Classic Elephant Trunk Research Articles

Thoracic endovascular aortic repair for hemolysis 17 years after insertion of classical elephant trunk: a case report

BackgroundThe classical elephant trunk (ET) technique is a very useful surgical procedure; however, haemolysis in the aorta associated with ET has been previously reported. It normally occurs within several years after the surgery, and it is a rare case of rapidly progressing haemolysis 10 or more years after aortic arch replacement with ET.Case presentationA 53-year-old man with a history of Stanford type A aortic dissection (DeBakey type Is), who was treated with total arch aortic replacement and aorto-femoral bypass using a prosthetic graft 17 years ago, developed severe progressive haemolytic anaemia. The ET used for the initial surgery was narrowed, and mechanical haemolysis was suspected. We assumed that progressive mechanical haemolysis occurred because of degeneration of the prosthetic graft. Thoracic endovascular aortic repair was performed, and haemolysis and anaemia were mitigated postoperatively.ConclusionsHaemolysis occurred 17 years after the initial surgery with ET. When haemolysis is suspected in a patient with ET, it must be identified as a cause of haemolysis even if 10 years or more have passed since the ET was inserted. To prevent this complication, attention should be paid to an appropriate ET length and diameter to avoid folding of the ET, particularly when the true cavity diameter is small.

Classical Elephant Trunk—old fashioned thus obsolete?

Classical Elephant Trunk—old fashioned thus obsolete?

Aortic Reoperation After Prior Acute Type A Aortic Dissection Repair: Don’t Despair the Repair

BackgroundThere is paucity of data regarding reoperation after acute type A aortic dissection (ATAD) repair. MethodsFrom October 2006 to March 2022, 75 patients received 123 reoperations after ATAD (proximal, n = 17; distal, n = 103; and both, n = 3) utilizing redo sternotomy (RS, n = 68), left thoracotomy (LT, n = 44), and endovascular approach (TEVAR, n = 11). The axillary artery cannulation was utilized in 97.1% of the RS cases. A classic elephant trunk technique was used as a 2-staged procedure for distal pathology. Most LT repairs (95.5%) were completed above the celiac axis. ResultsIndex ATAD repairs were predominantly ascending/hemiarch repair (73.3%). The median duration from the index repair was 2.0 years. Most reoperations were elective procedures (82.1%). Hospital mortality was 2.4% (RS, 1.5%; LT, 4.5%; TEVAR, 0%), and the stroke rate was 1.6%. There was no spinal cord ischemia. The 5-year overall survival and freedom from aortic mortality or procedure were 85.2% ± 5.6% and 80.6% ± 6.1%, respectively. There were 7 distal reinterventions (prior TEVAR, n = 3; prior LT, n = 4). Two patients required LT repair after prior TEVAR and 3 patients received infrarenal aortic repair after prior LT repair. Computed tomography after completion of the distal repair (n = 45) showed an increase of distal aorta at each level as follows: celiac axis 1.2 mm/y; renal artery 1.0 mm/y; and terminal aorta 1.2 mm/y. ConclusionsReoperation after ATAD repair can be safely performed as an elective procedure at experienced centers. Staged distal interventions utilizing classic elephant trunk insertion and open repair above the celiac axis showed durable outcomes.

"Why is frozen elephant trunk better than classical elephant trunk?"

The treatment of complex aortic arch disease, in chronic or acute setting, has always represented a fascinating challenge for the heart surgeon also because, often, the involvement of the aortic arch is associated with a simultaneous involvement of the ascending aorta and of the proximal portion of the descending thoracic aorta. In recent years, there have been many surgical and/or endovascular techniques and approaches in a single step or multiple steps proposed with the aim of treating and simplifying these complex conditions. The first procedure available for this purpose was the conventional elephant trunk technique, proposed by the German surgeon Hans Borst, back in 1983. In the following years, the technique has undergone modifications, up to what is nowadays considered its most modern evolution, represented by the frozen elephant trunk which allows managing the proximal descending thoracic aorta using the antegrade release of a self-expandable stent graft. In this review article, we try to analyze the advantages and drawbacks of both techniques from clinical and practical points of view.

