1. 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

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

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

4. 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

5. 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 ?

6. Objectives Characterize patients Assess risk vs benefit of
prophylactic ET

7. 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

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

9. 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%

10. 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

11. 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 %
Endo %
Surveillance 56%
Planned ETC 9%
Pts refused %
Lost FU %

12. 2nd stage completion: Indications
Progressive growth with Interval increase in diameter
80%, n=42/53
mean: 4±0.6 cm to 5±1 cm

13. 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

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

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

16. Survival % 100 80 60 40 1, 5 and 8 years 94%, 88% and 74% 20 2 4 6 82 4 6 8 10
Time (Years)

17. 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