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The hybrid elephant trunk procedure: A single-stage repair of an ascending, arch, and descending thoracic aortic aneurysm
From the Southern Association for Vascular Surgery
The hybrid elephant trunk procedure: A singlestage repair of an ascending, arch, and descending thoracic aortic aneurysm Ali Azizzadeh, MD, Anthony L. Estrera, MD, Eyal E. Porat, MD, Kenneth R. Madsen, MD, and Hazim J. Safi, MD, Houston, Texas Surgical repair of extensive aortic aneurysms requires a two-stage approach. We present the case of a single-stage repair using a hybrid procedure. This case demonstrates the technical feasibility of repairing properly selected extensive aortic aneurysms in a single procedure. ( J Vasc Surg 2006;44:404-7.)
Treatment of extensive aortic aneurysms presents a unique surgical challenge. The traditional repair requires a two-stage operation using the elephant trunk technique.1 Initially, the ascending and transverse arch is repaired through a median sternotomy. During the second stage, the descending or thoracoabdominal aorta is repaired through a left thoracoabdominal incision. Our operative technique and outcomes for this approach have previously been reported.2,3 Endovascular repairs have been used selectively in place of the second stage operation.4-13 Such repairs potentially allow the surgeon to avoid a second complex open procedure; however, they are currently limited to patients who meet certain anatomic criteria. We present the case of a single-stage repair of an ascending, arch, and descending thoracic aortic aneurysm. The ascending and transverse arch aneurysms were repaired through a median sternotomy. Endovascular repair of the descending thoracic aneurysm was performed in an antegrade fashion using the same exposure.
hypothermic circulatory arrest, and retrograde/antegrade cerebral perfusion. Electroencephalography and transesophageal echocardiography were performed. A 30-mm Hemashield (Boston Scientific, Natick, Mass) woven Dacron tube graft was used to make a 10-cm-long elephant trunk limb. The distal ends of the elephant trunk limb were marked with standard surgical staples for identification under fluoroscopy. The total circulatory arrest time was 39 minutes, and CPB time was 121 minutes. The patient was weaned off CPB, and motor and somatosensory evoked potential monitoring was initiated. The spinal cord function remained intact throughout the procedure. A side limb in the ascending graft was used to obtain antegrade access to the descending thoracic aorta with a 22F sheath (WL Gore & Associates, Flagstaff, Ariz). Retrograde access for diagnostic angiography was obtained through a 5F sheath inserted into the left common femoral artery. Two TAG devices (WL Gore & Associates) were delivered through an
CASE REPORT A 71-year-old woman with a history of hypertension was found to have an extensive aortic aneurysm during a work-up for chest pain. A computed tomography (CT) scan demonstrated a 5.2-cm aneurysm of the ascending aorta and a 7.0-cm aneurysm of the descending thoracic aorta (Fig 1). We repaired the ascending and transverse arch through a median sternotomy using cardiopulmonary bypass (CPB), deep From the Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Memorial Hermann Heart and Vascular Institute. Competition of interest: none. Presented at the Thirtieth Annual Meeting of the Southern Association for Vascular Surgery in Phoenix, Ariz, Jan 18-21, 2006. Reprint requests: Ali Azizzadeh, MD, Assistant Professor, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Memorial Hermann Heart and Vascular Institute, 6410 Fannin, Suite 450, Houston, TX 77030 (e-mail: [email protected]). 0741-5214/$32.00 Copyright © 2006 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2006.04.041
404
Fig 1. A three-dimensional computed tomography reconstruction demonstrates an extensive aortic aneurysm.
JOURNAL OF VASCULAR SURGERY Volume 44, Number 2
Fig 2. A single-stage repair of the ascending arch and descending thoracic aortic aneurysm.
antegrade approach. First, a 31-mm ⫻ 15-cm TAG device was placed in the nonaneurysmal aorta above the celiac axis. Next, a 34-mm ⫻ 20-cm TAG device was placed proximally. This 34-mm device was placed distally into the 31-mm device and proximally into the elephant trunk limb. Adequate overlapping (⬎5 cm) was allowed within the distal device as well as the elephant trunk limb (Fig 2). Angioplasty was performed on the proximal and distal landing zones and on the overlapping segments with a standard trilobed balloon (WL Gore & Associates). A completion angiogram demonstrated successful exclusion of the aneurysm without any evidence of endoleak (Fig 3). The patient tolerated the procedure well and woke from anesthesia neurologically intact. The patient received 8 units of packed red blood cells intraoperatively. The patient’s initial postoperative course was significant for coagulopathy and hypotension. She was transfused with 4 units of packed red blood cells. On postoperative day 1, delayed paraplegia developed. We placed a cerebrospinal fluid (CSF) drainage catheter. The initial CSF pressure was 19 to 24 mm Hg. CSF drainage was performed to keep the pressure ⱕ10 mm Hg. The patient regained bilateral lower extremity motor function 3 hours later. The remainder of her postoperative course was unremarkable. The CSF drain was removed and the patient was transferred to the floor on postoperative day 6. She was discharged on postoperative day 9. Follow-up CT scan studies at 1 and 3 months demonstrated a stable repair with regression of the descending thoracic aneurysm.
