Replacement of the entire thoracic aorta according to the reversed Elephant Trunk technique

The aim of this work is to present our modified Elephant Trunk technique to reduce circulatory arrest time and consequently mortality and morbidity rates. According to Borst's technique the ascending aorta and aortic arch are replaced first, under deep hypothermic circulatory arrest, while a graft segment is left in the descending thoracic aorta. In the second stage of the operation, the descending thoracic aorta is replaced through left thoracotomy using this graft segment. In our modified technique, after the flexion in the proximal segment of the graft, the descending thoracic aorta is replaced first through left thoracotomy in Bio-Pump protection, choosing the best aortic segment for proximal anastomosis. In the second stage we replace the ascending aorta and the aortic arch using the graft and applying Carrel patch anastamosis only to the epiaortic vessels, under deep hypothermic circulatory arrest. It is our opinion that the mortality incidence of this technique is similar to that obtained with Borst's technique, though certainly inferior to the one stage procedure , while the morbidity results are better than those obtained with the Borst Elephant Trunk technique and with the one stage procedure. In fact there are fewer stroke incidents thanks to the reduced times of deep hypothermic circulatory arrest, and fewer postoperative bleedings and respiratory failures thanks to the reduced times of the total cardiopulmonary bypass. At the beginning we used this technique to replace symptomatic aneurysms, covered ruptures, and hematomas of the wall of the descending thoracic aorta, which required replacement of the descending thoracic aorta first; we later extended the treatment to all types of thoracic aorta aneurysms.     

Replacement of the thoracic aorta with intraluminal sutureless prosthesis.

A survey of the collective experience reveals that between 1976 and 1990, a sutureless intraluminal prosthesis was used to replace the ascending thoracic aorta, arch, and descending thoracic aorta in 122, 14, and 81 patients, respectively. During these 217 operations, at least 364 of the 434 anastomoses were performed by sutureless fixation. The underlying disease processes consisted of acute and chronic dissections; atherosclerotic, Marfan's, and mycotic aneurysms; and intraoperative disruptions of the ascending aorta. The data in the literature suggest that sutureless fixation shortens aortic cross-clamp time and reduces blood loss. Early graft-related complications were few and probably can be further reduced by improving surgical techniques. The incidence of paraplegia and renal failure after descending aortic grafting was identical at 2.5%. The operative mortality rate for ascending aortic, arch, and descending aortic replacement was 13.1%, 42.9%, and 14.8%, respectively. Long-term follow-up of 143 patients revealed satisfactory graft function with three possible device-related deaths and no other known complications attributable to the prosthesis. There are, however, anecdotal references to late complications from the intraluminal prosthesis. Most of these relate to faulty implantation techniques, but some could be due to flaws inherent in the concept of sutureless grafting. The collective experience suggests that grafting of the thoracic aorta is less hazardous with the sutureless than with the conventional sutured anastomosis technique. The implications of the anecdotal accounts about late complications remain to be determined.     

An alternative approach to diffuse thoracic aortomegaly: on-pump hybrid total arch repair without circulatory arrest

Diffuse thoracic aortomegaly has conventionally been managed with a two-stage elephant trunk procedure, requiring prolonged circulatory arrest, with an inherent risk of major morbidity and mortality. Recently, to improve outcomes, several hybrid arch procedures have been proposed using off-pump techniques. We have adopted an alternative, single-stage hybrid strategy using cardiopulmonary bypass without circulatory arrest to replace the ascending aorta and perform arch debranching and antegrade endovascular stent graft deployment. Unlike off-pump procedures, pathology of the aortic valve, root, and ascending aorta is addressed while avoiding the complications of stent graft placement in the native ascending aorta.     