Hybrid Approach in Acute and Chronic Aortic Disease

The management of patients with aortic disease that involves the ascending aorta, the aortic arch, and the descending aorta represent a surgical challenge. Open surgical repair remains the gold standard for aortic arch pathologies. However, this operation requires a cardiopulmonary bypass and a period of profound hypothermia and circulatory arrest, which carries a substantial rate of mortality and morbidity. For these reasons, hybrid arch repair that involves a combination of open surgery with endovascular aortic stent graft placement has been introduced as a therapeutic alternative for those patients deemed unfit for open surgical procedures. Hybrid repair requires varying degrees of invasiveness and can be performed as a single-stage procedure or as a two-stage procedure. The choice of the technique is multifactorial, depending on the characteristics of the diseased arch with regard to position of the stent graft proximal landing zone, patient fitness and comorbid status, as well as surgical expertise and hospital facilities. Among the evolving hybrid procedures is the so-called “frozen” or stented elephant trunk technique. Adapted from the classical elephant trunk technique, this approach facilitates the repair of a concomitant aortic arch and proximal descending aortic aneurysms in a single stage under circulatory arrest. This technique is increasingly being used to treat extensive thoracic aortic disease and has shown promising results.

Staged Repair of Extensive Aneurysms of the Thoracic Aorta by Using the Elephant Trunk Technique

BackgroundStaged open repair of extensive aortic aneurysms by using the elephant trunk (ET) technique has facilitated the treatment of aortic aneurysms that affect the entire thoracic aorta. We describe our nearly 3-decade experience with classic ET repairs. MethodsFrom 1990 through 2021, we performed 363 stage 1 ET repairs to replace the transverse aortic arch in patients with a median age of 65 years (interquartile range, 56-71 years). Fifty-six patients (15.4%) presented with acute symptoms, and 182 (50.1%) underwent redo sternotomy. After a median interval of 3.2 months (interquartile range, 2.0-7.3 months), 203 patients (55.9%) underwent stage 2 ET completion; of these, 16 (7.9%) had acute symptoms. Stage 2 repairs comprised 162 (80.6%) extent I or II thoracoabdominal aortic replacements. We examined postoperative outcomes, including operative death, adverse event (a composite end point), survival, and repair failure. ResultsOperative mortality was 12.4% (45 of 363) after stage 1 and 10.3% (21 of 203) after stage 2. The rates of adverse event were 18.5% (67 of 363) for stage 1 and 18.4% (38 of 203) for stage 2. Acute symptoms independently predicted operative death and adverse events for both stage 1 and stage 2 repairs; additional predictors for stage 2 repairs were older age and extent II repair. Survival was significantly worse for patients who did not receive their stage 2 completion repair than for those who did (P < .001). ConclusionsTreating extensive aortic aneurysms by using the ET technique for staged repair is associated with substantial morbidity and mortality. Patients who present with acute symptoms are at greater risk of operative death and adverse events. Diligent surveillance is needed between stages.

Reoperative Total Arch Repair Using a Trifurcated Graft and Selective Antegrade Cerebral Perfusion

BackgroundThis study reviews the outcomes of our reoperative total arch repair technique using a trifurcated graft and selective antegrade cerebral perfusion. MethodsFifty patients underwent reoperative total arch repair from January 2005 to September 2020, with either a one-stage repair (n = 9) or two-stage repair (n = 41). The two-stage technique includes minimal dissection of the mediastinal structures, an arch-first technique using a trifurcated graft, and construction of a classical elephant trunk through a partial transverse incision distally in the old graft or in the aorta just distal to the old graft. ResultsThe median age was 63 years. Chronic dissection was the most frequent indication (88%), and 98% had undergone a previous proximal aortic repair at a median interval of 3 years. The median cardiopulmonary bypass, myocardial ischemic, selective antegrade cerebral perfusion, and lower body circulatory arrest times were 226, 103, 97, and 98 minutes, respectively. The minimum nasopharyngeal and bladder temperature were 16.5°C and 20.0°C, respectively. Operative mortality was 2%, the incidence of stroke was 2%, and the incidence of spinal cord injury was 0%. Stage II repair was performed in 37 patients (open, 33 patients; endovascular, 4 patients), with 2 mortalities and no spinal cord injury. The median duration between stage I and II was 63 days. Survival and aortic event free rates at 3 years were 88.4% ± 4.9%, and 89.8% ± 5%, respectively. ConclusionsWe report a reoperative total arch repair technique that minimizes dissection of the cardiac structures, simplifies the distal anastomosis, and protects vital organs, such as the brain, heart, and spinal cord.

