title: The classic elephant trunk technique for staged thoracic and thoracoabdominal aortic repair: long-term results.
abstract: OBJECTIVE
  The classic elephant trunk (ET) technique has become the standard approach for patients with diffuse aortic disease requiring a staged thoracic and thoracoabdominal aortic repair. The aim of this study was to assess long-term outcomes and predictors for survival after surgical repair of extensive thoracic aortic disease with the ET technique.
  
  
  METHODS
  Between 1984 and 2013, 248 consecutive patients were treated in our institution and analyzed retrospectively. Follow-up consisted of outpatient clinic visits including postoperative computed tomography imaging at 3 months and annually thereafter. Second-stage intervention was indicated if the diameter of the descending or thoracoabdominal aorta was greater than or equal to 60 mm, in case of a rapidly growing aneurysm and/or symptoms.
  
  
  RESULTS
  Mean age was 65 ± 10 years; 44% were male. After first-stage ET, in-hospital mortality was 8% and permanent neurologic deficits were observed in 2% of patients. Median follow-up after the first stage was 48 months (range, 1-210 months). One hundred twelve patients (45%) underwent second-stage ET. Overall survival after first-stage ET was 75% and 67% at 5 and 10 years, respectively. Survival in patients with second-stage ET was 87%, compared with 65% in the group who did not undergo second-stage ET at the 5-year follow-up (P < .001) and 67% compared with 36% at the 10-year follow-up (P < .001). Predictor for mortality was the absence of second-stage ET (P = .044).
  
  
  CONCLUSIONS
  A 2-stage approach for diffuse aortic disease is a safe method. The acceptable mortality at the first stage justifies the use of the classic ET technique and allows subsequent repair of the distal aorta. Long-term survival is increased when both stages are completed.
authors.affiliation: Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiac Surgery, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy. Electronic address: sebastiano.castrovinci@gmail.com.
authors.forename: Sebastiano
authors.initials: S
authors.lastname: Castrovinci
authors.affiliation: Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiac Surgery, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Murana
authors.affiliation: Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands.
authors.forename: Gijs E
authors.initials: GE
authors.lastname: de Maat
authors.affiliation: Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands.
authors.forename: Tim
authors.initials: T
authors.lastname: Smith
authors.affiliation: Department of Cardiovascular Surgery, AZ St Jan Hospital, Brugge, Belgium.
authors.forename: Marc A A M
authors.initials: MA
authors.lastname: Schepens
authors.affiliation: Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands.
authors.forename: Robin H
authors.initials: RH
authors.lastname: Heijmen
authors.affiliation: Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands.
authors.forename: Wim J
authors.initials: WJ
authors.lastname: Morshuis
mesh_terms: D000328:Adult; D000368:Aged; D001018:Aortic Diseases / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000401:mortality; D012086:Reoperation; D012189:Retrospective Studies; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods* / Q000401:mortality