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Hemodynamic alterations occur when the elephant trunk (ET) technique is adopted to treat extensive aortic aneurysms. In planning the 2nd stage operation to complete ET repair, surgeons must weigh an adequate recovery time after initial surgery against the risk of postoperative ET-related complications. The purpose of this study was to understand the mechanistic link between the flow alteration caused by the ET graft and the development of premature aortic rupture before the 2nd stage operation. Specifically, fluid-structure interaction (FSI) analysis was performed using the CT imaging data of aorta at different stages of ET repair, and then computational variables were compared to those observed in patients who underwent a prophylactic 2nd stage operation to complete aortic repair. Results show that intramural stress exerted near the distal ET anastomosis (IMS=37.5 kPa) at the time of urgent intervention was comparable to that of the extensive aortic aneurysm (IMS=47.4 kPa) at initial in-hospital admission, but was considerably higher than that occurring after the 1st stage procedure (IMS=3.5 kPa). Pressure index suggested higher peri-graft pressurization than aortic lumen pressure during diastole, imparting an apparent risk of aortic dilatation. These critical hemodynamic and structural parameters are related to the impending rupture of descending aorta observed clinically and can thus guide prophylactic intervention and optimal timing for the 2nd stage operation of a ET technique. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

We present our 14-year experience In the management of extensive aortic aneurysms. Significant progress has been made in reducing the morbidity and mortality associated with these procedures, Our strategies for organ protection, operative techniques, including the elephant trunk technique, and surgical results are discussed. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The ‘frozen’ elephant trunk technique allows for single-stage repair of combined aortic arch and descending aortic aneurysms using a ‘hybridprosthesis'' with a stented and a non-stented end. This report summarizes the operative- and follow-up data (mean follow-up 14 months) with this new treatment. Methods: Between 09/01 and 4/04, 22 patients (62±9 years; 9 female) with different aortic pathologies (15 aortic dissections, 7 aneurysms) were operated on after approval from the local institutional review board. The stented end of the hybridprosthesis was deployed in the descending aorta through the opened aortic arch during hypothermic circulatory arrest and selective antegrade cerebral perfusion. Results: All patients survived the procedure but one patient died of acute hemorrhage due to rupture of the false lumen in the descending aorta on the second postoperative day. Two patients required reexploration of the chest for bleeding complications. In 2 of 4 patients who developed neurological dysfunction, symptoms resolved completely. In one of them, the descending aorta was perforated intraoperatively due to misplacement of the stented end of the hybridprosthesis. In all follow-up CT-scans thrombus formation in the descending aortic aneurysm excluded by the stented end of the hybridprosthesis has been observed. Conclusions: This procedure is performed through median sternotomy and combines the concepts of the elephant trunk operation and endovascular stenting of descending aortic aneurysms. Favourable intraoperative and postoperative results during follow-up with regard to thrombus formation around the stented descending aortic segment encourage us to evaluate all patients with thoracic aneurysms extending to proximal and distal of the left subclavian artery for this treatment. [Copyright &y& Elsevier]

Objectives: Extensive aortic dissection with multiple entries often found in Marfan’s syndrome patients ultimately requires replacement of the whole aorta. We present a surgical strategy and results for total and subtotal arotic replacement. Methods: Subjects were 18 patients, including 14 Marfan’s patients undergoing total (n=13) or subtotal (excluding aortic arch) aortic replacement (n=5), for DeBakey type I aortic dissection (n=13) and DeBakey type IIIb aortic dissection with annuloaortic ectasia (n=5) between February 1991 and April 2001. Mean age was 39.9±0.8 years—34.9±6.6 years in Marfan’s patients vs. 57.7±4.7 years in non-Marfan patients. All operations were staged, with the mean number required per patient 3.1±0.8. Results: Early mortality was 0% and late mortality 11% (2 of 18). Paraplegia or paraparesis occurring in 11%. Except for these patients, all current survivors enjoy good quality of life. Conclusions: Total and subtotal aortic replacement for extensive aortic dissection may decrease mortality due to rupture or associated disease. [ABSTRACT FROM AUTHOR]

A median sternotomy is considered to have several advantages over a left thoracotomy as a route for the surgical treatment of a distal aortic arch aneurysm, including less pain and less lung damage. In a median sternotomy, distal anastomosis is such an important problem that we herein present a useful technique to prevent surgical bleeding from it. An invaginated 40-mm-long graft is inserted into the distal aorta, sutured to the aortic wall, unfolded, and anastomosed with a four-limbed tube graft. We applied this "mini-elephant trunk" technique to total arch replacement for both a saccural distal aneurysm, where the distal aorta was transected, and a fusiform aneurysm, where the invaginated graft was sutured by the "inclusion" method. This technique enables a greater surface contact area between the graft and the aortic wall at the distal anastomosis, thus resulting in a reduced risk of bleeding. [ABSTRACT FROM AUTHOR]