Is the classical elephant trunk better than the frozen elephant trunk?

Aortic diseases located in the ascending aorta, aortic arch or proximal descending aorta often require more than one surgical intervention depending on the type of pathology and its extent as well as future anticipated aortic problems. These obstacles were tackled in 1983 by Hans Borst with the introduction of the classic elephant trunk (cET). This was an outstanding and straightforward procedure. Since then, the cET was very often the first surgical approach for patients with extensive aortic pathology of the ascending aorta and arch extending into the downstream aorta. Thirteen years later, Suto and Kato introduced the frozen elephant trunk (fET) which was later on perfectionized by industry and applied in various ways by many surgical groups worldwide. Comparing the cET with the fET raises a lot of difficulties. 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. It would be very short-sighted to close all future discussions about the subject with this statement of the Hannover group made in 2011. Since both techniques and its results cannot be compared statistically due to the heterogeneity of patient groups, the lack of randomization, the difference in type and extent of pathology, the differences in surgical techniques, the learning curve in gaining experience in both techniques, and the lack of reporting standards, no scientific conclusion can be drawn as to which technique is most successful. Comparisons may even be considered futile. It is the purpose of this paper merely to make a descriptive observation of both techniques, to discuss some important elements of interest and to give some constructive and useful criticism.

Aortic Arch. The Final Frontier in Cardiac Surgery

ABSTRACTAortic arch pathologies such as acute aortic dissection and aneurysmal disease represent surgical challenges. Various emerging techniques and surgical prostheses have expanded the therapeutic armamentarium over the last years with one principal objective; to simplify the operation and reduce the surgical time. Besides the classic elephant trunk which has been regarded as an evolutionary leap in the treatment of extensive thoracic disease, other novel surgical approaches such as the frozen elephant trunk, the thoracic endovascular aortic repair (TEVAR) and the hybrid open branched stent grafts have been introduced. This brief review aims to evaluate the surgical alternatives used in the management of complex aortic arch and proximal descending aorta pathologies with particular consideration given to the contemporary approaches which endorse single stage operation.

When and how to replace the aortic arch for type A dissection.

Acute type A aortic dissection (AAAD) remains one of the most challenging diseases in cardiothoracic surgery and despite numerous innovations in medical and surgical management, early mortality remains high. The standard treatment of AAAD requires emergency surgery of the proximal aorta, preventing rupture and consequent cardiac tamponade. Resection of the primary intimal tear and repair of the aortic root and aortic valve are well-established surgical principles. However, the dissection in the aortic arch and descending untreated aorta remains. This injury is associated with the risk of subsequent false lumen dilatation potentially progressing to rupture, true lumen compression and distal malperfusion. Additionally, the dilatation of the aortic arch, the presence of a tear and retrograde dissection can all be considered indication for a total arch replacement in AAAD. In such cases a more aggressive strategy may be used, from the classic aortic arch operation to a single stage frozen elephant trunk (FET) technique or a two-stage approach such as the classical elephant trunk (ET) or the recent Lupiae technique. Although these are all feasible solutions, they are also complex and time demanding techniques requiring experience and expertise, with an in the length of cardiopulmonary bypass and both myocardial and visceral ischemia. Effective methods of cerebral, myocardial as well visceral protection are necessary to obtain acceptable results in terms of hospital mortality and morbidity. Moreover, a correct assessment of the anatomy of the dissection, through the preoperative angio CT scan, in addition to the clinical condition of the patients, remain the decision points for the best arch repair strategy to use in AAAD.

Total aortic arch repair: risk factor analysis and follow-up in 199 patients.