Fortschritte in der Behandlung thorakaler Aortenaneurysmen

Surgical treatment of combined pathologies of the ascending aorta, aortic arch and the descending aorta still makes great demands on the surgeon. In 1983 Borst et al. established the elephant trunk procedure for treatment of such complex aortic aneurysms, which subsequently became the recognized standard procedure and has simplified the surgical treatment of these pathologies. The frozen elephant trunk technique (hybrid procedure) was recently introduced as an extension of this procedure. This procedure permits the single-stage definitive treatment of intersegmental aneurysms extending over the ascending aorta, the aortic arch and the descending aorta via transmediastinal sternotomy using a new type of prosthetic bypass graft with stent portion, which is inserted anterograde in the descending aorta. The aortic arch and, if necessary, the ascending aorta are subsequently replaced in the conventional manner. The new procedure can be implemented with a risk probability which is comparable to that of the elephant trunk technique. The main advantage is that this is a single-stage approach and the second stage which is necessary by the conventional approach can be omitted. Although the surgical strategy is oriented to the individual pathology of each patient, the frozen elephant trunk technique could replace the previous conventional procedure as the treatment standard for extensive aortic aneurysms.     

Single-stage transmedial approach to a stanford type B dissection in a patient with Marfan''s syndrome

We report the case of a patient with Marfan's syndrome and a Stanford type B chronic aortic dissection in which replacement of the ascending aorta, aortic arch and descending aorta was accomplished in a single stage via median sternotomy. The patient was a 51-year-old woman with a 70 mm Stanford type B chronic aortic dissection and Marfan's syndrome. Median sternotomy and replacement of the ascending aorta, aortic arch, and descending aorta were performed under deep hypothermic circulatory arrest. Postoperatively, the patient developed paraplegia. However, after immediate placement of an intrathecal catheter and drainage of cerebrospinal fluid for 72 hours, the neurologic deficit fully resolved. Despite concerns related to the complexity of the procedure and neurological protection during the procedure, we believe that single-stage replacement of the ascending aorta, aortic arch, and descending aorta is possible and is one of several surgical choices for patients such as ours.     

Extensive aortic reconstruction for aortic aneurysms in Marfan syndrome

Background. Marfan syndrome patients frequently develop aneurysms or dissections involving multiple segments of the aorta, and occasionally require staged replacement of the entire aorta. This study reviews the surgical outcome of patients with Marfan syndrome who underwent extensive aortic reconstruction. Extensive reconstruction is defined as reconstruction of more than two segments of the ascending, arch, descending thoracic, or abdominal aorta.

Methods. From March 1973 to December 1997, 101 patients with Marfan syndrome underwent aortic operation. Twenty-six patients (25.7%) had extensive aortic reconstruction. All 26 patients suffered from aortic dissection: 13 patients had Stanford type A and 13 had type B dissection. Twenty-three patients (88.4%) had annuloaortic ectasia and aortic regurgitation. Surgical procedures included composite valve graft replacement (n = 23, 88.4%), aortic arch reconstruction (n = 15, 57.7%), graft replacement of the descending thoracic aorta (n = 6, 23.1%), and graft replacement of the thoracoabdominal aorta (n = 16, 61.5%). Five patients (19.2%) had total thoracoabdominal aortic replacement, and three patients (11.5%) had replacement of the entire aorta. Twenty-one patients (80.8%) required multiple operations.

Results. Follow-up was complete in all patients. The 30-day survival rate was 88.5%. None of the survivors had paraplegia or paraparesis. The overall long-term survival rate was 88.5 ± 6% at 1 year, and 81.7 ± 9% at 9 years.

Conclusions. Aortic surgery prolongs survival in patients with Marfan syndrome, and currently there is a relatively low associated morbidity and mortality even for aggressive surgical treatment.     

