovascular and open approach, the right chimney graft and the right renal artery remained occluded. While ch-EVAR is a viable and off-the-shelf solution for urgent and complex juxtarenal aortic aneurysms, it should be performed with awareness of the potential for graft thrombosis and persistent endoleaks. Despite these complications, the chimney technique can still be a viable treatment option. A better understanding of the indications and advancements in the devices used can lead to better long-term results.