title: The reversed elephant trunk technique used for treatment of complex aneurysms of the entire thoracic aorta.
abstract: OBJECTIVE
  A preferred technique for the staged treatment of patients with aneurysms involving the entire thoracic aorta is the elephant trunk technique, with replacement of the proximal (ascending and transverse aortic arch) aorta as the initial procedure. Some patients, however, need to have the distal aortic segments (descending and thoracoabdominal aorta) addressed during the first operation. We evaluated outcomes in a series of patients who underwent distal aortic replacement first using the reversed elephant trunk technique.
  
  
  METHODS
  Thirty-eight patients underwent first-stage graft repair of the descending thoracic (n = 3) or thoracoabdominal (n = 35) aorta using the reversed elephant trunk technique. Twelve patients (32%) ultimately underwent second-stage aortic arch replacement after a mean interval of 3.9 months (range, 1.6-14 months).
  
  
  RESULTS
  The operative mortality for the initial procedure was 16% (6/38 patients). One patient had a stroke (3%) and 1 patient developed paraparesis (3%). In the interval between the 2 procedures, there were 4 late deaths (4/32; 13%), 1 due to respiratory failure and 3 due to unknown causes. After the 12 completion procedures, there was 1 in-hospital death (8%) and there were no strokes. Five-year survival for the overall group was 51.3 +/- 10.8%.
  
  
  CONCLUSIONS
  Surgical treatment of aneurysms involving the entire thoracic aorta remains challenging and is associated with substantial morbidity and mortality. The reversed elephant trunk technique facilitates staged repair in patients who require distal aortic replacement during the first operation.
authors.affiliation: The Texas Heart Institute, St. Luke's Episcopal Hospital, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA. jcoselli@bcm.tmc.edu
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Coselli
authors.forename: Scott A
authors.initials: SA
authors.lastname: LeMaire
authors.forename: Stacey A
authors.initials: SA
authors.lastname: Carter
authors.forename: Lori D
authors.initials: LD
authors.lastname: Conklin
mesh_terms: D000328:Adult; D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods