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

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.