The birth of the elephant trunk technique

Abstract

Surgery on the aorta, except for its arch portion, had been well established in the sixth decade of the past century. My personal attention was drawn to the arch when consulting on a patient in 1963, who had experienced multiple shrapnel injuries in World War II. He now presented in severe heart failure due to a traumatic fistula between the mid-aortic arch and the innominate vein with a huge pseudoaneurysm. To repair this lesion, we decided to use circulatory arrest in deep hypothermia, a method that then had been practiced mainly in congenital lesions. Using a left-sided approach, a fist-size, vigorously pulsating aneurysm was encountered in the subaortic mediastinum. On extracorporeal circulation, the patient was cooled to a nasopharyngeal temperature of 19.5 C, and the circulation was stopped for 10 minutes. Most of the aneurysm was removed, and the 2 orifices of the fistula were closed by direct suture. The patient had an uneventful recovery. Anecdotal as this operation might appear, it was 1 of the first successful interventions on the aortic arch in deep hypothermic circulatory arrest—and possibly the last 1 up to now for an arteriovenous fistula in this location. About 10 years later, additional research in deep hypothermia and circulatory arrest, as well as increasing clinical experience, had firmly established surgery on the aortic arch. One serious problem, however, remained: the high risk of multiple-stage operations required for the frequently encountered aneurysms extending distally from the aortic arch. In particular, mobilization of the previous graft-toaorta anastomosis during the second-stage procedure was cumbersome and endangered the surrounding structures. In addition, the insertion of a separate downstream graft required prolonged aortic clamp times. In 1982, I was confronted with 2 patients in their mid-40s with the mega-aorta syndrome. In view of the problems previously encountered with such lesions, we decided to replace the aortic arch with a long graft, whose free ‘‘elephant trunk’’ extension was to be suspended freely in the distal aorta. During the subsequent operative act, the downstream aorta was clamped proximally, and the ‘‘elephant trunk’’ was identified and sutured to the desired distal landing site. In 1 of the patients, the arch and part of the descending aorta were replaced in 2 stages, and the other patient