title: Evolution in the management of the total thoracic aorta.
abstract: OBJECTIVE
  Extensive aneurysms of the ascending, arch, and descending thoracic aorta traditionally have been managed with a 2-stage "elephant trunk" procedure. Single-stage transmediastinal repairs have also been used, because in some patients the entire repair is not completed owing to either complications during first-stage repair or magnitude of the second-stage operation. Since 2006, second-stage elephant trunks have been preferentially completed with endovascular stent grafts in anatomically appropriate patients. This study compares outcomes of 2-stage elephant trunk, single-stage, and hybrid endovascular repairs of extensive thoracic aortic aneurysms.
  
  
  METHODS
  This is a single-institution retrospective cohort study of 103 patients (1992-2007) with extensive thoracic aortic aneurysms undergoing 2-stage elephant trunk repair with either surgical (OPEN) or endovascular (TEVAR) completion versus single-stage transmediastinal replacement (SS). Outcomes were analyzed with Statistica 8.0 software (Tulsa, Okla).
  
  
  RESULTS
  Of 103 patients, 74 had elephant trunk procedures, 24 TEVAR-eligible and 50 OPEN, and 29 had SS. Completion rates were higher with TEVAR than OPEN (78% vs 47%; P = .01). Seven of 18 TEVARs were performed during the index hospitalization. TEVAR patients had shorter second-stage hospital stay (5.5 vs 16.5 days [P < .01]), required fewer transfusions (P < .01), and had less acute kidney injury (P = .04). There were no differences in mortality, paraplegia, or stroke. Six-month Kaplan-Meier survival estimates for OPEN, TEVAR, and SS were 64%, 78%, and 64% (P = .08).
  
  
  CONCLUSIONS
  More patients complete the second stage when TEVAR is used after elephant trunk repair, with fewer hospital days and transfusions. TEVAR is feasible and safe in the hybrid management of extensive thoracic aortic aneurysms.
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine, Gainesville, Florida 32610-0286, USA.
authors.forename: Tad
authors.initials: T
authors.lastname: Kim
authors.forename: Tomas D
authors.initials: TD
authors.lastname: Martin
authors.forename: W Anthony
authors.initials: WA
authors.lastname: Lee
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Hess
authors.forename: Charles T
authors.initials: CT
authors.lastname: Klodell
authors.forename: Curtis G
authors.initials: CG
authors.lastname: Tribble
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Feezor
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Beaver
mesh_terms: D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014656:Vascular Surgical Procedures / Q000379:methods