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Hybrid treatment for aortic arch and proximal descending thoracic aneurysm: experience with stent grafting for second-stage elephant trunk repair

Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo 060-8543, Japan

Received 1 September 2008; received in revised form 14 May 2009; accepted 19 May 2009.

^_* Corresponding author. Tel.: +81 11 611 2111x3312; fax: +81 11 613 7318. (Email: nobuyosh{at}sapmed.ac.jp).

Background: Aortic aneurysm affecting the arch and proximal descending thoracic aorta may require a two-stage repair, which includes proximal elephant trunk graft placement and completion of descending thoracic aortic repair. The combination of open surgery and endovascular grafting may improve the morbidity and mortality of the patient population at risk. Methods: Between February 2001 and March 2007, 258 patients underwent thoracic aortic endovascular grafting at our institution, wherein 31 patients underwent a hybrid approach involving proximal arch repair and elephant trunk graft replacement, and endovascular completion procedures. All patients, who underwent combined endovascular and open procedures in the management of the aortic arch and proximal descending thoracic aortic aneurysms, were reviewed and analysed retrospectively. Results: The interval between the first and second stage ranged from 0 to 14 months with a mean interval of 3.1 months. Follow-up ranged from 0 to 70 months with a mean of 31 months. Technical success was achieved in all patients. The 1, 12, 36 and 60-month mortality rates were 6.4%, 16.5%, 26.7% and 26.7%, respectively. Caudal migration of the endograft occurred in three patients, who underwent conversion to open surgery. Two cases of paraparesis but no paraplegias or strokes were recorded. Conclusions: Staged procedures using endovascular grafting in the treatment of the arch and proximal descending thoracic aneurysm may have the potential to reduce morbidity and mortality rates. Although long-term results are still pending, this early experience demonstrates the safety and early-term effectiveness of this hybrid approach, which consists both of endovascular and open surgical procedures.

Key Words: Aneurysm • Elephant trunk • Endovascular • Stent-graft