CW Lee 1 , PJ Hess 2 , TD Martin 2 , TM Beaver 2 , CT Klodell 2 , RJ Feezor 1 and WA Lee 1

(1)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


Disclosure• WAL:– Cook Medical: Grants, consultant– Medtronic Endovascular: Consultant

• Off-label use of a commercial device


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


Elephant Trunk• Advantages:– Long, prosthetic proximal

landing zone– Single stage option

• Disadvantages:– Mobile, unsupported

structure– Difficult to access– Uncertain long-term stability


Arch Debranching• Advantages:– Long, native proximal landing

zone– Single stage option

• Disadvantages:– A short, dilated ascending aorta

may require ascending replacement and/or trans-valvular insertion

– 3-vessel debranching can be challenging

– Risk of ascending dissection


Objective & Methods

+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.

Arch Debranching vs. Elephant Trunk


DemographicsET (n=21) AD (n=37) p

Gender, M(%) 13(62) 23(62) 1.0Age (yrs) 68±11 63±15 0.24Comorbidities, n (%)

HTN 19(91) 31(84) 0.70Smoking 15(71) 27(73) 1.0

CAD 11(52) 23(62) 0.58Hyperlipidemia 8(38) 16(43) 0.79

CRI 3(14) 5(14) 1.0Stroke/TIA 2(10) 5(14) 1.0

Diabetes 2(10) 8(22) 0.30


Preoperative

ET (n=21) AD (n=37) p

ASA, n (%)II 0 2(5) 0.53

III 3(14) 6(16) 1.0≥ IV 18(86) 23(62) 0.08

Urgency, n (%)Elective 19(91) 33(89) 1.0

Emergent 2(10) 4(11) 1.0


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


Concomitant Surgeries (1st Stage)

ET (n=21)

AD (n=37)

Valve repair, n (%) 6 (29) 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) -


1st Stage (Open Surgical) Intraoperative

ET (n=21)

AD (n=37)

p

Cardiopulmonary bypass, n (%) 21(100) 25(68) <0.01

Cardiopulmonary bypass median time (min)

202 226 0.74

Circulatory arrest, n (%) 18(86) 10(27) <0.01

Circulatory arrest median time (min) 43 25 0.36


Perioperative DataET

(n=21)AD

(n=37)p

Median duration between stages (days) 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

Median combined LOS (days) 25 19 0.04


OutcomesET

(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


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

CW Lee 1 , PJ Hess 2 , TD Martin 2 , TM Beaver 2 , CT Klodell 2 , RJ Feezor 1 and WA Lee 1

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