title: Optimization of aortic arch replacement: two-stage approach.
abstract: BACKGROUND
  Aneurysms of the aortic arch seldom occur alone. They usually involve the ascending aorta. Occasionally, the aneurysm also involves the descending thoracic or thoracoabdominal aorta. We advocate a staged approach for repair of these extensive aortic aneurysms, with the ascending and arch generally being repaired in the first stage and the descending thoracic or thoracoabdominal aorta being repaired in the second stage.
  
  
  METHODS
  Between February 1991 and December 2005, we repaired aneurysms of the ascending, arch, descending thoracic, and thoracoabdominal aorta in 2120 patients. Of these, 254 (12.0%) involved the ascending, arch, and descending aorta (extensive aortic aneurysm). A first-stage repair was done in 254 patients, and 115 returned for a second-stage repair for a total of 369 procedures performed.
  
  
  RESULTS
  First-stage 30-day mortality was 6.3% (16/254), with the glomerular filtration rate (GFR) exceeding 70 mL/min in 2.9% of patients and less than 70 mL/min in 10.5% (p < 0.03). Second-stage 30-day mortality was 9.6% (11/115), with GFR exceeding 70 mL/min in 4.9% and less than 70 mL/min in 9.8% (not significant). The incidence of postoperative stroke for the first stage was 2.0% (5/254), and the rate of neurologic deficit (paraplegia and paraparesis) was .9% (1/115) in the second stage. The mortality for the interval of 31 days to 6 weeks after the first-stage operation was 2.9% (7/238).
  
  
  CONCLUSIONS
  Aneurysms involving the transverse arch with extensive involvement of the ascending and descending thoracic or thoracoabdominal aorta can be effectively repaired using the two-stage technique with acceptable morbidity and mortality. GFR correlates to surgical outcome in the first-stage repair. After the first stage, prompt treatment of the remaining segment of aorta is crucial to success.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, The University of Texas at Houston Medical School, Memorial Hermann Heart and Vascular Institute, Houston, Texas 77030, 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: Martin A
authors.initials: MA
authors.lastname: Villa
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Goodrick
authors.forename: Eyal
authors.initials: E
authors.lastname: Porat
authors.forename: Ali
authors.initials: A
authors.lastname: Azizzadeh
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000601:surgery*; D001014:Aortic Aneurysm / Q000503:physiopathology / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality / Q000592:standards; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D008297:Male; D008875:Middle Aged; D020335:Paraparesis / Q000209:etiology; D010264:Paraplegia / Q000209:etiology; D020521:Stroke / Q000453:epidemiology