title: Single-stage repair of extensive thoracic aortic aneurysms: experience with the arch-first technique and bilateral anterior thoracotomy.
abstract: 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%.
  
  
  CONCLUSIONS
  The single-stage, arch-first technique is a safe and suitable alternative to the 2-stage procedure for repair of extensive thoracic aortic disease.
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Missouti Baptist Medical Center, 3009 N. Ballas Road, St. Louis, MO, USA. ntkouch@aol.com
authors.forename: Nicholas T
authors.initials: NT
authors.lastname: Kouchoukos
authors.forename: Michael C
authors.initials: MC
authors.lastname: Mauney
authors.forename: Paolo
authors.initials: P
authors.lastname: Masetti
authors.forename: Catherine F
authors.initials: CF
authors.lastname: Castner
mesh_terms: D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery; D001011:Aorta / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods / Q000401:mortality; D013504:Cardiovascular Surgical Procedures / Q000379:methods* / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D016019:Survival Analysis; D013908:Thoracotomy / Q000379:methods / Q000401:mortality; D016896:Treatment Outcome