Interstage mortality in two‐stage elephant trunk surgery

Abstract

Purpose Diffuse mega‐aorta is challenging. Prior studies have raised concerns regarding the safety of the open two‐stage elephant trunk (ET) approach for extensive thoracic aortic aneurysm (TAA), specifically in regard to interstage mortality. This study evaluates the safety of the two‐stage ET approach for management of extensive TAA. Methods Between 2003 and 2018, 152 patients underwent a Stage I ET procedure by a single surgeon (mean age 64.5 ± 14.8). Second stage ET procedure was planned in 60 patients (39.4%) and to‐date has been performed in 54 patients (90%). (in the remaining patients, the ET was prophylactic for the long‐term, with no plan for near‐term utilization). Results In‐hospital mortality after the Stage I procedure was 3.3% (5/152). In patients planned for Stage II, the median interstage interval was 5 weeks (range: 0–14). Of the remaining six patients with planned, but uncompleted Stage II procedures, five patients expired from various causes in the interval period (interstage mortality of 8.3%). There were no cases of aortic rupture in the interstage interval. Stage II was completed in 58 patients (including four unplanned) with a 30‐day mortality of 10.3% (6/58). Seven patients developed strokes after Stage II (12%), and three patients (5.1%) developed paraplegia. Conclusions The overall mortality, including Stage I, interstage interval, and Stage II was 18.6%. This substantial cumulative mortality for the open two‐staged ET approach for the treatment of extensive TAA appears commensurate with the severity of the widespread aortic disease in this patient group. Fear of interstage rupture should not preclude the aggressive Two‐Stage approach to the management of extensive TAA.

Elephant trunk simplifies thoracoabdominal aortic aneurysm repair without impacting operative risk

“…16,17 Proposed advantages of hybrid techniques have included the potential to avoid the cumulative morbidity and mortality associated with two major aortic procedures, interval mortality, and failure to return for the second-stage completion. 18,19 Saeyeldin et al 19 Approximately half of our patients underwent surgery in an urgent or emergent status.…”

“…Saeyeldin et al 19 recently published their data on the interstage mortality for patients undergoing the open two‐stage ET approach over a 15‐year period. Of the 60 patients planned for a stage II procedure, only 5 patients (8.3%) expired in the interstage interval, with no cases of aortic rupture.…”

“…The most concerning disadvantages seen with hybrid techniques include higher than expected incidences of spinal cord injury (up to 24% in single center studies), renal failure, a significant need for reintervention, and a lack of data supporting improvement in operative mortality 16,17 . Proposed advantages of hybrid techniques have included the potential to avoid the cumulative morbidity and mortality associated with two major aortic procedures, interval mortality, and failure to return for the second‐stage completion 18,19 …”

“…No patients in the ET group experienced stroke or recurrent laryngeal nerve injury. Median partial bypass and cross-clamp times were significantly greater in the no ET group (28 [24-32] versus 19 [16][17][18][19][20][21][22] min; p ≤ .001 and 42 versus 30 [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39] min; p ≤ .001).Conclusions: Extent I and II TAAA repair after ET can be safely performed in a tertiary referral center with shorter bypass and cross-clamp times. ET eliminates the need for circulatory arrest or clamping a hostile arch.…”

“…No patients in the ET group experienced stroke or recurrent laryngeal nerve injury. Median partial bypass and cross-clamp times were significantly greater in the no ET group (28 [24-32] versus 19 [16][17][18][19][20][21][22] min; p ≤ .001 and 42 versus 30 [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39] min; p ≤ .001).…”