Elephant trunk procedure: newer indications and uses.
ABSTRACT The elephant trunk procedure is used for extensive aortic aneurysms. We evaluated its safety, newer indications, and influence of second-stage completion on survival.
Records were reviewed for 94 consecutive patients (age 67 +/- 11 years, 47% men) who underwent the procedure between November 1990 and February 2003. The trunk was implanted as an extension of the ascending aorta and arch graft in 83 of 94 (88.3%) patients, distal arch graft in 8 of 94 (8.5%) patients, and in 3 distal to the left subclavian artery (3 of 94 patients [3.2%]). Aortic dissection was present in 37 (39.4%) patients and Marfan syndrome was present in 7 (7.4%). Twenty-three were reoperations (24.5%). In 9 patients, the trunk procedure was adjunctive in preparation for the second operation. In 15 patients, the anastomosis was completed between the left subclavian and common carotid arteries. Coronary artery bypass was performed in 36 (38.4%) and aortic valve operation in 55 (58.5%; 20 root sparing repairs, 16 composite grafts and 19 replacements) patients.
There were two early 30-day in-hospital deaths (2.1%) and 5 permanent strokes (5.3%). Eleven died before the second-stage procedure. Forty-seven (57%) underwent second-stage procedures; 40 by thoracotomy and 7 by stent graft insertion, including 2 thoracoabdominal aneurysm repairs with visceral bypasses before stent grafting with 4 early deaths (8.5%). Five-year survival was 34% without a second-stage procedure versus 75% 3-year survival with it.
With a current total of 142 elephant trunk procedures, we found it is safe and should be used more with initial cardiac surgery before descending or thoracoabdominal aorta repair.
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ABSTRACT: The E-vita open plus is a one-stage endoluminal stent graft system used for treating complex aneurysms and dissections of the thoracic aorta. The National Institute for Health and Care Excellence (NICE), as a part of its Medical Technologies Evaluation Programme (MTEP), selected this device for evaluation and invited the manufacturer, JOTEC GmbH, to submit clinical and economic evidence. King’s Technology Evaluation Centre (KiTEC), an External Assessment Centre (EAC) commissioned by the NICE, independently critiqued the manufacturer’s submissions. The EAC considered that the manufacturer had included most of the relevant evidence for the E-vita open plus, based on international E-vita open registry data for 274 patients, but had provided only limited evidence for the comparators. The EAC therefore conducted a systematic review and meta-analysis of all comparators to supplement the information, and found ten additional studies providing outcome data for the three two-stage comparators. The EAC noted that the cost model submitted by the manufacturer did not include key complications during the procedures. The EAC developed a new economic model incorporating data on complications along with their long-term costs. The revised model indicated that the E-vita open plus might not provide cost savings when compared with some of the comparators in the short-term (1 year), but would have high cost savings in the long-term, from the second year onwards. The NICE Medical Technologies Guidance MTG 16, issued in December 2013, recommended the adoption of the E-vita open plus in selected patients within the National Health Service in England.Applied Health Economics and Health Policy 10/2014; 12(5):485-495. DOI:10.1007/s40258-014-0114-9This article is viewable in ResearchGate's enriched formatRG Format enables you to read in context with side-by-side figures, citations, and feedback from experts in your field.
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ABSTRACT: Objectives: Repair of thoracic aneurysms (TA) involving the ascending, arch, and descending aorta results in substantial morbidity and mortality. This study evaluates outcomes with a two-stage elephant trunk (ET) technique. Methods: Two hundred and fifteen consecutive patients (pts) underwent total arch replacement using an ET (02/90—09/06). One hundred and thirty-nine pts (65%), group PC (planned completion; median age 68; 28—86 years), had extensive descending TA (Ø ! 5 cm) or dissections requiring complete repair. Seventy-six pts (35%), group CS (close surveillance; median age: 68; 20—87 years), had less severe distal dilatation (Ø 5 cm), and had close follow up after ETrather than planned distal repair. Results: Hospital mortality in group PC pts (descending Ø: 6.2 AE 1.2 cm) was 6.5% (9/139) following ET. In group CS pts (descending Ø: 4.1 AE 0.7 cm), hospital mortality after ETwas 5.3% (4/76); 4.7% (10/215) had strokes but survived. Eighty-six percent (112/130) of group PC pts who survived proximal repair returned for planned surgical (101) or endovascular (11) completion after a median of 56 (0—2189) days. Hospital mortality for distal repair was 7.5% (9/120); two ET stage two pts (2%) developed paraplegia. Eighty-nine percent (16/18; descending Ø: 6.9 AE 1.0 cm) of group PC pts who did not undergo planned completion died a median of 5.4 (1.2—91.1) months after ETstage one. Overall cumulative survival in group PC, which includes pts dying before or without stage two, was 69% after 1, and 55% after 5 years. Survival in group CS pts was 88% at 1, and 57% at 5 years. Eight pts in group CS subsequently underwent distal repair, but 22/76 (29%) group CS pts who survived ET stage one died during follow-up despite surveillance. Conclusions: The low mortality after stage one justifies liberal use of the ET technique to facilitate future open or endovascular TA repair of the distal aorta. The 5-year cumulative mortality curves, however, suggest that staged repair of extensive TA is superior to one-step repair only if stage two can be done before rupture occurs. If one-step repair is possible, it may be preferable. # 2008 Published by Elsevier B.V. on behalf of European Association for Cardio-Thoracic Surgery.European Journal of Cardio-Thoracic Surgery 04/2008; · 2.81 Impact Factor
Dataset: Wallet Trunk An&An