Aortic arch surgery is associated with substantial perioperative risks. New prostheses as well as novel perfusion techniques have been developed to reduce the risks of these procedures. The routine application of these new techniques warrants reassessment of risk factors of aortic arch repair. Between April 2010 and December 2015, 199 patients [61% male, median age 63 years (interquartile range 52-70 years)] underwent total aortic arch repair in our institution. Forty-four per cent of the patients presented with acute aortic dissections (ADs, 32% with malperfusion), 22% with chronic aortic dissections (CDs), 34% with degenerative aneurysms, 24% underwent reoperations. Our surgical technique involved cold blood cardioplegia for cardiac procedures, non-cardioplegic continuous myocardial blood perfusion during aortic arch repair and early lower body reperfusion after distal aortic arch reconstruction. Anastomosis of head vessels is performed at the end of the procedure. Forty-four per cent of patients underwent aortic root surgery, 90% received a classical elephant trunk (ET) or frozen elephant trunk (FET). Median (interquartile range) cardiopulmonary bypass time, cardiac ischaemia time, hypothermic circulatory arrest time and selective antegrade cerebral perfusion time were 248 min (204-302), 105 min (51-150), 47 min (35-61) and 93 min (72-115), respectively. Operative mortality was 16%, stroke occurred in 10%, dialysis in 21% and spinal cord injury in 5%. Independent risk factors for mortality were age, rethoracotomy for bleeding, postoperative dialysis, maximum lactate value and maximum creatinine kinase-MB (CK-MB) value. 'Beating heart' aortic arch surgery significantly reduced the risk of mortality. Malperfusion syndrome and coronary artery bypass grafting were preoperative predictors of stroke. CD, preoperative renal dysfunction, operation time, rethoracotomy for bleeding and low cardiac output syndrome were risk factors for postoperative dialysis. Freedom from aortic reoperation was 91% (AD), 66% (CD) and 70% (aneurysm) after 2 years. Aortic arch repair remains a high-risk procedure, especially in multisegment aortic disease. Several peri- and postoperative factors predicted adverse outcome, indicating the need to further improve perioperative management (e.g. organ protection). Indications for FET treatment have to be thoroughly investigated (e.g. FET in CDs).

The classic elephant trunk technique for staged thoracic and thoracoabdominal aortic repair: Long-term results

ObjectiveThe classic elephant trunk (ET) technique has become the standard approach for patients with diffuse aortic disease requiring a staged thoracic and thoracoabdominal aortic repair. The aim of this study was to assess long-term outcomes and predictors for survival after surgical repair of extensive thoracic aortic disease with the ET technique. MethodsBetween 1984 and 2013, 248 consecutive patients were treated in our institution and analyzed retrospectively. Follow-up consisted of outpatient clinic visits including postoperative computed tomography imaging at 3 months and annually thereafter. Second-stage intervention was indicated if the diameter of the descending or thoracoabdominal aorta was greater than or equal to 60 mm, in case of a rapidly growing aneurysm and/or symptoms. ResultsMean age was 65 ± 10 years; 44% were male. After first-stage ET, in-hospital mortality was 8% and permanent neurologic deficits were observed in 2% of patients. Median follow-up after the first stage was 48 months (range, 1-210 months). One hundred twelve patients (45%) underwent second-stage ET. Overall survival after first-stage ET was 75% and 67% at 5 and 10 years, respectively. Survival in patients with second-stage ET was 87%, compared with 65% in the group who did not undergo second-stage ET at the 5-year follow-up (P < .001) and 67% compared with 36% at the 10-year follow-up (P < .001). Predictor for mortality was the absence of second-stage ET (P = .044). ConclusionsA 2-stage approach for diffuse aortic disease is a safe method. The acceptable mortality at the first stage justifies the use of the classic ET technique and allows subsequent repair of the distal aorta. Long-term survival is increased when both stages are completed.

Hybrid arch repair in chronic B dissection.

