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: 3.65). 08/2004; 78(1):109-16; discussion 109-16. DOI: 10.1016/j.athoracsur.2004.02.098
Source: PubMed

ABSTRACT 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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    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.
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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.
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    ABSTRACT: Die chirurgische Therapie kombinierter Pathologien der Aorta ascendens, des Aortenbogens sowie der Aorta descendens stellt auch heute noch hohe Ansprüche an den Operateur. 1983 wurde zur Therapie solch komplexer Aortenaneurysmen von Borst et al. das Verfahren der Elephant-trunk-Technik etabliert und hat seitdem als anerkanntes Standardverfahren die chirurgische Behandlung dieser Pathologien erleichtert. Als Erweiterung dieses Verfahrens wurde vor einigen Jahren die Frozen-elephant-trunk-Technik (Hybridverfahren) eingeführt. Sie erlaubt die einzeitige definitive Versorgung von segmentübergreifenden Aneurysmen der Aorta ascendens, des Aortenbogens und der Aorta descendens über eine mediane Sternotomie unter Verwendung einer neuartigen Gefäßprothese mit Stentanteil, der antegrad in die Aorta descendens eingebracht wird. Anschließend wird der Aortenbogen und ggf. auch die Aorta ascendens in konventioneller Weise ersetzt. Das neue Verfahren kann mit einem Risiko verwendet werden, das demjenigen der konventionellen Elephant-trunk-Technik vergleichbar ist. Sein wesentlicher Vorteil liegt darin, dass es sich hierbei um einen einzeitigen Eingriff handelt und damit ein mit der konventionellen Variante erforderlicher Zweiteingriff entfallen kann. Obwohl sich die chirurgische Strategie an der individuellen Pathologie des Patienten orientiert, könnte die Frozen-elephant-trunk-Technik das bisherige konventionelle Verfahren als Behandlungsstandard für ausgedehnte Aortenaneurysmen ersetzen. Surgical treatment of combined pathologies of the ascending aorta, aortic arch and the descending aorta still makes great demands on the surgeon. In 1983 Borst et al. established the elephant trunk procedure for treatment of such complex aortic aneurysms, which subsequently became the recognized standard procedure and has simplified the surgical treatment of these pathologies. The frozen elephant trunk technique (hybrid procedure) was recently introduced as an extension of this procedure. This procedure permits the single-stage definitive treatment of intersegmental aneurysms extending over the ascending aorta, the aortic arch and the descending aorta via transmediastinal sternotomy using a new type of prosthetic bypass graft with stent portion, which is inserted anterograde in the descending aorta. The aortic arch and, if necessary, the ascending aorta are subsequently replaced in the conventional manner. The new procedure can be implemented with a risk probability which is comparable to that of the elephant trunk technique. The main advantage is that this is a single-stage approach and the second stage which is necessary by the conventional approach can be omitted. Although the surgical strategy is oriented to the individual pathology of each patient, the frozen elephant trunk technique could replace the previous conventional procedure as the treatment standard for extensive aortic aneurysms.
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