DISCUSSION Endovascular approaches for the second stage elephant trunk completion have been reported previously. The endovascular procedure is often performed days to months after the first stage repair.4-6,9,12,13 When performed simultaneously, the devices used have been homemade or investigational.7,8,10,11
Azizzadeh et al 405
Stainless steel devices can be deployed under hypothermic circulatory arrest while the aorta is open. An advantage of this technique is the possibility of suturing the endograft to the aorta under direct vision. The distal landing zone, however, cannot be visualized angiographically under circulatory arrest conditions. This limits the open placement of devices when the distal landing zone is short. Nitinol devices require deployment under body temperature for full expansion. They have to be deployed in real time after the patient is weaned from CPB. This requires adequate oversizing in relation to the elephant trunk limb to avoid migration. Naturally, distal landing zone visualization is possible with angiography. In this patient, the ascending and transverse arch aneurysms were repaired using the traditional open technique; endovascular repair of the descending thoracic aortic aneurysm was performed simultaneously through an antegrade approach. To our knowledge from the literature, this is the first reported case of a single-stage repair of the ascending, transverse, and descending thoracic aorta using the Food and Drug Administration-approved TAG device in the United States. The single-stage hybrid approach is a technically feasible alternative to the two-stage open, or the two-stage open/endovascular technique. This operation avoids the cost, morbidity, and mortality of an additional procedure. It also has the potential to eliminate the mortality associated with interval rupture between the two stages. In our open series, 75% of the mortality in the interval period was due to rupture.2 Furthermore, the technique is particularly useful in patients with extensive aortoiliac disease in whom access complications for endovascular repair are a major source of morbidity. This patient would have otherwise required a retroperitoneal exposure and an iliac conduit for placement of the device. A few technical considerations for the hybrid procedure are worth mentioning. First, the presence of a sternal retractor during fluoroscopy limits the projections that can be obtained. In addition, precise localization of the distal extent of the elephant trunk limb is required to obtain adequate overlap. We selected standard stainless steel staples placed 180° apart on the distal edge of the elephant trunk limb. Other options include stainless steel suture or surgical clips. Some investigators have also added a pacer wire loop on the body of the elephant trunk for downward traction.5 The length of the elephant trunk limb can also be variable. We selected a relatively short limb (10 cm) to avoid fabric folding and to ease cannulation from below. This length also provides more than adequate overlap for the proximal landing zone. Finally, development of postoperative neurologic deficit remains a devastating complication.5,14-18 Risk factors include hemodynamic instability, extent of the aneurysm, and previous abdominal aortic aneurysm repair.5,14-18 Some investigators have
JOURNAL OF VASCULAR SURGERY August 2006
406 Azizzadeh et al
CONCLUSION This case demonstrates the feasibility of a singlestage hybrid technique for repair of extensive aortic aneurysms. The long-term durability of these combined reconstructions is currently unknown, and meticulous follow-up is required. Future advancements in device technology may make this technique available to a wider range of patients. The authors would like to thank their editor, Kirk Soodhalter, and their illustrator, Chris Akers, for their assistance.
REFERENCES
Fig 3. Completion angiogram demonstrates successful exclusion of the aneurysm.
adopted routine prophylactic CSF drainage, whereas others treat expectantly. In this patient, the neurologic deficit followed a period of hypotension secondary to bleeding. In addition, the entire descending thoracic aorta (extent C) was covered.19 Fortunately, the patient recovered uneventfully. In our practice, we place a CSF drain in all patients who undergo endovascular repair of a descending thoracic aortic aneurysm. Further study of the proper role for prophylactic CSF drainage during endovascular repair of descending thoracic aneurysms is warranted.
1. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988;95:11-3. 2. Safi HJ, Miller CC 3rd, Estrera AL, Huynh TT, Porat EE, Allen BS, et al. Staged repair of extensive aortic aneurysms: long-term experience with the elephant trunk technique. Ann Surg 2004;240:677-84; discussion 84-5. 3. Azizzadeh A, Miller CC 3rd, Huynh TT, Estrera AL, Porat EE, Safi HJ. Surgical repair of extensive aortic aneurysms. Perspect Vasc Surg Endovasc Ther 2005;17:217-23. 4. Fann, JI, Dake MD, Semba CP, Liddell RP, Pfeffer TA, Miller DC. Endovascular stent-grafting after arch aneurysm repair using the “elephant trunk.” Ann Thorac Surg 1995;60:1102-5. 5. Greenberg R, Resch T, Nyman U, Lindh M, Brunkwall J, Brunkwall P, et al. Endovascular repair of descending thoracic aortic aneurysms: an early experience with intermediate-term follow-up. J Vasc Surg 2000; 31:147-56. 6. Wong CH, Wyatt MG, Jackson R, Hasan A. A dual strategic approach to mega-aortic aneurysms. Eur J Cardiothorac Surg 2001;19: 528-30. 7. Orihashi K, Sueda T, Watari M, Okada K, Ishii O, Matsuura Y. Endovascular stent-grafting via the aortic arch for distal aortic arch aneurysm: an alternative to endovascular stent-grafting. Eur J Cardiothorac Surg 2001;20:973-8. 8. Usui A, Fujimoto K, Ishiguchi T, Yoshikawa M, Akita T, Ueda Y. Cerebrospinal dysfunction after endovascular stent-grafting via a median sternotomy: the frozen elephant trunk procedure. Ann Thorac Surg 2002;74:S1821-4; discussion S5-32. 9. Carroccio A, Spielvogel D, Ellozy SH, Lookstein RA, Chin IY, Minor ME, et al. Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage “elephant trunk” repair. Vascular 2005;13:5-10. 10. Chavan A, Karck M, Hagl C, Winterhalter M, Baus S, Galanski M, et al. Hybrid endograft for one-step treatment of multisegment disease of the thoracic aorta. J Vasc Interv Radiol 2005;16:823-9. 11. Karck M, Chavan A, Khaladj N, Friedrich H, Hagl C, Haverich A. The frozen elephant trunk technique for the treatment of extensive thoracic aortic aneurysms: operative results and follow-up. Eur J Cardiothorac Surg 2005;28:286-90; discussion 90. 12. Matsuda H, Tsuji Y, Sugimoto K, Okita Y. Secondary elephant trunk fixation with endovascular stent grafting for extensive/multiple thoracic aortic aneurysm. Eur J Cardiothorac Surg 2005;28:335-6. 13. Wolthuis AM, Houthoofd S, Deferm H, Haenen L, Verbist J, Peeters P. Complex thoracic aortic aneurysm: a combined open and endovascular approach. Acta Chir Belg 2005;105:400-2. 14. Moon MR, Mitchell RS, Dake MD, Zarins CK, Fann JI, Miller DC. Simultaneous abdominal aortic replacement and thoracic stent-graft placement for multilevel aortic disease. J Vasc Surg 1997;25:332-40. 15. Mitchell RS, Miller DC, Dake MD. Stent-graft repair of thoracic aortic aneurysms. Semin Vasc Surg 1997;10:257-71. 16. Gravereaux EC, Faries PL, Burks JA, Latessa V, Spielvogel D, Hollier LH, et al. Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysms. J Vasc Surg 2001;34:997-1003.
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17. Ellozy SH, Carroccio A, Minor M, Jacobs T, Chae K, Cha A, et al. Challenges of endovascular tube graft repair of thoracic aortic aneurysm: midterm follow-up and lessons learned. J Vasc Surg 2003;38:676-83. 18. Cheung AT, Pochettino A, McGarvey ML, Appoo JJ, Fairman RM, Carpenter JP, et al. Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms. Ann Thorac Surg 2005;80:1280-8; discussion 8-9.
19. Estrera AL, Miller CC, 3rd Chen EP, Meada R, Torres RH, Porat EE, et al. Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage. Ann Thorac Surg 2005;80:1290-6; discussion 6.
Submitted Feb 10, 2006; accepted Apr 6, 2006.
