title: Staged repair of extensive aortic aneurysms: long-term experience with the elephant trunk technique.
abstract: OBJECTIVE
  This paper reports our experience of a large series of elephant trunk patients accumulated over 12 years.
  
  
  BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston Medical School, Houston, TX, USA. Hazim.J.Safi@uth.tmc.edu
authors.forename: Hazim J
authors.initials: HJ
authors.lastname: Safi
authors.forename: Charles C
authors.initials: CC
authors.lastname: Miller
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Estrera
authors.forename: Tam T T
authors.initials: TT
authors.lastname: Huynh
authors.forename: Eyal E
authors.initials: EE
authors.lastname: Porat
authors.forename: Bradley S
authors.initials: BS
authors.lastname: Allen
authors.forename: Roy
authors.initials: R
authors.lastname: Sheinbaum
mesh_terms: D000206:Actuarial Analysis; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D000784:Aortic Dissection / Q000601:surgery; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000145:classification / Q000379:methods*; D002315:Cardiopulmonary Bypass; D002423:Cause of Death; D002560:Cerebrovascular Circulation / Q000502:physiology; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D020521:Stroke / Q000209:etiology; D015996:Survival Rate; D017585:Ultrasonography, Doppler, Transcranial