Elephant trunk procedure 27 years after Borst: what remains and what is new?

Abstract

The treatment of complex aortic pathology involving both the ascending and descending aortic segments at the same time represents a surgical challenge, with high postoperative morbidity and mortality rates reported. Over the past 27 years, different open surgical and endovascular techniques have been introduced and applied in various two-stage- or one-stage approaches to such cases. Thus, in 1983, Hans Borst significantly changed the traditional two-stage approach by introducing his elephant trunk technique. Leaving a segment of Dacron prosthesis reaching into the descending aorta during the first stage, the second-stage replacement of the residual dilated descending aorta was made far easier. The presence of interval mortality between the two stages, the unaffected need for two large operations to complete aortic repair, and the general failure of some patients to return for the second-stage repair set the scene for the development of one-stage procedures, both open surgical or hybrid surgical and endovascular, such as the frozen elephant trunk. However, the size of the operation, on the one hand, and the risk of spinal cord injury and need for surgical or endovascular completion during follow-up, on the other, have dampened enthusiasm. Recently, the introduction of supra-aortic debranching and endovascular aortic arch stent-graft repair has yet extended treatment to high-risk patients unsuitable to the more aggressive surgery, but mid- and long-term follow-up results are lacking. The lack of randomization and the presence of procedural and complication-related limitations for each technique do not allow for definitive conclusions about the ideal procedure to treat complex aortic pathology. However, the technical revolution experienced over the past 27 years, along with the improvement in perioperative management, has produced outstanding morbidity and mortality results even in this challenging patient population, but the decision regarding which pathology correlates with what operation remains highly debated and dependent also on regional competence.

Results of “elephant trunk” total aortic arch replacement using a multi-branched, collared graft prosthesis

“…Those two characteristics mark the main difference with other branched prostheses. The 30-day mortality of 5 % (n = 1) we experienced in our relatively small cohort fits the mortality rates reported by other authors (3.7-18.4 %) [16][17][18].…”

“…With a 33 % rate of 2nd-stage procedure after a mean follow-up of 9.6 months, Fig. 3 Kaplan-Meier survival curve we report numbers lower than the average of 45 % reported in a recent review by Lus and co-workers [18], but the same as the 32 % reported by Shresta et al [26]. We indicated the ET procedure for patients with type A dissection even if the diameter of the dissected descending aorta was normal, because a large number of patients might develop aneurysm of the descending aorta later on [27] and it carries no additional risk compared to the standard arch replacement [26].…”

“…Neurologic complications with permanent or transient stroke incidences between 1.2 and 20 % have been reported in the literature [18,23,24]. In our small cohort one patient suffered permanent stroke and one patient a lethal intracerebral hemorrhage (n = 2, 10 %).…”

Long-term results of simplified frozen elephant trunk technique in complicated acute type A aortic dissection: A case–control study

“…18 A worldwide experience of FET and its variations was recently analyzed in a population of 700 patients including 400 of both acute and chronic dissections, the mean perioperative mortality in dissection patients was 6% with Ius et al 3 A perioperative mortality of 14.7% in our study using sFETT is at least comparable to these prior reports and can be considered low given the fact that we performed sFETT only in patients with compromised aortic branch vessels a known risk factor for malperfusion and in hospital mortality. 3,19,20 The impact of the sFETT on the evolution of postoperative aortic dissection is impressive. After sFETT, there was a significantly lower incidence of branchvessel compromise the supraaortic vessels (40.7% vs. 17.5%; p < 0.05) and the renovisceral arteries (29.6% vs. 17.2%; p < 0.05) ( Table 2).…”

“…Latter floating graft facilitates secondary descending aortic repair through a lateral thoracotomy. [2][3][4] A major drawback of the ET technique is that the distal arch anastomosis might be challenging or impossible to seal especially when it is performed in patients with a severe coagulation disorder, as commonly encountered in acute aortic dissections. To face these drawbacks, the frozen elephant trunk (FET) technique was developed and first described in 2003.…”