COLLECTIONS OF PAPERS On the Web version of the Journal, selected articles have been grouped together for the convenience of the readers. The current collections include the following: American Board of Vascular Surgery Editorial Comments History Reporting Standards Technical Notes
Basic Science Reviews Guidelines Lifeline Research Meeting Abstracts Reviews
The hybrid elephant trunk procedure: A singlestage repair of an ascending, arch, and descending thoracic aortic aneurysm Ali Azizzadeh, MD, Anthony L. Estrera, MD, Eyal E. Porat, MD, Kenneth R. Madsen, MD, and Hazim J. Safi, MD, Houston, Texas Surgical repair of extensive aortic aneurysms requires a two-stage approach. We present the case of a single-stage repair using a hybrid procedure. This case demonstrates the technical feasibility of repairing properly selected extensive aortic aneurysms in a single procedure. ( J Vasc Surg 2006;44:404-7.)
Treatment of extensive aortic aneurysms presents a unique surgical challenge. The traditional repair requires a two-stage operation using the elephant trunk technique.1 Initially, the ascending and transverse arch is repaired through a median sternotomy. During the second stage, the descending or thoracoabdominal aorta is repaired through a left thoracoabdominal incision. Our operative technique and outcomes for this approach have previously been reported.2,3 Endovascular repairs have been used selectively in place of the second stage operation.4-13 Such repairs potentially allow the surgeon to avoid a second complex open procedure; however, they are currently limited to patients who meet certain anatomic criteria. We present the case of a single-stage repair of an ascending, arch, and descending thoracic aortic aneurysm. The ascending and transverse arch aneurysms were repaired through a median sternotomy. Endovascular repair of the descending thoracic aneurysm was performed in an antegrade fashion using the same exposure.
hypothermic circulatory arrest, and retrograde/antegrade cerebral perfusion. Electroencephalography and transesophageal echocardiography were performed. A 30-mm Hemashield (Boston Scientific, Natick, Mass) woven Dacron tube graft was used to make a 10-cm-long elephant trunk limb. The distal ends of the elephant trunk limb were marked with standard surgical staples for identification under fluoroscopy. The total circulatory arrest time was 39 minutes, and CPB time was 121 minutes. The patient was weaned off CPB, and motor and somatosensory evoked potential monitoring was initiated. The spinal cord function remained intact throughout the procedure. A side limb in the ascending graft was used to obtain antegrade access to the descending thoracic aorta with a 22F sheath (WL Gore & Associates, Flagstaff, Ariz). Retrograde access for diagnostic angiography was obtained through a 5F sheath inserted into the left common femoral artery. Two TAG devices (WL Gore & Associates) were delivered through an
CASE REPORT A 71-year-old woman with a history of hypertension was found to have an extensive aortic aneurysm during a work-up for chest pain. A computed tomography (CT) scan demonstrated a 5.2-cm aneurysm of the ascending aorta and a 7.0-cm aneurysm of the descending thoracic aorta (Fig 1). We repaired the ascending and transverse arch through a median sternotomy using cardiopulmonary bypass (CPB), deep From the Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Memorial Hermann Heart and Vascular Institute. Competition of interest: none. Presented at the Thirtieth Annual Meeting of the Southern Association for Vascular Surgery in Phoenix, Ariz, Jan 18-21, 2006. Reprint requests: Ali Azizzadeh, MD, Assistant Professor, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Memorial Hermann Heart and Vascular Institute, 6410 Fannin, Suite 450, Houston, TX 77030 (e-mail: [email protected]). 0741-5214/$32.00 Copyright © 2006 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2006.04.041
404
Fig 1. A three-dimensional computed tomography reconstruction demonstrates an extensive aortic aneurysm.
JOURNAL OF VASCULAR SURGERY Volume 44, Number 2
Fig 2. A single-stage repair of the ascending arch and descending thoracic aortic aneurysm.
antegrade approach. First, a 31-mm ⫻ 15-cm TAG device was placed in the nonaneurysmal aorta above the celiac axis. Next, a 34-mm ⫻ 20-cm TAG device was placed proximally. This 34-mm device was placed distally into the 31-mm device and proximally into the elephant trunk limb. Adequate overlapping (⬎5 cm) was allowed within the distal device as well as the elephant trunk limb (Fig 2). Angioplasty was performed on the proximal and distal landing zones and on the overlapping segments with a standard trilobed balloon (WL Gore & Associates). A completion angiogram demonstrated successful exclusion of the aneurysm without any evidence of endoleak (Fig 3). The patient tolerated the procedure well and woke from anesthesia neurologically intact. The patient received 8 units of packed red blood cells intraoperatively. The patient’s initial postoperative course was significant for coagulopathy and hypotension. She was transfused with 4 units of packed red blood cells. On postoperative day 1, delayed paraplegia developed. We placed a cerebrospinal fluid (CSF) drainage catheter. The initial CSF pressure was 19 to 24 mm Hg. CSF drainage was performed to keep the pressure ⱕ10 mm Hg. The patient regained bilateral lower extremity motor function 3 hours later. The remainder of her postoperative course was unremarkable. The CSF drain was removed and the patient was transferred to the floor on postoperative day 6. She was discharged on postoperative day 9. Follow-up CT scan studies at 1 and 3 months demonstrated a stable repair with regression of the descending thoracic aneurysm.
