title: Distal landing zone open fenestration facilitates endovascular elephant trunk completion and false lumen thrombosis.
abstract: BACKGROUND
  Controversy surrounds the endovascular treatment of chronic dissection because of inconsistent remodeling of the aorta. The purpose of this study was to assess efficacy and safety of a novel technique for repairing aneurysmal change associated with chronic descending aortic dissection.
  
  
  METHODS
  From July 2007 to April 2011, 24 patients with descending aortic aneurysmal change, consequent to previously repaired ascending aortic dissection or medically treated descending dissection, underwent combined open first-stage elephant trunk (ET) insertion and fenestration of the descending aorta intimal flap. Second-stage ET endovascular completion was performed with the index operation in 4 patients and later in 20 patients (median, 62 days). Repair was elective in 14 patients and urgent in 10 patients. Concomitant procedures were aortic valve replacement in 3 patients and coronary revascularization in 3 patients, and 16 procedures were reoperations. Chart review and analysis of 3-dimensional computed tomography (CT) scans were performed. Imaging follow-up was complete in 89% of patients during a median of 18 months (interquartile range [IQR], 10 to 28 months).
  
  
  RESULTS
  Technical success was achieved in all patients. Moderate reduction in aortic size occurred in most patients, with no retrograde false lumen flow. Late reintervention was required in 5 patients: endovascular for distal type I endoleak in 2 patients, type II endoleak in 1 patient, pseudoaneurysm of the abdominal aorta in 1 patient, and 1 open repair for aneurysm of the untreated distal segment in 1 patient. One patient died of pulmonary embolism on postoperative day 19 after 1-stage repair (4.0%) and 1 patient (4%) had a transient stroke, but there was no renal failure, respiratory failure, or permanent spinal cord injury. Median length of stay was 13 days (IQR, 8 to 16 days) after first-stage ET and 8 days (IQR, 5 to 12 days) after endovascular ET completion. One patient died during a mean of 23 ± 11 months of follow-up.
  
  
  CONCLUSIONS
  Open distal landing zone fenestration during first-stage ET facilitates endovascular completion for aneurysm associated with chronic distal dissection. Early results suggest that this technique is efficacious in eliminating retrograde false lumen filling and promoting aortic size reduction and is safe for patients.
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA. roselle@ccf.org
authors: Eric E
authors: EE
authors: Roselli
authors: Edgardo
authors: E
authors: Sepulveda
authors: Akshat C
authors: AC
authors: Pujara
authors: Jahanzaib
authors: J
authors: Idrees
authors: Edward
authors: E
authors: Nowicki
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D013927:Thrombosis / Q000209:etiology*; D014057:Tomography, X-Ray Computed