Simultaneous Operations for Combined Thoracic and Abdominal Aortic Aneurysms

Purpose. To assess whether simultaneous operations are appropriate for combined thoracic and abdominal aortic aneurysms.Methods. Simultaneous operations were performed for combined thoracic and abdominal aortic aneurysms in nine patients. The thoracic aortic aneurysm (TAA) was repaired first, followed by repair of the abdominal aortic aneurysm (AAA). Selective cerebral perfusion was used in eight patients, after the exception of one who underwent replacement of the ascending aorta under hypothermic circulatory arrest. The abdominal organs were perfused during distal anastomosis in surgery for Stanford type A aortic dissection or aortic arch aneurysm; via the femoral artery with an aortic balloon occlusion catheter in one patient, and via an occlusion catheter with a perfusion lumen in two patients.Results. All patients underwent planned simultaneous repair of the AAA. One of the patients who underwent simultaneous replacement of both the descending thoracic and abdominal aorta was left with paraplegia, and one patient died suddenly of massive hemoptysis and melena on the 29th postoperative day. Autopsy revealed that the bleeding had been caused by aorto-broncho-esophageal fistulae. The overall operative mortality was 11%.Conclusions. Simultaneous repair of combined TAA and AAA can be safely performed; however, the risk of paraplegia should be considered, especially with simultaneous repair of concomitant aneurysms of the descending thoracic and abdominal aorta.     

Single-stage transmedial approach to a stanford type B dissection in a patient with Marfan's syndrome

We report the case of a patient with Marfan's syndrome and a Stanford type B chronic aortic dissection in which replacement of the ascending aorta, aortic arch and descending aorta was accomplished in a single stage via median sternotomy. The patient was a 51-year-old woman with a 70 mm Stanford type B chronic aortic dissection and Marfan's syndrome. Median sternotomy and replacement of the ascending aorta, aortic arch, and descending aorta were performed under deep hypothermic circulatory arrest. Postoperatively, the patient developed paraplegia. However, after immediate placement of an intrathecal catheter and drainage of cerebrospinal fluid for 72 hours, the neurologic deficit fully resolved. Despite concerns related to the complexity of the procedure and neurological protection during the procedure, we believe that single-stage replacement of the ascending aorta, aortic arch, and descending aorta is possible and is one of several surgical choices for patients such as ours.     

Staged repair of extensive aortic aneurysms

BACKGROUND: We adopted a two-stage approach (elephant trunk procedure) in the repair of extensive aortic aneurysms in 1991, performing 241 procedures in 155 patients. METHODS: Reversed elephant trunk (graft replacement of the descending thoracic aorta followed by ascending/arch replacement) was performed in 18 patients. All other patients underwent conventional staged repair. The first stage was performed in 137 patients, with 86 patients returning for the second stage. RESULTS: First stage 30-day mortality was 9.5% (13 of 137). There was no second stage immediate neurologic deficit. Second stage mortality was 7.0% (6 of 86). During the interval of 31 days to 6 weeks after stage one, mortality was 10 of 124 (8%). Seven of the 10 interval deaths (70%) were due to rupture of the untreated aortic segment. The mortality rate was 32.1% (18 of 56) in the group of patients who did not return for the second stage repair. CONCLUSIONS: Extensive aortic aneurysms can be repaired with acceptable morbidity and mortality using the elephant trunk technique. After stage one, prompt treatment of the remaining aneurysm is crucial to success.     

The surgical treatment for the Stanford type A aortic dissection]

Twenty-nine patients who underwent operation at Shinshu University Hospital for the Stanford type A dissecting aneurysm were analysed. The patients were operated on in the acute stage within 2 weeks after onset. In 13 of these 26 acute cases, the graft replacement of the ascending and arch of the aorta was performed (group A). The patients were operated under a separate perfusion to the brain and the distal anastomosis to the proximal portion of the descending aorta was performed using the method of open distal anastomosis. In other 13 cases, the graft replacement of the ascending aorta was performed (group B). Operative mortality rate was 19% in this series (group A: 23%, group B: 15%). There was no significant difference in their operative mortality of acute stage. And there was also no significant difference in their post operative course of acute stage operations. We concluded that the graft replacement of the ascending and arch of the aorta was better than the graft replacement of the ascending aorta alone for the patients with Stanford type A acute aortic dissection.     

