Elephant trunk procedure: Newer indications and uses

Center for Aortic Surgery, Marfan Syndrome and Connective Tissue Disorders Clinic and Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA.
The Annals of thoracic surgery (Impact Factor: 3.85). 08/2004; 78(1):109-16; discussion 109-16. DOI: 10.1016/j.athoracsur.2004.02.098
Source: PubMed


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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    • "To simplify the two-stage repair of the combined disease of the aortic arch and the proximal descending aorta, 'Elephant trunk (ET) technique' was introduced by Borst et al. at our centre in March 1982 [1]. Over the years, the indication for this technique has been expanded to include aortic dissections, both acute and chronic [2] [3]. Endovascular stent-graft technology was introduced by Dake et al. to treat aortic pathology in 1998 [4]. "
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    ABSTRACT: Acute type A aortic dissection (AADA) is a surgical emergency. In patients with aortic arch and descending aorta (DeBakey type I) involvement, performing a total aortic arch replacement with frozen elephant trunk (FET) for supposedly better long-term results is controversial. We hereby present our results. From February 2004 to August 2013, 52 patients with acute aortic dissection DeBakey type I received a FET procedure at our centre (43 males, age 59.21 ± 11.67 years). All patients had an intimal tear in the aortic arch and/or proximal descending aorta. Concomitant procedures were Bentall (n = 15) and aortic valve repair (n = 30). Cardiopulmonary bypass (CPB), X-clamp and cardiac arrest times were 262 ± 64, 159 ± 45 and 55 ± 24 min, respectively. The 30-day mortality rate was 13% (n = 7). Stroke and re-thoracotomy for bleeding were 12% (n = 6) and 23% (n = 12), respectively. Postoperative recurrent nerve palsy and spinal cord injury rates were 10% (5 of 52) and 4% (2 of 52), respectively. Follow-up was 40 ± 24 months. During follow-up, no patient died and no patient required a reoperation for the aortic arch. Our results with FET in AADA show acceptable results. Total aortic arch replacement with an FET in AADA patients does demand high technical skills. In spite of this, we believe FET improves long-term outcomes in cases of AADA with intima tear or re-entry in the aortic arch or the descending aorta (DeBakey type I). Modern grafts with four side branches as well as sewing collars for the distal anastomosis have helped to further 'simplify' the FET implantation. However, such a strategy is not appropriate in all AADA cases; it should be implemented only in experienced centres and only if absolutely necessary.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 05/2014; 47(2). DOI:10.1093/ejcts/ezu185 · 3.30 Impact Factor
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    • "Author Year Mortality at first-stage ET Patients underwent second-stage operation Mortality at second-stage operation Reference Safi et al. 2007 16/254 (6.3%) 115/254 (45.3%) 11/115 (9.6%) [3] Coselli et al. 2006 18/148 (12.2%) 76/148 (51.4%) 3/76 (3.9%) [4] Svensson et al. 2005 2/94 (2.1%) 47/94 (50%) 4/47 (8.5%) including 7 pts. with stenting [5] Hanafusa et al. a 2002 1/12 (8.3) 0 [14] Kuki et al. 2002 0/17 (0%) 9/17 (52.9%) 0/9 (0%) [15] Takahara et al. 2002 3/37 (8.1%) 0 [16] Schepens et al. 2002 8/100 (8%) 44/100 (44%) NA [17] Kirali et al. b 2002 9/28 (32.1%) 0 [18] Naka et al. 1999 1/9 (11.1%) 6/9 (66.7%) 2/6 (33.3%) [21] Ando et al. 1998 2/15 (13.3%) 0 [22] "
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    ABSTRACT: Patients with extensive aortic aneurysms involving the ascending aorta, aortic arch, and the descending aorta are still considered to be a challenge for many cardiovascular surgeons. The introduction of the elephant trunk technique by Borst et al. in 1983 has greatly facilitated surgery on this kind of pathology and this technique has been recognized as a standard modality for treatment of extended aortic aneurysms. As a next step, the frozen elephant trunk technique has been introduced in some institutes in the late 1990s. With this technique, surgery is performed through a median sternotomy, and an endovascular stent-graft is placed into the descending aorta in an antegrade fashion through the opened aortic arch. Then the ascending aorta and the aortic arch are replaced conventionally. The frozen elephant trunk technique enables one-stage repair of extended aortic aneurysms in a certain patient cohort with similar operative mortality as with the conventional elephant trunk technique, in which a second-stage operation is a prerequisite. Although the surgical strategy should be adjusted specifically to each patient's individual pathology, the frozen elephant trunk technique may become the next standard treatment for extended aortic aneurysm instead of its conventional variant.
    European Journal of Cardio-Thoracic Surgery 07/2008; 33(6):1007-13. DOI:10.1016/j.ejcts.2008.02.030 · 3.30 Impact Factor
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    • "Although conceptually promising – considering sobering results of surgical repair (Svennson et al 2004) – adjunctive management by stent-graft placement in distally extending dissection lacks the support of long-term follow-up data. Nevertheless, over several years of follow-up after stent-graft placement for the treatment of both thoracic and abdominal aneurysms, late adverse effects were infrequent and may justify “bridging” stent-grafts even in relatively young patients with Marfan syndrome after aortic root surgery (Nienaber et al 1999a, 1999b; Ince et al 2003, 2005; Svennson et al 2004) in the attempt to avoid the risks of (emergent) repeat surgery. "
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    ABSTRACT: The Marfan syndrome is a heritable disorder of the connective tissue which affects the cardiovascular, ocular, and skeletal system. The cardiovascular manifestation with aortic root dilatation, aortic valve regurgitation, and aortic dissection has a prevalence of 60% to 90% and determines the premature death of these patients. Thirty-four percent of the patients with Marfan syndrome will have serious cardiovascular complications requiring surgery in the first 10 years after diagnosis. Before aortic surgery became available, the majority of the patients died by the age of 32 years. Introduction in the aortic surgery techniques caused an increase of the 10 year survival rate up to 97%. The purpose of this article is to give an overview about the feasibility and outcome of stent-graft placement in the descending thoracic aorta in Marfan patients with previous aortic surgery.
    Vascular Health and Risk Management 02/2008; 4(1):59-66.
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