Since its introduction in 1983 by Hans Borst, numerous variations of the classic elephant trunk technique have been introduced. Among them, the ‘frozen elephant trunk technique’ (FET) certainly represents the most innovative (1). The FET technique, involving arch replacement and concomitant stenting of the descending thoracic aorta, has been developed as a hybrid operation to treat patients with complex pathologies of the thoracic aorta in a single stage (2). Management of chronic type B aortic dissection is challenging. Thoracic endovascular aortic repair (TEVAR), or alternatively, open surgery through a left thoracotomy, is usually indicated in the presence of complications including dilatation or rupture (3). In addition, an uncomplicated type B dissection which dilates over time in the chronic setting can be treated during operations primarily addressing more proximal aneurysms or pathological aortic conditions. Based on our growing experience with FET surgery, we have extended its use to selected patients with chronic type B aortic dissection. In particular, we have used this approach in patients with concomitant pathologies of the proximal aorta and when TEVAR was deemed unfeasible. Here we show a FET procedure in a patient with a chronic type B aortic dissection and concomitant aneurysm of the aortic arch (Video 1). Video 1 Hybrid arch repair in chronic B dissection. The case A 53-year-old man with migrating back pain was admitted to our hospital. Medical history revealed hypertension, smoking, dyslipidemia, and family history of ischemic heart disease. Computed tomography (CT) angiogram showed an acute type B aortic dissection extending to the iliac bifurcation, involving the celiac trunk and left renal artery. The entry tear was located at the proximal descending thoracic aorta, distal to the offspring of the left subclavian artery. A wide abdominal re-entry was identified at the level of the renal arteries, with the maximal diameter at the descending thoracic aorta and the aortic arch being 34 and 46 mm, respectively. Without clinical and imaging signs of impending aortic rupture, medical management was initiated and after 2 weeks, the patient was uneventfully discharged. A CT angiogram was scheduled at 4 months. This revealed a 5 mm growth of the aortic arch, a perfused false lumen without significant dimensional modifications, and obliteration of the celiac trunk (Figure 1). Coronary angiogram ruled out a significant coronary artery disease. Arch replacement with the FET technique was scheduled. Figure 1 The pre-operative CT angiogram scan showed a 50 mm aortic arch aneurysm, a chronic type B aortic dissection with the intimal tear located at the proximal descending thoracic aorta. CT, computed tomography. Surgical techniques A median sternotomy was performed to approach the aorta, the arch vessels, and the heart. After systemic heparinization, a guide wire was inserted through the femoral artery in the true lumen of the descending thoracic aorta, under transesophageal echocardiographic control. The ascending aorta and the right atrium were cannulated for cardiopulmonary bypass (CPB) institution. A left ventricle drainage was inserted through the right superior pulmonary vein and cooling was initiated at nasopharyngeal temperature of 26 °C. The ascending aorta was clamped and myocardial protection achieved by means of antegrade infusion of crystalloid cardioplegia (Custodiol, Koehler Chemie, Alsbach-Haenlein, Germany). Circulatory arrest was subsequently instituted, the aortic arch was opened and antegrade selective cerebral perfusion established (10 mL/kg/min) by means of endoluminal cannulation of the arch vessels (4). The arch was completely resected and the proximal descending aorta was prepared with obliteration of the false lumen using an external Teflon felt fixed with four internal pledgetted U-stitches. The E-vita open plus delivery system was then introduced and appropriately advanced into the descending thoracic aorta over the previously positioned stiff guide-wire. The 30-mm stent graft was carefully deployed into the true lumen. The incorporated Dacron graft was pulled back and sutured to the previously prepared descending aorta using a 2/0 polypropylene running suture. After 10 minutes of lower body reperfusion, the arch vessels were re-implanted ‘en bloc’ to the E-vita open plus prosthesis. Antegrade reperfusion of the arch and thoracoabdominal aorta was then obtained by cannulating the clamped vascular graft. Rewarming was started. The proximal anastomosis to the native ascending aorta completed the aortic repair. Subsequently, CPB was easily weaned off with no need for inotropic support.

Total aortic arch replacement with the elephant trunk technique: single-centre 30-year results