Total circulatory arrest for the replacement of the descending and thoracoabdominal aorta

HYPOTHESIS: Hypothermic total circulatory arrest (TCA) in the resection and replacement of the thoracoabdominal and descending thoracic aorta is safe, will significantly decrease the incidence of postoperative renal failure, and should be preferentially performed over left heart bypass (LHB). DESIGN: Retrospective review case series. SETTING: Large, private, urban teaching hospital. PATIENTS: All adult patients with aortic disease that involved the distal aortic arch, the descending thoracic aorta, or the thoracoabdominal aorta who underwent resection and graft replacement of the diseased segment via LHB or TCA at our institution from 1989 to 2001 are included in this study. A total of 59 patients were evaluated: 10 had descending thoracic aneurysms, 20 had thoracoabdominal aneurysms, 22 had chronic type B dissections, 4 had acute type B dissections, and 3 had adult coarctations. INTERVENTIONS: In 1989 to 1994, LHB was primarily used; in 1994 to 2001, TCA was primarily used. MAIN OUTCOME MEASURES: Renal failure, 30-day operative mortality, paraplegia, and any other morbidities. RESULTS: A significant decrease occurred in the incidence of postoperative renal failure from 15% (3/20) in patients who underwent LHB to 0% (0/39) in patients who underwent TCA (P = .04). Furthermore, a significant decrease occurred in the 30-day operative mortality, which decreased from 20% (4/20) in patients who underwent LHB to 5% (2/39) in patients who underwent TCA (P = .04). Postoperative paraplegia decreased from 5% (1/20) in patients who underwent LHB to 2.6% (1/39) in patients who underwent TCA (P > .99). CONCLUSIONS: Our use of TCA in the resection and replacement of the diseased thoracoabdominal and descending thoracic aorta has produced excellent results. Our patients have experienced no postoperative renal failure and a low 30-day operative mortality. The use of TCA in this patient population is a viable option for surgeons comfortable with the technique.     

Aortic arch aneurysms; Surgical experience

Background: Several recent modifications in technical, operative and perfusion techniques have enabled good operative results and final outcome for patients with aneurysms of the aortic arch. Although surgical procedures for this disease still remain a formidable challenge, availability of improved prosthetic grafts, myocardial protection techniques, brain protection protocols and better blood bank facilities ensure minimal postoperative morbidity and mortality. Methods: Records of 28 patients operated between January 1994 and January 2001 for aneurysms of the aortic arch were analysed. The study group includes patients with isolated aortic arch aneurysms or with concomitant involvement of the ascending and/or descending thoracic aorta. There were 22 males and 6 females, with an age range of 9–78 years. The mean age at operation was 45.5 years. Etiology included myxomatous degeneration (Marfan’s) in 10; myxomatous degeneration (NonMarfan’s) in 11; atherosclerosis in 6 and traumatic in 1 patient. Graft replacement of the transverse aortic arch with reimplantation of arch vessels was done for 6 patients; Bentall’s procedure with hemiarch replacement for 3 patients; Bentall’s procedure with arch replacement and vessel reimplantation for 4 patients; supracoronary replacement of the ascending aorta plus hemiarch repair in 2 patients; graft replacement of the distal arch alone in 11 patients and ascending, transverse and descending thoracic aorta repair using the elephant trunk technique in 2 patients. Results: Early hospital mortality was seen in 2 patients with 1 late death. Postoperative complications seen were hemorrhage requiring reoperation in 3 patients, pulmonary insufficiency in 1 patient, renal dysfunction in 1 patient, neurological morbidity in 2 patients and wound sepsis in 2 patients. Mean postoperative hospital stay was 11.4 days. Followup to the present date was completed for all survivors the range being 2–72 months (mean 29.2 months). Majority of the patients reported significant improvement in their symptoms. Conclusion: With sufficient technical skill and precautions, operative treatment for aneurysms of the aortic arch can be carried out with acceptable mortality and morbidity rates.     

One-stage total thoracic aortic repair for mega-aorta using frozen elephant trunk technique

We report the case of a 71-year-old female with mega-aorta extending from the ascending aorta to the descending aorta, who was successfully treated with a one-stage total thoracic aortic repair by the frozen elephant trunk technique using a stent-graft. We used a home-made frozen elephant trunk with four giant-turco Z-stents on the distal side that was inserted into the downstream descending aorta via an aortic arch guiding pull-through wire. The stent-graft was distally positioned at the level of the 12th thoracic vertebra after total arch replacement had been performed using a four-branch graft. The postoperative course was good, and there was no paraplegia or other complications. A postoperative computed tomography scan demonstrated complete thrombosis of the descending thoracic aneurysm without endoleak. In conclusion, the frozen elephant trunk was effective as a one-stage operation for mega-aorta.     

