Modifications, Classification, and Outcomes of Elephant-Trunk Procedures

Distal Repair After Total Aortic Arch Replacement With Frozen Elephant Trunk in Patients With Chronic Multilevel Thoracic Aortic Disease

OBJECTIVE

To examine the management of distal aortic disease after total arch replacement with the frozen elephant trunk (TAR + FET) in patients with chronic thoracic aortic disease.

METHODS

Two centre retrospective study of consecutive patients treated between January 2010 and December 2019. The primary endpoint was 30 day or in hospital death. The secondary endpoint was midterm survival. Data are presented as median (interquartile range [IQR]). The χ2 or Fisher's exact test was used as appropriate. Estimated survival (standard error) was assessed by calculating the Kaplan-Meier product limit estimator with right censoring of survival data. A p value of < .050 was considered statistically significant. STROBE guidelines were followed.

RESULTS

A total of 158 patients (72 men; median age 70 years, IQR 64, 75; median distal aortic diameter 58 mm, IQR 46, 68; 127 aneurysmal disease, 31 chronic dissection) underwent TAR + FET. The peri-operative mortality rate was 10.1% (9/107 elective, 7/51 non-elective). Of 74 (46.8%) patients with a primary distal seal, seven (9.5%) died peri-operatively, the distal seal was maintained during follow up in 51, nine underwent late distal repair (two planned, seven unplanned; one open, eight endovascular; one peri-operative death) with a median interval to unplanned repair of 777 days (IQR 462, 1480), and seven with loss of seal had no intervention. Distal seal failed in 2/28 (7%) patients with a distal seal length > 30 mm and device oversizing > 10%, compared with 12/39 (31%) patients who did not meet these criteria (p = .031). In 84 patients without a primary distal seal, nine (10.7%) died peri-operatively, the distal aorta remained below the size threshold for repair during follow up in 12 patients, 44 had distal repair (median aortic diameter 64 mm, IQR 60, 75; eight open, one hybrid, 35 endovascular repairs; no deaths) at a median of 256 days (IQR 135, 740), and 19 did not have distal repair at the end of the follow up period: six died before planned repair at a median interval of 115 days (IQR 85, 120); eight were considered unfit; one was assessed as fit but declined; and four patients were awaiting assessment. Median follow up was 46 months (IQR 26, 75): no patients were lost to follow up. Estimated ± standard error five year survival was 61.5 ± 4.1%: elective 70.6 ± 4.7%, non-elective 43.2 ± 7.2%.

CONCLUSION

TAR + FET achieved primary distal seal in 47% of patients, but late failure occurred in 21%. Distal repair was ultimately indicated in 84% of survivors without a primary distal seal and of these 70% underwent repair, almost 10% died before planned repair, and 13% were considered unfit. Earlier distal endovascular repair and better assessment of patient fitness may improve midterm outcomes.

Total aortic arch replacement using a frozen elephant trunk device: Results of a 1-year US multicenter trial

OBJECTIVE

In this prospective US investigational device exemption trial, we assessed the safety and 1-year clinical outcomes of the Thoraflex Hybrid device (Terumo Aortic) for the frozen elephant trunk technique to repair the ascending aorta, aortic arch, and descending thoracic aorta.

METHODS

For the trial, which involved 12 US sites, 65 patients without rupture were recruited into the primary study group, and 9 patients were recruited into the rupture group. All patients underwent open surgical repair of the ascending aorta, aortic arch, and descending thoracic aorta in cases of aneurysm and/or dissection. The primary end point was freedom from major adverse events (MAE), defined as permanent stroke, permanent paraplegia/paraparesis, unanticipated aortic-related reoperation (excluding reoperation for bleeding), or all-cause mortality.

RESULTS

In the primary study group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 81% (51/63). Seven patients (11%) died (including 2 before 30 days or discharge), 3 patients (5%) suffered permanent stroke, and 3 (5%) developed permanent paraplegia/paraparesis. Twenty-six patients (41%) underwent planned extension procedures, including 22 endovascular procedures within a median of 122 (interquartile range, 64-156) days. In the aortic rupture group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 71% (5/7). One patient (14%) died, 2 patients (29%) had permanent stroke, and none had permanent paraplegia/paraparesis. No extension procedures were performed in the rupture group.

