Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Arch Debranching versus Elephant Trunk
Procedures for Hybrid Repair of Proximal
Thoracic Aortic Pathologies
CW Lee1, PJ Hess2, TD Martin2, TM Beaver2, CT Klodell2, RJ Feezor1 and WA Lee1
Divisions of Vascular Surgery and Endovascular Therapy1 and Thoracic and
Cardiovascular Surgery2
University of Florida, Gainesville
(1)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Disclosure
• WAL:
– Cook Medical: Grants, consultant
– Medtronic Endovascular: Consultant
• Off-label use of a commercial device
(2)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Background
• Hybrid (1st stage: open surgical +
2nd stage: endovascular) repairs of
complex arch diseases are feasible
and effective
• Optimal technique (elephant
trunk vs. arch debranching) for
creation of a suitable proximal
landing zone for endovascular
repair remains undecided
(3)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Elephant Trunk
• Advantages:
– Long, prosthetic proximal
landing zone
– Single stage option
• Disadvantages:
– Mobile, unsupported
structure
– Difficult to access
– Uncertain long-term stability
(4)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Arch Debranching
• Advantages:
– Long, native proximal landing
zone
– Single stage option
• Disadvantages:
– A short, dilated ascending aorta
may require ascending
replacement and/or transvalvular insertion
– 3-vessel debranching can be
challenging
– Risk of ascending dissection
(5)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Objective & Methods
Arch Debranching vs. Elephant Trunk
+
Endovascular Stent Graft
• Retrospective review of consecutive patients with
proximal thoracic aortic pathologies
• Prospective database, imaging, medical records
• Categorical variables were compared using Fisher’s exact
test. Continuous variables with nonparametric
distribution were compared using the Mann-Whitney U
test. A p-value <0.05 was considered significant.
(6)
(7)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Demographics
Gender, M(%)
Age (yrs)
Comorbidities, n (%)
HTN
Smoking
CAD
Hyperlipidemia
CRI
Stroke/TIA
Diabetes
ET (n=21)
13(62)
AD (n=37)
23(62)
p
1.0
68±11
63±15
0.24
19(91)
15(71)
11(52)
8(38)
3(14)
2(10)
2(10)
31(84)
27(73)
23(62)
16(43)
5(14)
5(14)
8(22)
0.70
1.0
0.58
0.79
1.0
1.0
0.30
(8)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Preoperative
ET (n=21)
AD (n=37)
p
II
III
≥ IV
0
3(14)
18(86)
2(5)
6(16)
23(62)
0.53
1.0
0.08
Elective
Emergent
19(91)
2(10)
33(89)
4(11)
1.0
1.0
ASA, n (%)
Urgency, n (%)
(9)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Indications for Treatment
ET (n=21) AD (n=37)
p
Aneurysm, n (%)
21(100)
34(92)
0.55
Dissection, n (%)
0
3(8)
0.55
(10)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Concomitant Surgeries (1st Stage)
Valve repair, n (%)
ET
(n=21)
6 (29)
AD
(n=37)
11 (30)
Root replacement, n (%)
3 (14)
3 (8)
Ascending replacement, n (%)
-
17 (46)
Arch replacement, n (%)
-
16 (43)
CABG, n (%)
5 (24)
11 (30)
Brachiocephalic reconstruction, n (%)
4 (19)
-
(11)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
1st Stage (Open Surgical) Intraoperative
Cardiopulmonary bypass, n (%)
Cardiopulmonary bypass median
time (min)
Circulatory arrest, n (%)
Circulatory arrest median time (min)
ET
(n=21)
21(100)
AD
(n=37)
25(68)
p
<0.01
202
226
0.74
18(86)
10(27)
<0.01
43
25
0.36
(12)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Perioperative Data
ET
AD
(n=21) (n=37)
Median duration between stages (days)
p
54
29
0.16
Aortic complications between stages, n (%)
1(5)
1(3)
1.0
Failure to complete 2nd stage, n (%)
5(24)
9(24)
1.0
25
19
0.04
Median combined LOS (days)
(13)
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Outcomes
ET
(n=21)
AD
(n=37)
p
30-day mortality, n (%)
4(19)
6(16)
1.0
Spinal cord ischemia (n)
0
0
1.0
CVA, n (%)
2(10)
4(11)
1.0
Type 1a endoleak at 1 mo., n (%)
2(10)
1(3)
0.54
Late secondary procedures, n (%)
3(14)
9(24)
0.51
Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta
Conclusions
• Arch debranching was associated with:
– Less frequent need for CPB/circulatory arrest
– Shorter overall LOS
– Earlier 2nd stage completion
– One-third the incidence of proximal endoleaks
(14)