Surgical technologies in the treatment of aneurysms of thoracic and thoraco-abdominal aorta

From 1993 to 2001 279 patients with aneurysms of the thoracic and thoracoabdominal aorta were operated. Cause of aneurysm formation in 74% cases was degenerative changes of aortal wall (Marfan's disease or Erdheim syndrome). Aneurysms were revealed in ascending aorta in 38 (14%) cases, in the ascending aorta with insufficiency of aortic valve--in 67 (24%), in the ascending aorta and aortic arch--31 (11%), in descending aorta--54 (19%), thoracoabdominal aneurysms--in 89 (32%). Twenty patients underwent surgery for combined aneurysms of the ascending aorta with it arch and descending part, thoracoabdominal aneurysms, and also for thoracic aneurysms in combination with coronary heart disease. Lethality in early postoperative period in patients with aneurysms of the ascending aorta was 5%, with aneurysms of the ascending aorta and insufficiency of the aortic valve--6.2%, in aneurysms of the ascending aorta and aortic arch--16.2%, in aneurysms of the descending aorta--6.4%, in thoracoabdominal aneurysms--15%.     

Thoracic aortic aneurysm associated with congenital bicuspid aortic valve.

Congenital bicuspid aortic valve is a relatively rare malformation. It is reported that the presence of this anomaly predisposes the patient to development of true aortic aneurysms or dissecting aortic aneurysms. Between 1981 and August 1997, 25 patients with an aneurysm of the thoracic aorta associated with congenital bicuspid aortic valve underwent surgical treatment at the authors' institution. There were 20 males and five females. The age of the patients ranged from 27 to 74 years (mean 53 years). There were 18 patients with true ascending aortic aneurysms (of which 10 presented with annulo-aortic ectasia) and seven with dissecting aortic aneurysms (four with DeBakey type I dissection, two with type II and one with type IIIb). These 25 patients constituted 2.6% (25/973) of all cases of surgical operations for aneurysms in the thoracic aorta. Aortic valve dysfunction was noted in 20 patients. The authors performed a valved conduit operation in nine patients, aortic valve replacement and wrapping of the ascending aorta in six, graft replacement of the ascending aorta in five, graft replacement of the ascending aorta and aortic arch in four, and graft replacement of the descending aorta in one. No hospital deaths occurred in the authors' patients. Pathological examination of surgical specimens of the aortic wall showed cystic medial necrosis in 11 patients and mucoid degeneration in nine. In patients with congenital bicuspid aortic valve, attention should be paid to aneurysmal dilatation and aortic dissection as complications in addition to valve dysfunction.     