CONCLUSIONS

One-year results with the Thoraflex Hybrid device are acceptable. Long-term data are necessary to assess the durability of these repairs.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Hybrid Treatment of Complex Diseases of the Aortic Arch and Descending Thoracic Aorta by Frozen Elephant Trunk Technique

The surgical management of acute and chronic complex diseases involving the aortic arch and the descending thoracic aorta remains challenging. Hybrid procedures associating total open arch replacement and stent-grafting of the proximal descending aorta were developed to allow a potential single-stage treatment, promote remodeling of the downstream aorta, and facilitate a potential second-stage thoracic endovascular aortic repair by providing an ideal landing zone. While these approaches initially used various homemade combinations of available conventional prostheses and stent-grafts, the so-called frozen elephant trunk technique emerged with the development of several custom-made hybrid prostheses. The aim of this study was to review the contemporary outcomes of this technique in the management of complex aortic diseases, with a special focus on procedural planning, organ protection and monitoring, refinements in surgical techniques, and long-term follow-up.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Elephant trunk simplifies thoracoabdominal aortic aneurysm repair without impacting operative risk

BACKGROUND AND AIM

An open two-stage elephant trunk (ET) technique may aid in the technical ease of subsequent thoracoabdominal aortic aneurysm (TAAA) repair. We analyze whether the presence of an ET improves outcomes for patients undergoing extent I and II TAAA repair.

METHODS

From September 1997 to October 2020, 469 patients underwent extent I or II TAAA repair. We compared those with prior ET to those without. Primary outcome was composite major adverse events (MAE) including operative mortality, myocardial infarction, permanent spinal cord injury, cerebrovascular accident, need for tracheostomy, and new need for dialysis.

RESULTS

Thirty-eight (8.1%) patients had prior ET and 431 (91.9%) did not. There were no differences in baseline characteristics. The no ET group was more likely to undergo urgent or emergent procedures. Composite MAE occurred in 82 (19%) of the no ET group and 5 (15.8%) of the ET group (p = .785). Operative mortality was 5.5% and not significantly different between the groups (p = 1.00). No patients in the ET group experienced stroke or recurrent laryngeal nerve injury. Median partial bypass and cross-clamp times were significantly greater in the no ET group (28 [24-32] versus 19 [16-22] min; p ≤ .001 and 42 [32-53] versus 30 [25-39] min; p ≤ .001).

CONCLUSIONS

Extent I and II TAAA repair after ET can be safely performed in a tertiary referral center with shorter bypass and cross-clamp times. ET eliminates the need for circulatory arrest or clamping a hostile arch.

Fenestrated-branched endovascular repair for distal thoraco-abdominal aortic pathology after total aortic arch replacement with frozen elephant trunk

OBJECTIVE

To report the outcomes of fenestrated-branched endovascular repair (FBEVAR) for thoracoabdominal aortic pathology after total aortic arch replacement with frozen elephant trunk (TAR+FET).

METHODS

Interrogation of prospectively-maintained databases from four high volume aortic centres identified consecutive patients treated with distal FBEVAR after prior TAR+FET between August 2013 and September 2020. Primary endpoint was 30-day/in-hospital mortality. Secondary end points were technical success, early clinical success, mid-term survival and freedom from re-intervention. Data are presented as median (IQR).

RESULTS

39 patients [21 men; median age, 73 years (67-75)] with degenerative (n=22) and post-dissection TAAAs (n=17) [median diameter 71 mm (61-78)] were identified. Distal FBEVAR was intended in 27 patients [median interval 9.8 months (6.2-16.6)], anticipated in seven and unexpected in five. 31 patients had a two (n=24) or three (n=7) stage distal FBEVAR. Reno-visceral target vessel preservation was 99.3% (145 of 146). Early primary and secondary technical success was 92% and 97%, respectively. 30-day mortality was 2.6% [n=1; respiratory failure and spinal cord ischaemia (SCI)]. Six survivors also developed SCI which was associated with complete (n=4), or partial recovery (n=2) at hospital discharge. No patients required renal replacement therapy or suffered a stroke. Early clinical success was 95%. Median follow-up was 30.5 months (23.7-49.7). Eleven patients required 16 late re-interventions. Estimated 3-year survival and freedom from re-intervention were 84±6% and 63±10%, respectively.