The combined disease of the aortic arch and the descending aorta (aneurysms and dissection) remains a surgical challenge. Various approaches have been used to treat this complex pathology. In the two-stage operation, at the first-stage operation, the aortic arch is replaced through a median sternotomy. Later, at the second-stage operation, the descending thoracic aorta is replaced through a lateral thoracotomy. The elephant trunk (ET) technique was introduced by H.G. Borst at our centre in March 1982, greatly simplifying the second-phase operation. We present our 30-year experience. From March 1982 to March 2012, 179 patients (112 males, age 56.4±12.6 years) received an ET procedure for the combined disease of the aortic arch and the descending aorta (91 aneurysms, 88 dissections (47 acute)). Fifty-six of these patients had undergone previous cardiac operations. Concomitant procedures were performed if necessary. The cerebral protection was done either by deep (till 1999) or moderate hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP, after 1999). Cardiopulmonary bypass (CPB) and X-clamp times were 208.5±76.5 min and 123.7±54.8 min, respectively. The intraoperative mortality and 30-day mortality during the first-stage operation were 1.7% (3/179) and 17.3% (31/179, 15 with AADA), respectively. Perioperative stroke was 7.9% (n=14/176). Postoperative recurrent nerve palsy was present in 18.2% (32/176) and paraplegia in 5.6% (10/176). The second-stage completion operation was performed as early as possible. Fifty-seven second-stage completion procedures were performed, either surgically (n=50) or through interventional techniques (n=7). The intraoperative and 30-day mortality after the second-stage completion procedures were 5.2% (3/57) and 7.0% (4/57), respectively. The stroke, recurrent nerve palsy and paraplegia rates were 0, 0 and 7% (4/54), respectively. The ET technique has greatly facilitated the two-stage approach to the surgical treatment of combined diseases of the aortic arch and descending aorta. The initial learning curve, acute dissections, re-do and concomitant procedures partially explain the higher mortality rate. Despite the development of new hybrid techniques, there is still a role for the classical ET in selected patients, particularly in the context of proven long-term results and cost effectiveness.

Editorial Comment: The Borst elephant trunk technique is not lethal!

The paper by Kondoh et al. [1] describes the results of total arch replacement with a long elephant trunk ending at the level of T6–T8. This technical modification simultaneously differs to, and matches, the classic Borst technique, or a variations of, in a number of ways. What are the similarities? First, the portion of the prosthesis, the trunk, extending into the descending aorta is non-stented and free floating. The length of the trunk is longer than in the classic elephant trunk technique, where it is generally limited to only 5–10 cm (although it has always been a matter of debate as to what the ideal trunk length should be). What are the differences? The proximal anastomosis of the elephant trunk is now located in the distal ascending aorta at the origin of the innominate artery leaving the arch untouched and even unopened. This makes it possible to arrest body circulation only for a brief time period (25 min). The distal end of the elephant trunk is located at the level of T6–T8. Kondoh’s technique also differs from the frozen elephant trunk technique in that the trunk diameter is undersized rather than oversized and, of course, non-stented. In dissection patients it is introduced in the true lumen and the false lumen is not obliterated anymore as in the frozen elephant trunk technique. The fixation of the trunk is also located more proximally. The body arrest temperatures (25°C) are lower than contemporary series, which have described their results with the frozen elephant trunk. Antegrade selective cerebral perfusion is used as in every total arch replacement perfusing both axillary arteries and the left common carotid artery to protect the brain. What could be the advantages of this new technique? The body arrest time is short, all anastomoses can be reached easily, making it obvious that no patient required a re-exploration for bleeding. In-hospital mortality (9 of 127, 7%) is acceptable but not extremely low. What could be the disadvantages? There are still 3.2% spinal cord injuries which is comparable with the frozen elephant trunk but substantially higher than in the classic elephant trunk technique. In-hospital mortality of the second stage is rather high (2 of 12, 16%). As in thoracic endografting, it is understandable that the longer the graft, the higher the risk of paraplegia. During follow-up, there are a high number of aorto-enteric fistulizations, a well-known and almost lethal complication after the frozen elephant trunk but something that has almost never been described after the classic elephant trunk. It is important to stress that, despite the undersizing of the diameter of the graft, the authors found a thromboexclusion in the majority (86%) of the patients treated. This number is even higher than in the frozen elephant trunk. Apparently aortic arch aneurysms extending into the descending thoracic aorta for various lengths, but not below the diaphragm, can nowadays be treated surgically by a multitude of different alternatives. Roughly speaking, one can prefer a one-step approach to a two-step procedure. Of course, the one-step approach offers the advantage of solving the problem in one operation and is theoretically devoted with a morbidity and mortality that is limited to this single procedure. The two-step approach offers the advantage that the repair can be extended below the diaphragm if necessary, but obviously includes a substantial dual risk. In recent years, endovascular techniques, be they pure or hybrid procedures, have been added to the surgical armamentarium, making choices not only more numerous but also more difficult. The question is no longer can we solve the problem, it is rather a matter of choosing the best strategy taking into account patient-, surgeon-, procedureand hospital-related factors. The authors advocating this new technique cannot convince me with this new approach. We are making hardly any progress. On the contrary, I believe that we have rather taken a step back: more paraplegia and paraparesis, more fistulizations in the long run, a high mortality rate, taking into account both steps. The wave of frozen elephant trunks that has overwhelmed us in the last few years and has been embraced by a lot of surgeons as the ultimate solution, has apparently not resulted in better results. The total arch replacement, herein described, with the long elephant trunk has not either. So, clearly, the classic elephant trunk technique is not so bad still, and is not lethal. New techniques come and go, but they will only stay if their results exceed those of previously established procedures. This critical comment does not mean that the authors should not be congratulated for their courage in creating a modification

