Endovascular versus open elephant trunk completion for extensive aortic disease.
To compare the outcomes between patients undergoing endovascular (EEC) or open (OEC) approaches to second-stage elephant trunk completion (EC).



From 1993 to 2010, 225 patients underwent second-stage EC (EEC, n = 92; OEC, n = 133). Propensity matching was performed for a fair comparison.



The EEC patients were older, more likely to have atrial fibrillation, and had a smaller proximal aorta. The 30-day mortality was 6.2% (6.5% EEC vs 6% OEC, P = .88). No difference was found in bleeding (8.8%), stroke (3%), renal failure (4%), or spinal cord injury (4%); however, the OEC patients required tracheostomy more often (10 vs 1, P = .014). Survival after second-stage EC at 6 months and 1 and 5 years was 91%, 90%, and 77%, respectively. Survival and major morbidity did not differ after matching (44 pairs). However, the EEC group had shorter stays (9.9 ± 13 vs 13 ± 9 days, P < .0001) and received less blood (3 ± 8 vs 6 ± 8 U, P = .0001) than did the OEC group. This was maintained after matching. During follow-up, 32 endoleaks (3 type I, 27 type II, 2 type III) occurred; 26 (28%) EEC and 13 of 76 (17%) OEC patients underwent reoperation. The approach was not related to the risk of death in either hazard phase, but a larger descending diameter predicted a greater risk in the early phase.



Death and complications occur similarly after OEC or EEC. The early toll might be greater after OEC, at the cost of reintervention for EEC. EEC expands the options to older patients and allows for earlier completion. Second-stage repair should not be delayed, and all patients require lifelong imaging surveillance.
Aorta Center and Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address: roselle@ccf.org.
Eric E
EE
Roselli
Sreekumar
S
Subramanian
Zhiyuan
Z
Sun
Jay
J
Idrees
Edward
E
Nowicki
Eugene H
EH
Blackstone
Roy K
RK
Greenberg
Lars G
LG
Svensson
Bruce W
BW
Lytle
D000367:Age Factors; D000368:Aged; D000784:Aortic Dissection / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001281:Atrial Fibrillation / Q000150:complications; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D057867:Endoleak / Q000209:etiology / Q000601:surgery; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D057216:Propensity Score; D012042:Registries; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
26; 26.1; 28; EC; EEC; OEC; elephant trunk completion; endovascular elephant trunk completion; open elephant trunk completion