CONCLUSIONS

Distal FBEVAR after prior TAR+FET is associated with high technical success and low early mortality. The risk of SCI is significant although the majority of patients demonstrate full or partial recovery before hospital discharge. Mid-term patient survival is favourable but there remains a high requirement for late re-intervention. FBEVAR represents an acceptable alternative to distal open TAAA repair.

“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.

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

BACKGROUND

Staged open repair of extensive aortic aneurysm 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.

METHODS

From 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]. Fifty-six patients (15.4%) presented with acute symptoms, and 182 (50.1%) underwent redo sternotomy. After a median interval of 3.2 months [IQR: 2.0-7.3], 203 (55.9%) patients underwent stage-2 ET completion; few (n=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 mortality, adverse event (a composite end point), survival, and repair failure.

RESULTS

Operative mortality was 12.4% (45/363) after stage-1 and 10.3% (21/203) after stage-2. The rates of adverse event were 18.5% (67/363) for stage-1 and 18.4% (38/203) for stage-2. Acute symptoms independently predicted operative mortality and adverse event 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 <0.001).

CONCLUSIONS

Treating 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 mortality and adverse event. Diligent surveillance is needed between stages.

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.

Hybrid repair of extensive thoracic aortic aneurysms

OBJECTIVES

METHODS

This was a multicentre, observational study. Data were collected prospectively between January 2002 and March 2019 and analysed retrospectively. Inclusion criteria for the final analysis were the treatment of elective or urgent ETAA performed in a single-stage or a planned two-stage approach. Early and late survival rates were the primary outcomes.

RESULTS

Indications for repair were degenerative ETAA in 27 (64.3%) patients and dissection-related ETAA in 15 (35.7%). The mean aortic diameter was 68 ± 16 mm (interquartile range 60–75). Five (11.9%) patients had a single-stage repair; and 37 underwent a two-stage approach. Three (7.1%) patients died in-hospital. The median follow-up was 49 months (range 0–204). During the follow-up period, 4 (9.5%) patients underwent aortic reintervention after a median of 32 months; however, no aortic rupture of the treated segment occurred. Overall, the estimated survival rate was 85% ± 6% [95% confidence interval (CI) 70.8–93] at 12 and 36 months and 69.5% ± 9% (95% CI 49.7–84) at 60 months.

CONCLUSIONS

Hybrid repair of ETAA had satisfactory early results in this cohort of patients. At the midterm follow-up, the aneurysm-related mortality rate was acceptable with the reconstruction proving to be durable and safe with few distal aortic events.

Are We There Yet? Emerging Milestones in Aortic Dissection Care

See Article Reutersberg et al.

Neurologic Outcomes in Aortic Arch Repair With Frozen Elephant Trunk Versus 2-Stage Hybrid Repair

BACKGROUND

We compared outcomes of single-stage hybrid aortic arch replacement (frozen elephant trunk) versus 2-stage hybrid repairs with primary open arch procedures followed by thoracic endovascular stenting.

METHODS

This study reports a single-center retrospective review (2003 to 2016) of 118 patients undergoing hybrid repair of the aortic arch including 48 single-stage repairs versus 70 two-stage repairs.

RESULTS

Single-stage repair was performed in 48 patients, including 31 (64.6%) men and 17 (35.4%) women with a mean age of 64 ± 11 years and a 2-stage procedure was performed in 70 patients, including 42 (60%) men and 28 (40%) women with a mean age of 65.67 ± 13.3 years (p = 0.46). More emergent single-stage procedures were performed in 23 of 48 (47.9%) patients versus 2-stage procedures in 8 of 70 (11.43%) patients (p < 0.001). Between the single- and 2-stage groups, there was no difference in stroke (6.25% [3 of 48] versus 14.28% [10 of 70]; p = 0.23), spinal cord ischemia (4.16% [2 of 48] versus 5.7% [4 of 70]; p = 1.0), or 30-day mortality rate: 8 of 48 (16.7%) patients versus a combined 30-day mortality rate of the 2-stage procedure of 14.8% (4 of 70 [5.7%] at the first stage and 5 of 55 [9.1%] at the second stage; p = 0.56), respectively. After exclusion of the 30-day mortality, midterm survival was 86% at 1 to 2 years for single-stage patients versus 80% at 1 year and 46% at 2 years for the 2-stage patients (p = 0.0019).