主动脉夹层的细化分型及其应用

目的探讨在Stanford分型的基础上根据主动脉夹层的部位和病变程度再进行细化分型,对指导临床选择手术时机、确定治疗方案和手术方式,以及判断预后的价值。方法1994年1月至2004年12月我院治疗主动脉夹层708例。其中Stanford A型夹层477例：（1）根据主动脉根部病变程度分为3型。A1型（主动脉窦部正常型）212例,行保留主动脉窦部的主动脉替换;A2型（主动脉窦部轻度受累型）72例,行主动脉窦部成形63例、David手术9例;A3型（主动脉窦部重度受累型）193例,行主动脉根部替换术（Bentall手术）。（2）根据主动脉弓部病变分为2型。C型（复杂型）78例,行主动脉弓部替换＋象鼻术;S型（单纯型）399例,行部分主动脉弓部替换。Stanford B型夹层231例,（1）根据主动脉扩张的范围分为3型：B1型：降主动脉无扩张或仅有近端扩张,147例,行腔内带膜支架主动脉腔内修复术103例（B1S型）、部分胸降主动脉替换术32例、部分胸降主动脉替换术＋远端支架象鼻术12例;B2型：全部胸降主动脉扩张,53例,行部分胸降主动脉替换术＋主动脉成形32例、全部胸降主动脉替换术21例;B3型：全部胸降主动脉及腹主动脉扩张,31例行胸腹主动脉替换术。（2）根据左锁骨下动脉和远端主动脉弓部是否受夹层累及分为2型：C型（复杂型）：夹层累及左锁骨下动脉或远端的主动脉弓部,44例,在深低温停循环下手术治疗;S型（单纯型）：远端主动脉弓部和左锁骨下动脉未受夹层累及,187例,介入治疗103例、手术治疗84例（常温阻断下手术60例,股动脉-股静脉转流下手术24例）。结果Stanford A型夹层住院病死率为4．6％（22／477）,并发症发生率为14．5％（69／477）。Stanford B型夹层：介入治疗组病死率1．9％（2／103）,并发症发生率为2．9％（3／103）,轻度内漏发生率为9．7％（10／103）;手术治疗组住院病死率为3．1％（4／128）,并发症发生率为18．8％（24／128）。结论细化主动脉夹层的分型对于术前判断手术时机、制定手术方案和初步判断预后,具有重要的指导作用。     

Simultaneous repair of arch and abdominal aortic aneurysms

Objective: Atherosclerotic aneurysms in the aortic arch are associated with abdominal aortic aneurysms in up to 37% of cases. We have developed a single-stage approach to the repair of both aneurysms using a temporary bypass. Subjects: Since November 1996, 5 patients underwent simultaneous repair of aneurysms in the aortic arch and in the infrarenal abdominal aorta, using a new temporary bypass graft technique. Entire arch replacement with simultaneous abdominal aortic aneurysmectomy was performed in one patient. The other 4 patients underwent distal hemiarch replacement distal from the orifice of the brachiocephalic artery with simultaneous repair of the abdominal aortic aneurysm. Method: For the entire arch replacement procedure, blood flow to all major branches of the aortic arch was established using a bifurcated graft. This graft anastomosed to the ascending aorta was used as the proximal inflow of the temporary bypass graft. For the hemiarch replacement procedure, the proximal inflow segment of the temporary bypass graft was anastomosed to the brachiocephalic artery. In both cases, the distal outflow segment of the temporary bypass graft was the graft used for repair of the abdominal aortic aneurysm. In order to prevent any clamp injury, Teflon felt was tightly wrapped around the aorta before the clamp was applied. Results: Evaluation of the hemodynamic parameters measured during cross-clamping of the aortic arch revealed stable distal perfusion to the visceral organs and no excessive increase in cardiac afterload. All patients had an uneventful postoperative course and were discharged within 1 month of surgery. Conclusion: Our temporary bypass method is recommended for simultaneous replacement of aneurysms in the aortic arch and the abdominal aorta.     

Simultaneous repair of arch and abdominal aortic aneurysms. A simple new technique using a temporary bypass graft.

OBJECTIVE: Atherosclerotic aneurysms in the aortic arch are associated with abdominal aortic aneurysms in up to 37% of cases. We have developed a single-stage approach to the repair of both aneurysms using a temporary bypass. SUBJECTS: Since November 1996, 5 patients underwent simultaneous repair of aneurysms in the aortic arch and in the infrarenal abdominal aorta, using a new temporary bypass graft technique. Entire arch replacement with simultaneous abdominal aortic aneurysmectomy was performed in one patient. The other 4 patients underwent distal hemi-arch replacement distal from the orifice of the brachiocephalic artery with simultaneous repair of the abdominal aortic aneurysm. METHOD: For the entire arch replacement procedure, blood flow to all major branches of the aortic arch was established using a bifurcated graft. This graft anastomosed to the ascending aorta was used as the proximal inflow of the temporary bypass graft. For the hemi-arch replacement procedure, the proximal inflow segment of the temporary bypass graft was anastomosed to the brachiocephalic artery. In both cases, the distal outflow segment of the temporary bypass graft was the graft used for repair of the abdominal aortic aneurysm. In order to prevent any clamp injury, Teflon felt was tightly wrapped around the aorta before the clamp was applied. RESULTS: Evaluation of the hemodynamic parameters measured during cross-clamping of the aortic arch revealed stable distal perfusion to the visceral organs and no excessive increase in cardiac afterload. All patients had an uneventful postoperative course and were discharged within 1 month of surgery. CONCLUSION: Our temporary bypass method is recommended for simultaneous replacement of aneurysms in the aortic arch and the abdominal aorta.     

