Staged repair of extensive aortic aneurysms

Background. We adopted a two-stage approach (elephant trunk procedure) in the repair of extensive aortic aneurysms in 1991, performing 241 procedures in 155 patients. Methods. Reversed elephant trunk (graft replacement of the descending thoracic aorta followed by ascending/ arch replacement) was performed in 18 patients. All other patients underwent conventional staged repair. The first stage was performed in 137 patients, with 86 patients returning for the second stage. Results. First stage 30-day mortality was 9.5% (13 of 137). There was no second stage immediate neurologic deficit. Second stage mortality was 7.0% (6 of 86). During the interval of 31 days to 6 weeks after stage one, mortality was 10 of 124 (8%). Seven of the 10 interval deaths (70%) were due to rupture of the untreated aortic segment. The mortality rate was 32.1% (18 of 56) in the group of patients who did not return for the second stage repair. Conclusions. Extensive aortic aneurysms can be repaired with acceptable morbidity and mortality using the elephant trunk technique. After stage one, prompt treatment of the remaining aneurysm is crucial to success.