CONCLUSIONS

Both single-stage and 2-stage hybrid arch replacements are effective approaches for treating complex aortic arch diseases. Early deaths and neurological outcomes in the single-stage group are comparable to those in the combined 2-stage group. Furthermore, in this series, patients who had a single-stage hybrid procedure had a higher survival rate at 2 years.

Staged repair of thoracoabdominal aneurysm with infra-renal elephant trunk graft

A patient with residual thoracoabdominal aortic aneurysm and chronic dissection extending into the branch iliac arteries underwent staged open and endovascular repair. Open repair of the reno-visceral segment was performed with an "elephant trunk" trunk graft placed distally into a 12-cm infra-renal aorta. One month later, the patient underwent a successful completion endovascular aortic repair. This case demonstrates the utility of combining traditional and endovascular surgery to manage complex aortic pathologies.

Protecting the brain and spinal cord in aortic arch surgery

Protection of the central nervous system-either the brain or the spinal cord-during aortic surgery has been the subject of intense research over the past several decades. While it took some 30 years to prove that some of the techniques first practiced in animals are valuable, surgeons can now take courage from 50 years of research that has resulted in superb outcomes, particularly when compared with historical results. Complex total arch operations and descending aortic operations can now be performed with less than a 2% rate of stroke, spinal cord injury, or death. Thoracoabdominal aortic operations and endovascular procedures have also become considerably safer with excellent results reported. The following review will discuss some of the historical outcomes, innovations, iterations, current techniques, and outcomes.

Total Aortic Arch Replacement: Advantages of Varied Techniques

We review the operative techniques of aortic arch replacement. Aortic arch replacement presents several formidable challenges, as it requires arresting the circulation to the body and replacement of the brachiocephalic vessels with special consideration for protecting the central nervous system. Perfusion strategies, selective antegrade cerebral perfusion, and operative graft selection are key elements in aortic arch replacement surgery. Standard approaches include the island technique, the branched graft technique, and the "Spielvogel" trifurcated graft technique-each having its own advantages. In addition, thoracic aortic aneurysms involving the arch and descending aorta pose a substantial surgical challenge and often require hybrid or nonclamp technique with staged operative interventions. Hybrid and endovascular (thoracic endovascular aortic repair) techniques for the descending aorta are evolving and require consideration in operative planning. Areas of controversy include management of the subclavian artery, extent of distal arch replacement, elephant trunk and hybrid frozen elephant trunk techniques, and use and timing of staged approaches. Aortic arch replacement remains a complex, potentially difficult procedure. Better understanding of the potential open approaches to arch replacement will optimize the potential outcomes for patients. Aortic arch pathology is best served by tailoring the procedure to the patient-specific anatomy and pathology.

Outcomes after aortic graft-to-graft anastomosis with an automated circular stapler: A novel approach

OBJECTIVE

Patients with complex aortic disease often require multistaged repairs with numerous anastomoses. Manual suturing can be time consuming. To reduce ischemic time, a circular stapling device has been used to facilitate prosthetic graft-to-graft anastomoses. Objectives are to describe this technique and assess outcomes.

METHODS

From February 2009 to May 2014, 44 patients underwent complex aortic repair with a circular end-to-end anastomosis (EEA) stapler at Cleveland Clinic. All patients had extensive aneurysms: 17 after ascending dissection repair, 10 chronic type B dissections, and 17 degenerative aneurysms. Stapler was used during total arch repair as an end-to-side anastomosis (n = 36; including first stage elephant trunk [ET] in 32, frozen ET in 3) and an end-to-end anastomosis during redo thoracoabdominal repair (n = 11). Three patients had the stapler used during both stages of repair. Patients underwent early and annual follow-ups with computed tomography analysis.

RESULTS

There were no bleeds, ruptures, or leaks at the stapled site, but 2 patients died. Complications included 7 reoperations not related to the site of stapled anastomosis and 6 tracheostomies, but there was no paralysis or renal failure. Mean circulatory arrest time was 16 ± 5 minutes. Mean follow-up was 26 ± 17 months and consisted of imaging before discharge, at 3 to 6 months, and at 1 year. Planned reinterventions included 21 second-stage ET completion: Endovascular (n = 18) and open (n = 3). There were 4 late deaths.

CONCLUSIONS

Use of an end-to-end anastomotic automated circular stapler is safe, effective, and durable in performing graft-to-graft anastomoses during complex thoracic aortic surgery. Further evaluation and refinement of this technique are warranted.

