title: Hybrid approaches to thoracic aortic aneurysms: the role of endovascular elephant trunk completion.
abstract: BACKGROUND
  Thoracic aortic aneurysm affecting the arch and proximal descending thoracic aorta requires 2-stage repairs that include proximal elephant trunk graft placement and completion of thoracic or thoracoabdominal repair. The application of endovascular grafting to complete the proximal procedure avoids a thoracotomy and may improve the morbidity and mortality of the patient population at risk.
  
  
  RESULTS
  A retrospective review of 399 thoracic endovascular grafts at our institution between 2000 and 2004 identified 22 patients who required elephant trunk and endovascular completion. Three patients underwent mesenteric bypass in addition to their proximal repairs. Mean follow-up was 10 months (range 1 to 42 months); there were no ruptures, and all patients returned for follow-up. Technical success was achieved in all patients. The 1-, 12-, and 24-month mortality rates (by Kaplan-Meier analysis) were 4.5%, 15.8%, and 15.8%, respectively. Caudal migration of the endograft occurred in 1 patient, and all but 2 aneurysms decreased or remained stable in size. The 2 patients with growth included a type III endoleak (which resolved after treatment) and pressurization through an expanded PTFE stentgraft. Three cases of transient paraparesis occurred (all in patients requiring mesenteric bypass or abdominal aortic aneurysm repair), and there were no paraplegias or strokes.
  
  
  CONCLUSIONS
  Endovascular completion of elephant trunks is feasible and can be accomplished with minimal mortality. Meticulous imaging follow-up is required to detect persistent aneurysm pressurization and to verify the integrity of the repair. Improvements in implant design and delivery systems will further simplify the second-stage portion of these complex aneurysm repairs.
authors.affiliation: The Center for Aortic Surgery, Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. greenbr@ccf.org
authors.forename: Roy K
authors.initials: RK
authors.lastname: Greenberg
authors.forename: Fady
authors.initials: F
authors.lastname: Haddad
authors.forename: Lars
authors.initials: L
authors.lastname: Svensson
authors.forename: Sean
authors.initials: S
authors.lastname: O'Neill
authors.forename: Esteban
authors.initials: E
authors.lastname: Walker
authors.forename: Sean P
authors.initials: SP
authors.lastname: Lyden
authors.forename: Daniel
authors.initials: D
authors.lastname: Clair
authors.forename: Bruce
authors.initials: B
authors.lastname: Lytle
mesh_terms: D001013:Aorta, Thoracic / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D002986:Clinical Trials as Topic; D006801:Humans; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D015607:Stents