Treatment of complex disease of the thoracic aorta: the frozen elephant trunk technique with the E-vita open prosthesis☆

The treatment of complex aortic pathologies of the thoracic aorta remains a challenging issue in aortic surgery. The most recent development of the classic elephant trunk technique, the 'frozen elephant trunk' technique, represents the combination of an endovascular approach with a conventional surgical treatment for a hybrid approach. Between January 2007 and July 2008, 34 patients were operated on for complex pathologies of the thoracic aorta using the frozen elephant trunk technique. There were 29 males (85.3%) and the mean age of 61.7+/-9.6 years. The majority of patients (n=18, 52%) presented type A chronic dissection, 7 (21%) patients had chronic aneurysm of distal aortic arch and 7 (21%) type B aortic dissection associated with ascending aorta/aortic arch aneurysm. There were two (6%) cases of acute aortic dissection. Nineteen patients (56%) underwent previous cardiovascular operations. The overall in-hospital mortality was 6% (two patients). No patient developed postoperative stroke. Ischemic spinal cord injury occurred in three cases (9%) (two paraparesis, one paraplegia). There were five cases (15%) of renal failure (dialysis) and four patients (12%) had pulmonary complications with prolonged mechanical ventilation. Four patients (12%) needed rethoracotomy for surgical bleeding. Six patients (18%) required extension of the descending thoracic aorta repair with endovascular treatment for persistent perfusion of the dilated false lumen. The frozen elephant trunk technique with the new E-vita open prosthesis combines surgical and interventional technologies and represents a feasible and efficient option in the treatment of complex aortic pathologies. Strict monitoring of the patient has to be carried out in order to detect possible evolution of the aortic lesion, which can require prompt treatment. However, long-term follow-up is required.

The frozen elephant trunk: An interesting hybrid endovascular-surgical technique to treat complex pathologies of the thoracic aorta

The treatment of complex aortic pathologies involving the ascending aorta, the aortic arch, and the descending aorta remains a challenging issue in aortic surgery. The frozen elephant trunk procedure effectively combines surgical and interventional technologies in the treatment of extensive aortic aneurysms and dissections. We present two patients with complex aortic lesions involving all three segments of the thoracic aorta. The device used in our series is the new E-vita open hybrid prosthesis consisting of a proximal woven polyester tube and a distal self-expandable nitinol stent graft, which can be delivered antegrade into the descending aorta.

The frozen elephant trunk technique

The so-called 'frozen elephant trunk' technique is adapted from the classical elephant trunk technique first described by H.G. Borst in 1983 and allows the repair of concomitant aortic arch and proximal descending aortic aneurysms in a single stage. A 'hybrid' vascular graft consisting of a conventional tube graft with an endovascular stented graft at the distal end is utilised to achieve a blood-tight seal in the descending aorta that cannot easily be accessed directly from an anterior approach. Thus, the concept of a traditional elephant trunk, otherwise completed with a secondary endovascular or surgical procedure, is achieved in one single step. First intra- and postoperative results of this technique in terms of successful exclusion of the proximal descending aortic aneurysm are good and following the learning curve, the prolongation of circulatory arrest and cerebral perfusion, as compared to the traditional elephant trunk procedure, is within minutes and thus acceptable. Currently all patients with thoracic aneurysms extending from the arch beyond the left subclavian artery are evaluated for this treatment at our institution. Furthermore, acute aortic dissections (type A and B) are an area of intensive clinical evaluation at present.