The elephant trunk technique: operative results in 100 consecutive patients

Schepens, Marc A.A.M.; Dossche, Karl M.; Morshuis, Wim J.; Barselaar, Peter J. van den; Heijmen, Robin H.; Vermeulen, F.

doi:10.1016/s1010-7940(01)01088-0

Cited by 128 publications

(99 citation statements)

References 11 publications

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“…1,3,9,10 Mortality rates of 5.1% for the first-stage operation, 3.6% during the interval period (of which 75% were due to rupture), and 6.2% for the second-stage operation were reported by Safi and colleagues 3 and recently updated 1 and confirmed by others. 12 In our own series of 142 elephant trunks, the first-stage operative mortality rate was 2%, and of those patients who underwent the distal repair, a 4% mortality rate was noted. 9 Endovascular therapy avoids a left lateral thoracotomy.…”

Section: Discussionmentioning

confidence: 74%

Hybrid Approaches to Thoracic Aortic Aneurysms

et al. 2005

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Background-Thoracic aortic aneurysm affecting the arch and proximal descending thoracic aorta requires 2-stage repairs that include proximal elephant trunk graft placement and completion of thoracic or thoracoabdominal repair. The application of endovascular grafting to complete the proximal procedure avoids a thoracotomy and may improve the morbidity and mortality of the patient population at risk. Methods and Results-A retrospective review of 399 thoracic endovascular grafts at our institution between 2000 and 2004 identified 22 patients who required elephant trunk and endovascular completion. Three patients underwent mesenteric bypass in addition to their proximal repairs. Mean follow-up was 10 months (range 1 to 42 months); there were no ruptures, and all patients returned for follow-up. Technical success was achieved in all patients. The 1-, 12-, and 24-month mortality rates (by Kaplan-Meier analysis) were 4.5%, 15.8%, and 15.8%, respectively. Caudal migration of the endograft occurred in 1 patient, and all but 2 aneurysms decreased or remained stable in size. The 2 patients with growth included a type III endoleak (which resolved after treatment) and pressurization through an expanded PTFE stentgraft. Three cases of transient paraparesis occurred (all in patients requiring mesenteric bypass or abdominal aortic aneurysm repair), and there were no paraplegias or strokes. Conclusions-Endovascular completion of elephant trunks is feasible and can be accomplished with minimal mortality.Meticulous imaging follow-up is required to detect persistent aneurysm pressurization and to verify the integrity of the repair. Improvements in implant design and delivery systems will further simplify the second-stage portion of these complex aneurysm repairs.

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Section: Discussionmentioning

confidence: 74%

Hybrid Approaches to Thoracic Aortic Aneurysms

et al. 2005

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“…Table 1 shows the most up-to-date conventional ET case series reports. Even if the cumulative in-hospital mortality and neurological complications including first and second stages are reported, the results are excellent [8,10,[12][13][14][15][16][17][18][19][20][21][22][23][24][25]. As confidence grew and technical adjuncts, such as cerebral protection with retrograde and eventually selective antegrade cerebral perfusion during arrest [26] and various supraaortic vessels reconstruction techniques, were introduced, ET indications were further extended.…”

Section: Conventional Et Techniquementioning

confidence: 99%

“…As confidence grew and technical adjuncts, such as cerebral protection with retrograde and eventually selective antegrade cerebral perfusion during arrest [26] and various supraaortic vessels reconstruction techniques, were introduced, ET indications were further extended. For example, in patients scheduled for descending or thoraco-abdominal aortic surgery, who presented at the same time with a severe coronary artery or valvular disease requiring operation, an ET was placed in the descending aorta to facilitate subsequent aortic repair and similarly, so to speak prophylactically, in selected patients undergoing aortic arch replacement with a downstream aneurysm not requiring immediate surgery at the time, but whose diameter and growth pattern, along with patient risk factors and characteristics (e.g., Marfan syndrome and connective tissue disorders, blood hypertension, and young patients) would suggest an unfavorable development toward further dilation and earlier need for operation [13,14,[20][21][22]25]. Evidence for false-lumen obliteration and healing following the use of the ET technique in patients with acute aortic dissection further encouraged its use [10,[14][15][16][17][18][19][20][21]24].…”

Section: Conventional Et Techniquementioning

confidence: 99%

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

Ius¹,

Hagl²,

Haverich³

et al. 2011

European Journal of Cardio-Thoracic Surgery

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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.

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“…They have generally reported excellent results even when both first and second stage operations were included (37)(38)(39).…”

Section: The "Elephant Trunk" Techniquementioning

confidence: 99%

Open repair techniques in the aortic arch are still superior

Bachet¹

2018

Ann. Cardiothorac. Surg.

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Conventional arch replacement can be carried out in a great majority of patients. Hybrid procedures are often as invasive and technically difficult as conventional ones. Moreover, their immediate results are, in many reported experiences, not better and their long-term results less favourable than the ones observed with conventional methods. So, yes, the open conventional arch replacement is still "the gold standard".

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The elephant trunk technique: operative results in 100 consecutive patients

Abstract: The first step in the repair of a mega aorta, the implantation of an ET, can be performed with a low mortality and an acceptable morbidity. The risk of central neurologic damage is higher in emergency interventions.

Cited by 128 publications

References 11 publications

Hybrid Approaches to Thoracic Aortic Aneurysms

Hybrid Approaches to Thoracic Aortic Aneurysms

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

Open repair techniques in the aortic arch are still superior

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