"Extroverted Cuff", a novel modification of the elephant trunk technique for distal anastomosis of ragged descending aorta

BACKGROUND

The elephant trunk technique has been applied in various situations including distal aortic dissection, entire aortic replacement, proximal aortic aneurysm, proximal aortic dissection, and Marfan's syndrome. The elephant trunk technique remains a challenge in cardiac surgery. Here we report a modification of this surgical approach.

CASE PRESENTATION

The "extroverted cuff" technique that we propose is a novel modification of the flanged technique for the elephant trunk construction. The technique consists in the graft extroversion which is than located inside the descending aorta. Then the distal anastomosis is constructed between the descending aorta and the circular free edge the external layer of the graft. Such a technique was successfully applied in a patient with type A aortic dissection undergoing modified elephant trunk technique, aortic arch replacement and Bentall operation.

CONCLUSION

Such a modification seems suitable for aortic arch aneurysm with ragged descending thoracic aorta that minimizes bleeding from the distal anastomosis and potentially prevents distal embolization of atheromatous plaque.

Prophylactic stage 1 elephant trunk for moderately dilated descending aorta in patients with predominantly proximal disease

OBJECTIVE

Staged elephant trunk (ET) repair is a commonly performed procedure for extensive aortic disease. A significant proportion of patients with predominantly proximal aortic pathology often have in addition a moderately dilated descending aorta (<5 cm) that can progress over time. Objectives were to characterize patients, determine completion rate after prophylactic stage 1 ET, and assess outcomes.

METHODS

From 1992 to 2012, a total of 572 patients underwent stage 1 ET for degenerative aneurysm and dissection at Cleveland Clinic. Prophylactic stage 1 ET was performed in 117 (20.5%) who had predominantly proximal disease (5.5 ± 1 cm) with moderate dilation of the descending aorta (4 ± 0.6 cm). Aortic pathology included: aneurysm (n = 56 [48%]); chronic dissection (n = 41 [35%]); pseudoaneurysm (n = 9 [7.7%]); penetrating ulcer (n = 9 [7.7%]); and intramural hematoma (n = 2 [1.7%]). Other diagnoses included connective tissue disorder (12 [10%]); aortitis (20 [17%]); bicuspid aortic valve (9 [7.6%]); and previous type A dissection repair (27 [23%]).

RESULTS

Operative mortality was 0.8% (1 of 117). This patient suffered postoperative myocardial infarction and mesenteric ischemia, resulting in sepsis and death. Other complications included: stroke (n = 7 [6%]); tracheostomy (n = 6 [5%]); renal dialysis (n = 4 [3.3%]); and reoperation for bleeding (n = 7 [6%]). The mean follow-up time was 4 ± 3 years. Fifty-three (45%) patients completed the stage 2 ET (open: 20 [38%]; endovascular: 33 [62%]) at a median interval of 6 months (9 days-10 years). The mean descending diameter increased from 4.1 ± 0.6 cm to 5 ± 1 cm at the time of stage 2 completion. In 11 patients, stage 2 was performed for acute aortic events. Estimated survival at 1, 5, and 8 years was 94%, 88%, and 74%, respectively.

CONCLUSIONS

Prophylactic ET for moderately dilated descending aorta is an effective strategy for staged repair, especially in patients with chronic dissection, connective tissue disorder, and aortitis. In addition, this approach can be beneficial for emergency treatment of late distal aortic complications.

Aortic arch replacement with frozen elephant trunk-when not to use it

Current scientific evidence suggests the frozen elephant trunk (FET) technique plays an important role in modern aortic arch repair operations, both for aneurysmal disease and acute aortic dissection. Its use in extended aneurysm is generally therapeutic, aiming for complete exclusion of the diseased descending thoracic aorta. In acute aortic dissection type A, the application of FET is more prophylactic in nature, with the aim of preventing late dilatation of the proximal descending thoracic aorta. This review will present the journey of the elephant trunk from its conception to the current available technology. By tracing the historical evolution of the FET technique and prosthesis development, we explore the challenges and limitations of evidence-based surgical research. We present data from our growing experience in aortic arch reconstruction, the results from our latest 27 patients undergoing the 4-branch FET indicating substantially reduced morbidity and mortality (0%) in this complex patient cohort.