DISCUSSION Endovascular approaches for the second stage elephant trunk completion have been reported previously. The endovascular procedure is often performed days to months after the first stage repair.4-6,9,12,13 When performed simultaneously, the devices used have been homemade or investigational.7,8,10,11
Azizzadeh et al 405
Stainless steel devices can be deployed under hypothermic circulatory arrest while the aorta is open. An advantage of this technique is the possibility of suturing the endograft to the aorta under direct vision. The distal landing zone, however, cannot be visualized angiographically under circulatory arrest conditions. This limits the open placement of devices when the distal landing zone is short. Nitinol devices require deployment under body temperature for full expansion. They have to be deployed in real time after the patient is weaned from CPB. This requires adequate oversizing in relation to the elephant trunk limb to avoid migration. Naturally, distal landing zone visualization is possible with angiography. In this patient, the ascending and transverse arch aneurysms were repaired using the traditional open technique; endovascular repair of the descending thoracic aortic aneurysm was performed simultaneously through an antegrade approach. To our knowledge from the literature, this is the first reported case of a single-stage repair of the ascending, transverse, and descending thoracic aorta using the Food and Drug Administration-approved TAG device in the United States. The single-stage hybrid approach is a technically feasible alternative to the two-stage open, or the two-stage open/endovascular technique. This operation avoids the cost, morbidity, and mortality of an additional procedure. It also has the potential to eliminate the mortality associated with interval rupture between the two stages. In our open series, 75% of the mortality in the interval period was due to rupture.2 Furthermore, the technique is particularly useful in patients with extensive aortoiliac disease in whom access complications for endovascular repair are a major source of morbidity. This patient would have otherwise required a retroperitoneal exposure and an iliac conduit for placement of the device. A few technical considerations for the hybrid procedure are worth mentioning. First, the presence of a sternal retractor during fluoroscopy limits the projections that can be obtained. In addition, precise localization of the distal extent of the elephant trunk limb is required to obtain adequate overlap. We selected standard stainless steel staples placed 180° apart on the distal edge of the elephant trunk limb. Other options include stainless steel suture or surgical clips. Some investigators have also added a pacer wire loop on the body of the elephant trunk for downward traction.5 The length of the elephant trunk limb can also be variable. We selected a relatively short limb (10 cm) to avoid fabric folding and to ease cannulation from below. This length also provides more than adequate overlap for the proximal landing zone. Finally, development of postoperative neurologic deficit remains a devastating complication.5,14-18 Risk factors include hemodynamic instability, extent of the aneurysm, and previous abdominal aortic aneurysm repair.5,14-18 Some investigators have
JOURNAL OF VASCULAR SURGERY August 2006
406 Azizzadeh et al
CONCLUSION This case demonstrates the feasibility of a singlestage hybrid technique for repair of extensive aortic aneurysms. The long-term durability of these combined reconstructions is currently unknown, and meticulous follow-up is required. Future advancements in device technology may make this technique available to a wider range of patients. The authors would like to thank their editor, Kirk Soodhalter, and their illustrator, Chris Akers, for their assistance.
REFERENCES
Fig 3. Completion angiogram demonstrates successful exclusion of the aneurysm.
adopted routine prophylactic CSF drainage, whereas others treat expectantly. In this patient, the neurologic deficit followed a period of hypotension secondary to bleeding. In addition, the entire descending thoracic aorta (extent C) was covered.19 Fortunately, the patient recovered uneventfully. In our practice, we place a CSF drain in all patients who undergo endovascular repair of a descending thoracic aortic aneurysm. Further study of the proper role for prophylactic CSF drainage during endovascular repair of descending thoracic aneurysms is warranted.
1. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988;95:11-3. 2. Safi HJ, Miller CC 3rd, Estrera AL, Huynh TT, Porat EE, Allen BS, et al. Staged repair of extensive aortic aneurysms: long-term experience with the elephant trunk technique. Ann Surg 2004;240:677-84; discussion 84-5. 3. Azizzadeh A, Miller CC 3rd, Huynh TT, Estrera AL, Porat EE, Safi HJ. Surgical repair of extensive aortic aneurysms. Perspect Vasc Surg Endovasc Ther 2005;17:217-23. 4. Fann, JI, Dake MD, Semba CP, Liddell RP, Pfeffer TA, Miller DC. Endovascular stent-grafting after arch aneurysm repair using the “elephant trunk.” Ann Thorac Surg 1995;60:1102-5. 5. Greenberg R, Resch T, Nyman U, Lindh M, Brunkwall J, Brunkwall P, et al. Endovascular repair of descending thoracic aortic aneurysms: an early experience with intermediate-term follow-up. J Vasc Surg 2000; 31:147-56. 6. Wong CH, Wyatt MG, Jackson R, Hasan A. A dual strategic approach to mega-aortic aneurysms. Eur J Cardiothorac Surg 2001;19: 528-30. 7. Orihashi K, Sueda T, Watari M, Okada K, Ishii O, Matsuura Y. Endovascular stent-grafting via the aortic arch for distal aortic arch aneurysm: an alternative to endovascular stent-grafting. Eur J Cardiothorac Surg 2001;20:973-8. 8. Usui A, Fujimoto K, Ishiguchi T, Yoshikawa M, Akita T, Ueda Y. Cerebrospinal dysfunction after endovascular stent-grafting via a median sternotomy: the frozen elephant trunk procedure. Ann Thorac Surg 2002;74:S1821-4; discussion S5-32. 9. Carroccio A, Spielvogel D, Ellozy SH, Lookstein RA, Chin IY, Minor ME, et al. Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage “elephant trunk” repair. Vascular 2005;13:5-10. 10. Chavan A, Karck M, Hagl C, Winterhalter M, Baus S, Galanski M, et al. Hybrid endograft for one-step treatment of multisegment disease of the thoracic aorta. J Vasc Interv Radiol 2005;16:823-9. 11. Karck M, Chavan A, Khaladj N, Friedrich H, Hagl C, Haverich A. The frozen elephant trunk technique for the treatment of extensive thoracic aortic aneurysms: operative results and follow-up. Eur J Cardiothorac Surg 2005;28:286-90; discussion 90. 12. Matsuda H, Tsuji Y, Sugimoto K, Okita Y. Secondary elephant trunk fixation with endovascular stent grafting for extensive/multiple thoracic aortic aneurysm. Eur J Cardiothorac Surg 2005;28:335-6. 13. Wolthuis AM, Houthoofd S, Deferm H, Haenen L, Verbist J, Peeters P. Complex thoracic aortic aneurysm: a combined open and endovascular approach. Acta Chir Belg 2005;105:400-2. 14. Moon MR, Mitchell RS, Dake MD, Zarins CK, Fann JI, Miller DC. Simultaneous abdominal aortic replacement and thoracic stent-graft placement for multilevel aortic disease. J Vasc Surg 1997;25:332-40. 15. Mitchell RS, Miller DC, Dake MD. Stent-graft repair of thoracic aortic aneurysms. Semin Vasc Surg 1997;10:257-71. 16. Gravereaux EC, Faries PL, Burks JA, Latessa V, Spielvogel D, Hollier LH, et al. Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysms. J Vasc Surg 2001;34:997-1003.
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17. Ellozy SH, Carroccio A, Minor M, Jacobs T, Chae K, Cha A, et al. Challenges of endovascular tube graft repair of thoracic aortic aneurysm: midterm follow-up and lessons learned. J Vasc Surg 2003;38:676-83. 18. Cheung AT, Pochettino A, McGarvey ML, Appoo JJ, Fairman RM, Carpenter JP, et al. Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms. Ann Thorac Surg 2005;80:1280-8; discussion 8-9.
19. Estrera AL, Miller CC, 3rd Chen EP, Meada R, Torres RH, Porat EE, et al. Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage. Ann Thorac Surg 2005;80:1290-6; discussion 6.
Submitted Feb 10, 2006; accepted Apr 6, 2006.
COLLECTIONS OF PAPERS On the Web version of the Journal, selected articles have been grouped together for the convenience of the readers. The current collections include the following: American Board of Vascular Surgery Editorial Comments History Reporting Standards Technical Notes
Basic Science Reviews Guidelines Lifeline Research Meeting Abstracts Reviews