Repair Of Extensive Aortic Aneurysm: A Single-center Experience With The Elephant Trunk Technique Over Two Decades
Hazim J Safi, Anthony L Estrera*, Charles C Miller, III*, Ali Azizzadeh*, Harleen K Sandhu*
University of Texas Health Science Center at Houston, HOUSTON, TX
Management of aneurysm involving the entire aorta is a significant challenge. Given the anatomical complexity, a single-stage surgical procedure is associated with high morbidity. We report our experience with two-stage repair using the elephant trunk technique.
Between 1991 and 2013 we repaired 3012 aneurysms of the ascending or thoracoabdominal aorta. Of these, we performed 474 operations in 352 patients using the traditional (or in 61 cases, distal segment first) elephant trunk technique. Mean age was 62.5 +/- 13.9, and 218/474 (45.9%) operations were in women. 291 patients underwent ascending /arch repair first with 122 receiving a completion second stage repair.
Stage 1 mortality was 25/352 (7.1%). Stage 2 mortality was 15/122=12.3%. Of the 327 patients surviving the initial stage, 7/327 (2.1%) died within the 30-45 day optimal repair interval, suggesting that 6 week wait is safe. Mortality was associated with glomerular filtration rate (GFR), with 4.6% mortality in patients with GFR above 75. Stroke after ascending /arch repair was 10/294 (3.4%) and neurologic deficit was 1/181 (0.5%). In the 230 patients who did not receive second stage repair after 6 weeks, 26 (11.3%) died.
Extensive aortic aneurysm is a complex problem, but should be managed with good results with a two stage open procedure. The symptomatic segment can be approached first. In asymptomatic cases we approach the ascending /arch portion first due to the shorter recovery time. The use of elephant trunk technique remains a valuable approach for repair of extensive aortic aneurysm.
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