title: Prophylactic stage 1 elephant trunk for moderately dilated descending aorta in patients with predominantly proximal disease.
abstract: OBJECTIVE
  Staged elephant trunk (ET) repair is a commonly performed procedure for extensive aortic disease. A significant proportion of patients with predominantly proximal aortic pathology often have in addition a moderately dilated descending aorta (<5 cm) that can progress over time. Objectives were to characterize patients, determine completion rate after prophylactic stage 1 ET, and assess outcomes.
  
  
  METHODS
  From 1992 to 2012, a total of 572 patients underwent stage 1 ET for degenerative aneurysm and dissection at Cleveland Clinic. Prophylactic stage 1 ET was performed in 117 (20.5%) who had predominantly proximal disease (5.5 ± 1 cm) with moderate dilation of the descending aorta (4 ± 0.6 cm). Aortic pathology included: aneurysm (n = 56 [48%]); chronic dissection (n = 41 [35%]); pseudoaneurysm (n = 9 [7.7%]); penetrating ulcer (n = 9 [7.7%]); and intramural hematoma (n = 2 [1.7%]). Other diagnoses included connective tissue disorder (12 [10%]); aortitis (20 [17%]); bicuspid aortic valve (9 [7.6%]); and previous type A dissection repair (27 [23%]).
  
  
  RESULTS
  Operative mortality was 0.8% (1 of 117). This patient suffered postoperative myocardial infarction and mesenteric ischemia, resulting in sepsis and death. Other complications included: stroke (n = 7 [6%]); tracheostomy (n = 6 [5%]); renal dialysis (n = 4 [3.3%]); and reoperation for bleeding (n = 7 [6%]). The mean follow-up time was 4 ± 3 years. Fifty-three (45%) patients completed the stage 2 ET (open: 20 [38%]; endovascular: 33 [62%]) at a median interval of 6 months (9 days-10 years). The mean descending diameter increased from 4.1 ± 0.6 cm to 5 ± 1 cm at the time of stage 2 completion. In 11 patients, stage 2 was performed for acute aortic events. Estimated survival at 1, 5, and 8 years was 94%, 88%, and 74%, respectively.
  
  
  CONCLUSIONS
  Prophylactic ET for moderately dilated descending aorta is an effective strategy for staged repair, especially in patients with chronic dissection, connective tissue disorder, and aortitis. In addition, this approach can be beneficial for emergency treatment of late distal aortic complications.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Jay J
authors.initials: JJ
authors.lastname: Idrees
authors.affiliation: Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: roselle@ccf.org.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.affiliation: Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Charles M
authors.initials: CM
authors.lastname: Wojnarski
authors.affiliation: Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Ke
authors.initials: K
authors.lastname: Feng
authors.affiliation: Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Aftab
authors.affiliation: Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Douglas R
authors.initials: DR
authors.lastname: Johnston
authors.affiliation: Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Edward G
authors.initials: EG
authors.lastname: Soltesz
authors.affiliation: Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.affiliation: Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D000785:Aneurysm, Infected / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D004108:Dilatation, Pathologic; D018450:Disease Progression; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009820:Ohio; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: aneurysm; aortic operation; ascending aorta; complications; outcomes; stroke; surgery