Treatment of Aortic Arch Dissection Using the Elephant Trunk Technique

Kieffer, Édouard; Koskas, Fabien; Godet, G.; Bertrand, Michèle; Bahnini, Amine; Benhamou, Albert-Claude; Cluzel, Philippe; Eyraud, Daniel

doi:10.1007/s100169910111

Cited by 37 publications

(29 citation statements)

References 14 publications

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“…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].…”

Section: Commentsupporting

confidence: 89%

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

et al. 2014

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We report on our experience with a simplified elephant trunk (ET) procedure with a multi-branched prosthesis (Vascutek(®) Siena™ Collared Graft). It consists of a proximal portion (20 cm) with prefabricated side branches, a collar and a distal portion (30 cm). The collar, which can be trimmed into any desired diameter, constitutes the suture portion to the descending aorta. Radiopaque markers in the distal portion indicate the landing zone. Between January 2011 and June 2013, 20 consecutive patients (10 women; mean age, 66 ± 9.3 years) underwent ET procedure, including 6 re-do cases. Underlying aortic diseases were acute dissection (n = 6), chronic dissection (n = 4), aneurysm (n = 8) and PAU (n = 2). Mean preoperative diameter of the descending aorta was 49.1 ± 12.9 mm (range 74.7-29.7 mm). Concomitant procedures included ascending aortic replacement in 16 patients; root replacement in 2; AVR in 2, CABG in 3 and mitral repair in 1 patient. CPB time was 263 ± 94 min; mean duration of ACP was 65 ± 14 min. Two patients died on POD 8 and 78, respectively. Major adverse events included stroke (n = 1), resternotomy for bleeding (n = 2), renal failure requiring temporary dialysis (n = 1) and recurrent nerve paresis (n = 2). After a mean follow-up of 10 ± 8 months, all discharged patients were alive. Seven patients underwent stent-graft implantation of the descending aorta and one patient underwent open descending aortic replacement. The last generation of multi-branched arch prosthesis and especially the Vascutek(®) Siena™ Collared Graft make ET procedure a reasonable treatment option even in patients with acute aortic dissection.

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Section: Commentsupporting

confidence: 89%

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

et al. 2014

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“…9 Endovascular therapy avoids a left lateral thoracotomy. Stenting of the aorta as a completion of arch repair has been reported with a variety of techniques 9,[13][14][15][16][17][18] ; however, in some series, up to 25% of the patients have become paralyzed. The present series represents the largest number of endovascular completions to date and also provides intermediate-term follow-up.…”

Section: Discussionmentioning

confidence: 99%

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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“…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%

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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Treatment of Aortic Arch Dissection Using the Elephant Trunk Technique

Cited by 37 publications

References 14 publications

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

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

Hybrid Approaches to Thoracic Aortic Aneurysms

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

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