Single-stage repair of extensive thoracic aortic aneurysms: experience with the arch-first technique and bilateral anterior thoracotomy

BACKGROUND: Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with a substantial cumulative mortality (>20%) that includes hospital mortality for the 2 procedures and death (often from aortic rupture) in the interval between the 2 procedures. We have used a single-stage technique for operative repair of most or all of the thoracic aorta. METHODS: Forty-six patients with extensive disease of the thoracic aorta were managed with a single-stage procedure by using a bilateral anterior thoracotomy and transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the aortic arch vessels first to minimize brain ischemia. Thirty-one patients with chronic, expanding type A aortic dissections had previous operations for acute type A dissection (n = 22), aortic valve repair or replacement (n = 4), coronary artery bypass grafting (n = 4), or no previous operation (n = 1). The remaining 15 patients had degenerative aneurysms (n = 12) or chronic type B dissections with proximal extension (n = 3). The ascending aorta and aortic arch were replaced in all patients combined with resection of various lengths of descending aorta (proximal one third [n = 19], proximal two thirds to three quarters [n = 22], or all [n = 5]). Coronary artery bypass grafting, valve replacement, or both were performed concomitantly in 19 patients. RESULTS: Hospital mortality was 6.5% (3 patients). Morbidity included reoperation for bleeding (17%), mechanical ventilation for more than 72 hours (42%), temporary tracheostomy (13%), and temporary renal dialysis (9%). No patient sustained a stroke. There have been 5 late deaths (3, 18, 34, 51, and 79 months postoperatively) unrelated to the aortic disease. Four patients have undergone successful reoperation on the aorta (false aneurysm [n = 1], endocarditis [n = 1], and progression of disease [n = 2]). Five-year survival was 75%. CONCLUSION: The single-stage, arch-first technique is a safe and suitable alternative to the 2-stage procedure for repair of extensive thoracic aortic disease.     

Staged repair of extensive aortic aneurysms: long-term experience with the elephant trunk technique

OBJECTIVE: This paper reports our experience of a large series of elephant trunk patients accumulated over 12 years. SUMMARY BACKGROUND DATA: Extensive aneurysms of the ascending/arch and descending thoracic or thoracoabdominal aorta are significant surgical problems that have potential for great morbidity. We adopted a staged approach known as the elephant trunk procedure in 1991, and we have used it with some modifications since that time. METHODS: Between February 1991 and December 2003, we performed 1660 operations for ascending/arch or descending thoracic/thoracoabdominal aortic aneurysms. Of these, 321 operations were performed in 218 patients for extensive aneurysms with the elephant trunk technique. We performed 218 ascending/arch repairs and 103 descending thoracic or thoracoabdominal aortic replacements. RESULTS: In 218 ascending/arch repairs, strokes occurred in 3 of 218 (2.7%) patients, with 1 of 187 (0.5%) in the retrograde cerebral perfusion group and 2 of 31 (6.5%) in the no-retrograde cerebral perfusion group (odds ratio 0.08, P < 0.009). Thirty-day mortality for this group was 19 of 218 (8.7%). Among 199 recovering patients after stage 1 repair, 4 of 199 (2%) died during the 30-day to 6-week interval between stages. After stage 2 repair, 0 of 103 patients experienced immediate neurologic deficit, and 10 of 103 (9.7%) died within 30 days of surgery. Actuarial survival after completed stage 2 was 71% at 5 years. CONCLUSION: Despite extreme underlying disease, long-term survival is excellent in patients with extensive aneurysms when both stages of repair are completed. To prevent rupture, the second stage should be completed as soon as the patient's condition permits, preferably within 6 weeks.