Jay J. Idrees, MD Eric E. Roselli, MD Lars G. Svensson, MD

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Presentation transcript:

Jay J. Idrees, MD Eric E. Roselli, MD Lars G. Svensson, MD Prophylactic 1st Stage Elephant Trunk for Moderately Dilated Descending Aorta in Patients with Proximal Disease Jay J. Idrees, MD Eric E. Roselli, MD Lars G. Svensson, MD

Disclosures Jay J. Idrees None Eric Roselli Bolton, Cook, Medtronic,Terumo Lars Svensson

Extensive Aortic Disease Staged repair is the standard of care 2 Stage Elephant Trunk

ACCF/AHA/AATS/STS/SVM 2010 Hiratzka LF et al, Circulation Guidelines Elective Surgical Replacement Proximal Aorta : 5* to 5.5 cm Descending Aorta : 5.5* to 6 cm * With high risk features ACCF/AHA/AATS/STS/SVM 2010 Hiratzka LF et al, Circulation

Should we do Ascending Plus Hemiarch OR Prophylactic ET ? Managing Moderately Dilated Descending 69y/o Female, vague chest pain w/o CAD Ascending aorta 6.1cm and Descending aorta 4.6cm Should we do Ascending Plus Hemiarch OR Prophylactic ET ?

Objectives Characterize patients Assess risk vs benefit of prophylactic ET

Patients 1992 to 2012 572 First stage ET Prophylactic: N=117 Proximal Replacement Indicated + Descending Aorta < 5cm but abnormal Mean age: 63±13 years 57% had concomitant cardiac procedures

Patient Characteristics Previous Type A repair 23% 77 % 17 10 8 Aortitis CTD BAV HTN

Aortic Morphology Max asc/arch 5.5±1 cm Max descending 4±0.6 cm PseudoAn 7.6% Chronic dissection 36% Pen Ulcer 7.6% IMH 1.7% Deg Aneurysm 47%

Early Outcomes (1st Stage) 7 Strokes: Severe atheroma 5 ACP 1 Axillary cannulation 3 % 5.9 5.9 5 3.3 0.8 Mortality Stroke Bleed Trach dialysis

First stage Prophylactic ET Elephant Trunk Fate Mean FU: 4 ± 3 years First stage Prophylactic ET N=117 Stage II n=53,45% Death n=10, 9% Event Free n=54,46% Open 37% Endo 63% Surveillance 56% Planned ETC 9% Pts refused 5% Lost FU 14%

2nd stage completion: Indications Progressive growth with Interval increase in diameter 80%, n=42/53 mean: 4±0.6 cm to 5±1 cm

Urgent 2nd Stage completion Acute pathology of descending aorta Complicated dissection P. ulcer 3 2 Pseudo-coarctation 1 4 1 Rupture Rapid growth >0.5cm in 2 mo

Outcomes after 2nd stage % Same pt 1.9 1.9 1.9 1.9 Mortality Stroke Bleed Trach Paresis

Probability of 2nd stage Median interval 6 months (9d to 10 yrs) 100 80 % 60 40 Probability of completion: 1, 5 and 10 years 39%, 59% and 83% 20 2 4 6 8 10 Time (Years)

Survival % 100 80 60 40 1, 5 and 8 years 94%, 88% and 74% 20 2 4 6 8 2 4 6 8 10 Time (Years)

Prophylactic 1st Stage ET Effective strategy for staged repair of moderately dilated descending aorta Should be considered in high risk pts with chronic dissection, connective tissue disorder, aortitis, etc. Offers long term benefit for treatment of late distal aortic disease progression and acute complications with EEC or OEC