We report a rare case of a patient with hemolytic anemia who underwent emergency total arch replacement using the elephant trunk technique for type A acute aortic dissection 3 years earlier. The 78-year-old woman was referred to our hospital for diagnosis of the cause of the hemolytic anemia, which required twice weekly blood transfusion. Although contrast-enhanced computed tomography could not provide sufficient information, transesophageal echocardiography (TEE) revealed graft flection with high velocity. After percutaneous balloon dilatation, the hemolytic anemia improved and follow-up TEE showed no re-stenosis of the dilatation site. [ABSTRACT FROM AUTHOR]

Objectives: Our goal was to determine the early and midterm outcomes after total arch replacement with the frozen elephant trunk (FET) technique compared to those of the conventional elephant trunk (ET) technique for acute retrograde type A aortic dissection., Methods: Between 2012 and 2019, a total of 49 patients had total arch replacement for acute retrograde type A aortic dissection. Patients were divided into the conventional ET (n = 17) and FET (n = 32) groups. The false lumen status was evaluated using enhanced computed tomography (CT) 1 week postoperatively. The diameter of the downstream aorta was evaluated annually using CT. The median follow-up period was 29 months., Results: Preoperative data and neurological complications were not significantly different in the 2 groups. The diameter and length of the ET prosthesis were significantly larger and longer in the FET group. The overall early mortality rate was 10.2% (5/49) with no differences between the 2 groups. The mean follow-up period was significantly longer in the conventional ET group. The rates of freedom from aortic events at 3 years were significantly lower in the FET group. At the level of the distal arch, postoperative false lumen patency was significantly lower and the follow-up aortic diameter was significantly smaller in the FET group., Conclusions: The FET technique facilitates false lumen thrombosis and aortic remodelling at the distal arch level, with fewer adverse aortic events during the follow-up period with acceptable early outcomes; however, these findings are exploratory and require investigation., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: To illustrate our experience and results in patients with diffuse aneurysmal disease treated with arch replacement using the Siena collared graft, a device designed in 2002 to improve the elephant trunk technique. Results of the first step surgical implant and the subsequent treatment strategies, with extensive use of endovascular techniques, are reported., Methods: All aortic arch-replacement procedures using the Siena graft between February 2002 and January 2020 were retrospectively analyzed for early and late clinical outcomes., Results: Of 146 patients (54 women, 36.9%) with a median age of 69.1 years (interquartile range 58.4-75.0 years), 55 (37.6%) had acute/chronic dissection with false lumen aneurysmal dilatation, 91 (62.3%) had degenerative aneurysms, 45 (30.8%) were redo operations, and 14 (9.5%) had connective tissue disease. First-stage outcomes: 10.9% 30-day mortality (n = 16); 5.4% stroke (n = 8, 6 disabling, 2 nondisabling; 3 fatal); and 0.6% paraplegia. Outcomes for 113 second-stage procedures (77.3%, n = 97 endovascular [66.4%], n = 16 surgical [10.9%]) were 5.3% and 8.8% 30-day and 180-day mortality; no stroke; 10.6% paraplegia. Median follow-up was 5.7 years (range: 0-18.02 years) median survival was 16.65 years (95% lower confidence limit, 10.06 years) with no significant difference between aneurysm and dissection patients. Freedom from further treatment was 87.0% (95% confidence interval, 79.9%-94.7%) at 5 years and 71.4% (95% confidence interval, 71.4%-84.7%) at 10 years; median time to reintervention was 2.59 years (interquartile range, 0.52-5.20 years) with no difference ( P  = .22) between dissection and aneurysm groups., Conclusions: Siena collared graft represents a reliable platform for the treatment of diffuse aneurysmal disease. This device offers the flexibility required in the treatment of extended aortic lesions and guarantees the choice of the most appropriate approach for treatment completion. In this context, the availability of hybrid grafts has not modified the role of this device in arch surgery., (© 2020 The Authors.)

The elephant trunk technique is used as a standard method in the approach to staged repair of extensive thoracic aneurysms. Here, we present a rare case of a graft infection, in which vegetation was attached to the distal end of the elephant trunk. A 36-year old male who had undergone total arch replacement with elephant trunk installation for type A aortic dissection was readmitted for high-grade fever. At the time of admission, Osler's nodules were present and brain magnetic resonance imaging showed multiple small emboli and haemorrhages. Transoesophageal echocardiography could not locate any sign of infection within the cardiac chambers, but disclosed vegetation attached to the elephant trunk. He underwent successful emergent graft replacement of the lesion, and no recurrence of the infection has been observed. [ABSTRACT FROM AUTHOR]