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Cardiovascular Surgery Service, Texas Heart Institute at St. Luke’s Episcopal Hospital, Division of Cardiothoracic Surgery, Baylor College of Medicine, One Baylor Plaza, BCM 390, Houston, Texas 77030
(Email: slemaire{at}bcm.edu; jcoselli{at}bcm.edu).
In light of Dr Kouchoukos’ enormous contributions to the field of thoracic aortic surgery, we are especially grateful that he has extended the discussion of treatment options for patients with extensive thoracic aortic aneurysms [1]. Indeed, recognizing that this field is rapidly evolving, we wrote our report [2] to provide a snapshot assessment of where we are now and to encourage dialogue about the relative merits of the elephant trunk technique and alternative approaches. Similar dialogues in the past have encouraged us to reassess our own practices and have led to important improvements in our approach to treating aortic disease.
In this spirit, several issues regarding elephant trunk repairs warrant discussion. We share Dr Kouchoukos’ [1] concern about the substantial risk of death from distal aortic rupture during the interval between staged operations, and we have adopted two strategies to reduce this risk. First, to minimize the interval between operations, we perform the second one as soon as is clinically feasible instead of routinely prescribing a 6-week recovery period. Second, to prevent catastrophic suture line disruption, we frequently use techniques that reduce tension at the distal anastomosis. When there is a significant size discrepancy between the graft and the dilated proximal descending thoracic aorta, we perform the distal anastomosis at a more proximal location where the aortic diameter is smaller (ie, between the left common carotid and left subclavian arteries, between the innominate and left common carotid arteries, or immediately proximal to the innominate artery). Advocates of this approach have described a variety of options for managing the brachiocephalic branches [3–5]; we have recently found Spielvogel and colleagues’ [4] trifurcated graft technique to be particularly useful for this purpose. We have also used the collared elephant trunk graft described by Neri and colleagues [6] to reduce anastomotic tension.
An emerging chapter in the elephant trunk story is the use of this technique to facilitate endovascular repair of the descending thoracic aorta. Because the elephant trunk graft provides an excellent landing zone for a stent graft, hybrid repairs that combine open arch replacement and endovascular exclusion of the descending thoracic aorta are becoming increasingly popular [7, 8]. The open arch repair and endovascular completion procedure can be performed during a single operation or in stages. In staged procedures, the interval can be short, because the endovascular procedure is considerably less physiologically demanding than an open repair. This opportunity to perform a less invasive second-stage operation may decrease the number of patients who undergo the first-stage arch repair and never receive completion procedures, and it should reduce the cumulative mortality risk. Although hybrid approaches may be effective in carefully selected patients with degenerative aneurysms, these approaches should be applied cautiously in patients with aortic dissection.
Dr Kouchoukos [1] has appropriately questioned the prophylactic use of elephant trunk procedures in patients who require aortic arch replacement but do not meet criteria for descending thoracic aortic repair. We only use this approach in patients who seem likely to need distal aortic repair in the future (eg, young patients with moderate descending thoracic aortic dilatation), but we concede that the long-term utility of this practice is uncertain. Svensson and colleagues [8] used this prophylactic strategy in 16 of 72 (22%) elephant trunk procedures performed at the Cleveland Clinic and raised the intriguing possibility that elephant trunk grafts prevent further dilatation of the descending thoracic aorta. Although we believe that prophylactic elephant trunks may be beneficial in the long term, particularly given the opportunity for endovascular completion procedures, this supposition will require careful analysis in the future.
The approach favored by Dr Kouchoukos [1] (ie, single-stage repair through a bilateral anterior thoracotomy) is unquestionably a valuable alternative to the elephant trunk technique. We have also used this technique, although we have tended to reserve it for cases in which the two-stage approach was not possible [2]. In many of our patients, the single-stage approach was not feasible because their aneurysms extended below the diaphragm. The two recent references [9, 10] cited by Dr Kouchoukos [1] illustrate the wide variability in results that remains associated with this technique and makes generalized application difficult. Although these reports describe comparable rates of mortality and other complications, they differ substantially in the reported incidence of respiratory failure and stroke. Nevertheless, as Dr. Kouchoukos points out, these reports demonstrate that results have improved in recent years. The superb early survival achieved in experienced centers and the elimination of the cumulative mortality risk associated with staged operations make a strong case for considering this approach.
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