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Ann Thorac Surg 1995;60:7
© 1995 The Society of Thoracic Surgeons
DR RANDALL B. GRIEPP (New York, NY): The elephant trunk procedure is one of those things that elicits the response: ``Of course! How very obvious! How appropriate to the problem. And why couldn't I have thought of that?'' Soon after it was described by Dr Borst in 1983, the elephant trunk was rapidly incorporated into the armamentarium of most aortic surgeons. It is clearly a major advance in dealing with the patient who, in addition to an arch aneurysm, has an aneurysm in the descending thoracic aorta, the distal extent of which cannot be reached easily.
I would like to emphasize some of the points Dr Heinemann made with regard to technical factors. Putting the doubled graft down inside the descending thoracic aorta certainly simplifies the procedure. One then can work very easily on the distal anastomosis of the first stage. One can put Teflon felt around it if needed for a friable aorta, or transect the aorta; there are a number of possible variations. Once the distal anastomosis is complete, it is simple to pull out the inverted graft to get the piece one needs for the arch anastomosis.
If necessary, the distal anastomosis of the first stage can be made between the carotid and left subclavian arteries, if that is where the aorta is narrowest, although this then will require separate revascularization of the left subclavian artery subsequently.
As Dr Heinemann has described, the second stage of the procedure is simplified if one clamps the aorta just beyond the anticipated site of distal anastomosis, then opens the aorta proximally and reaches in to pull out the elephant trunk. There would be a terrible sinking feeling if the graft were not there, but I have not encountered that yet.
My colleagues and I have used an elephant trunk for aneurysms of the arch and proximal descending aorta in which we have anticipated doing the second stage within a matter of weeks to months. A number of patients in Dr Heinemann's series have had a substantially longer interval after the first operation: only 17 of 40 have undergone the second procedure, an average of 9 months later. In view of this, I would like to ask Dr Heinemann to outline his indications for placement of a proximal elephant trunk. Are all patients undergoing arch replacement candidates for an elephant trunk? If not, what are the specific indications for this procedure?
My second question concerns the rationale for the use of an elephant trunk in the distal descending aorta: I have not been able to convince myself that its presence makes the second operation in the distal descending aorta much easier. An elephant trunk does obviate the need to gain proximal control, but if the previously placed graft in the descending thoracic aorta is readily accessible, gaining proximal control is rarely a problem. Perhaps Dr Heinemann could explain why using an elephant trunk in the distal descending aorta is advantageous.
Finally, I would like to ask a question about the second stage, which, although relatively simple, is still an operation. I wonder whether Dr Heinemann and his colleagues have given thought to anchoring the distal graft in the descending aorta using a noninvasive transfemoral approach.
DR HEINEMANN: The first question was about indications for placing an elephant trunk proximally; does one use it liberally? We would not insert a proximal elephant trunk in an aortic arch aneurysm that ends at the descending aorta or in a true fusiform aneurysm. In any kind of more or less generalized aortic dilatation we always would recommend insertion of an elephant trunk, because so far we have not seen any additional morbidity.
That brings me to the second question about the distal elephant trunk. It is probably not so necessary to insert a distal elephant trunk as it is helpful inserting a proximal one, as far as a redo is concerned. We believe that it just does not take any more time to insert a distal trunk. We also have seen that if you stay above the level of T-7 or T-8 with the descending aortic replacement, there is no paraplegia without doing anything else than a left atrial to femoral arterial bypass. So if you can stay above that level, it is pretty safe. If you need to do a more extensive replacement, you may need a thoracoabdominal incision and evaluation of the spinal cord blood supply. I must confess that we are always glad if we can postpone these things a bit. So we would advocate doing a distal elephant trunk routinely for limited descending aortic replacement and restricting indications for more extensive one-stage procedures.
About the third question, if there are noninvasive, nonsurgical methods of unfolding or hooking-up of an elephant trunk, I do not know for sure. I think that Dr Dake or Dr Craig Miller of Stanford University would be the people to ask, because they are so tremendously good with their noninvasive placing of stent-grafts and things, but so far I am not aware of any technique that could do that for us.
Thank you again for the exceptional honor of opening this prestigious convention, although I do realize that one never gets a second chance to make a first impression.
Related Article
Ann. Thorac. Surg. 1995 60: 235-494.
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