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Evolution in the Management of the Total Thoracic Aorta
T. Kim, T. D. Martin, W. A. Lee, P. J. Hess, C. T. Klodell, C. G. Tribble, R. J. Feezor, T. M. Beaver. University of Florida, Gainesville, FL,
OBJECTIVES:
Extensive aneurysms of the ascending, arch, and descending thoracic aorta have been managed with either a traditional two-stage elephant trunk technique or single-stage transmediastinal replacement of the total thoracic aorta. Starting in 2006, we began preferentially completing elephant trunks with endovascular stent grafts in anatomically appropriate patients. However, some patients fail to complete the entire repair due to either complications sustained during the first stage ascending aortic replacement or the magnitude of the second stage repair of the descending thoracic segment. In this study, we compare the outcomes of single-stage, 2-stage elephant trunk, and hybrid endovascular repairs of extensive thoracic aortic aneurysms.
METHODS:
We retrospectively reviewed the medical records from 1992 to 2007 of 103 patients with extensive thoracic aortic aneurysms undergoing either single-stage transmediastinal replacement (SS) or 2-stage elephant trunk repair, involving either surgical (OPEN) or endovascular (TEVAR) 2nd stage techniques. Patients were considered completion failures if they expired before the second stage, were lost to follow up, or were untreated for any cause, except in those whose descending thoracic aorta was <6.0-cm. Completion rates and outcomes were analyzed on an intention-to-treat basis using Statistica 8.0 (Tulsa, OK).
RESULTS:
Of the 103 patients, 8 (7 OPEN and 1 TEVAR) are currently being followed. Of the remaining 95 patients, 29 had SS and 66 had elephant trunk procedures, among whom 23 were eligible for TEVAR and 43 were assigned to the OPEN group for the 2nd-stage. Completion rates were significantly higher with TEVAR than with OPEN (78.3%, 18/23 vs. 46.5%, 20/43, p=0.01). 7 of the 18 TEVARs were performed during the index hospitalization but as separate procedures. In the elephant trunk patients, median total (1st + 2nd stages) length of stay was shorter with TEVAR than with OPEN, due to the shorter 2nd stage hospitalization (5.5 vs. 16.5 days, p=0.00001). TEVAR patients also required fewer blood transfusions (p=0.0001). There were no significant differences among the three groups in 30-day/inpatient mortality or rates of spinal cord ischemia, stroke, or acute kidney injury (AKI, STS criteria). In subgroup analysis of patients with completed elephant trunk repairs, there was a reduction in acute kidney injury at the 2nd stage with TEVAR 0% (0/18) vs. OPEN 25% (5/20) p=0.03. Kaplan-Meier estimates of survival at 6-months were 64.4%, 78%, and 63.9%, respectively for the SS, OPEN, and TEVAR groups (p=0.08).
CONCLUSION:
More patients are able to complete their 2nd-stage procedures after elephant trunk repair utilizing endovascular techniques. TEVAR is less invasive and, therefore, may be performed during the index hospitalization with overall reduced length of stay and transfusion requirements. For patients with suitable anatomy, elephant trunk repair with second-stage TEVAR is our preferred approach in the management of total thoracic aortic aneurysms.
Table of Completion Rates and Outcomes | SS (n=29) | OPEN (n=50) | TEVAR (n=24) | p | | Completed | 29/29(100%) | 20/43 (46.5%) | 18/23 (78.3%) | 0.01 | | Median length of stay (days) | 16 | 29 | 20 | 0.008 | | 30d/inpatient mortality | 7 (24.1%) | 7 (14%) | 4 (16.7%) | 0.52 | | Stage I 30d mortality | | 5 (10%) | 2 (8.3%) | 0.82 | | Stage II 30d mortality | | 2 (4%) | 2 (8.3%) | 0.45 | | AKI | 12 (41.4%) | 14 (28%) | 3 (12.5%) | 0.07 | | Permanent paraplegia | 2 (6.9%) | 3 (6%) | 0 | 0.45 | | Stroke | 2 (6.9%) | 5 (10%) | 1 (4.2%) | 0.67 | | Intraop PRBC (units) | 6.2 | 10.5 | 3.4 | 0.0001 |
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