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Staged repair of thoracic and thoracoabdominal aortic aneurysms using the elephant trunk technique: a consecutive series of 215 first stage and 120 complete repairs

^a Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY, USA
^b Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY, USA

Received 29 November 2007; received in revised form 3 April 2008; accepted 8 April 2008.

^_* Corresponding author. Address: Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, One Gustave L. Levy Place, PO-Box: 1028, New York, NY 10029, USA. Tel.: +1 212 659 6800; fax: +1 212 659 6818. (Email: christian.etz{at}mountsinai.org).

Objectives: Repair of thoracic aneurysms (TA) involving the ascending, arch, and descending aorta results in substantial morbidity and mortality. This study evaluates outcomes with a two-stage elephant trunk (ET) technique. Methods: Two hundred and fifteen consecutive patients (pts) underwent total arch replacement using an ET (02/90–09/06). One hundred and thirty-nine pts (65%), group PC (planned completion; median age 68; 28–86 years), had extensive descending TA (Ø 5 cm) or dissections requiring complete repair. Seventy-six pts (35%), group CS (close surveillance; median age: 68; 20–87 years), had less severe distal dilatation (Ø 5 cm), and had close follow-up after ET rather than planned distal repair. Results: Hospital mortality in group PC pts (descending Ø: 6.2 ± 1.2 cm) was 6.5% (9/139) following ET. In group CS pts (descending Ø: 4.1 ± 0.7 cm), hospital mortality after ET was 5.3% (4/76); 4.7% (10/215) had strokes but survived. Eighty-six percent (112/130) of group PC pts who survived proximal repair returned for planned surgical (101) or endovascular (11) completion after a median of 56 (0–2189) days. Hospital mortality for distal repair was 7.5% (9/120); two ET stage two pts (2%) developed paraplegia. Eighty-nine percent (16/18; descending Ø: 6.9 ± 1.0 cm) of group PC pts who did not undergo planned completion died a median of 5.4 (1.2–91.1) months after ET stage one. Overall cumulative survival in group PC, which includes pts dying before or without stage two, was 69% after 1, and 55% after 5 years. Survival in group CS pts was 88% at 1, and 57% at 5 years. Eight pts in group CS subsequently underwent distal repair, but 22/76 (29%) group CS pts who survived ET stage one died during follow-up despite surveillance. Conclusions: The low mortality after stage one justifies liberal use of the ET technique to facilitate future open or endovascular TA repair of the distal aorta. The 5-year cumulative mortality curves, however, suggest that staged repair of extensive TA is superior to one-step repair only if stage two can be done before rupture occurs. If one-step repair is possible, it may be preferable.

Key Words: Elephant trunk • Aortic arch repair • Descending/thoracoabdominal aortic aneurysm repair (TAAA) • Intention to treat