Chimney Endovascular Aneurysm Repair is now Officially Recommended as an Alternative Treatment Option Based on the New European Society for Vascular Surgery Abdominal Aortic Aneurysm Guidelines of 2019: Do We Want to Keep Looking at the Tree and Not the Forest?

We read the commentary from Alric and Canaud regarding our case of a symptomatic patient unfit for open repair symptomatic with persistent gutter related type Ia endoleak after chimney endovascular aneurysm repair (ch-EVAR). The goal of our case presentation was to provide information about possible solutions for suboptimal performance, as a lesson learned after 10 years of clinical experience and treatment of more than 250 cases by ch-EVAR.3, 4 As the authors published when they reported on the role of physician modified endografts “to break the rules you must first master them.” And, in this context, we believe that presentation of successful management of challenging cases with persistent post-operative flow to the aneurysm sack is of particular importance, having as a sustained goal of optimising the outcome in favour of the patient.

The authors are wondering whether ch-EVAR is in general, an alternative option. The answer could be very easily given from recommendation 97 of the European Society for Vascular Surgery (ESVS)'s newest guidelines regarding juxtarenal aneurysms. It is stated that ch-EVAR can be considered as an alternative option when fenestrated endografting (f-EVAR) is not indicated or not available. The level of evidence (C) is the same as for f-EVAR, and our case is in full alignment with this recommendation. There is no evidence in the new guidelines supporting other alternative therapies rather than chimney grafts as the authors of the commentary suggested.

In summary, the use of chimney grafts is no longer a matter of faith but a fact. The evidence in the literature supports its complementary role for the treatment of juxtarenal aneurysms and in agreement with that the ongoing ENCHANT Study as a fully prospective multicentre trial of ch-EVAR (clinicaltrials.gov identifier: NCT03320252) will provide further evidence bringing the technique to a higher level of evidence (B) than f-EVAR (C). Do we want to keep looking at the tree and not the forest?