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Ann Thorac Surg 2006;81:1561-1569
© 2006 The Society of Thoracic Surgeons

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Original article: Cardiovascular

The Elephant Trunk Technique for Staged Repair of Complex Aneurysms of the Entire Thoracic Aorta

Texas Heart Institute at St. Luke's Episcopal HospitalDivision of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas

Accepted for publication November 22, 2005.

^_* Address correspondence to Dr LeMaire, Baylor College of Medicine, One Baylor Plaza, BCM 390, Houston, TX 77030; (Email: slemaire{at}bcm.edu).

Presented at the Fifty-first Annual Meeting of the Southern Thoracic Surgical Association, Cancun, Mexico, Nov 2–4, 2004.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
BACKGROUND: Extensive thoracic aortic aneurysms that involve the ascending, arch, and descending segments require challenging repairs associated with substantial morbidity and mortality. The purpose of this report is to evaluate contemporary outcomes after surgical repair of extensive thoracic aortic aneurysms using a two-stage approach with the elephant trunk technique.

METHODS: During a 15-year period, 148 consecutive patients underwent total aortic arch replacement using the elephant trunk technique. Seventy-six of these patients (51%, 76/148) returned for second-stage repair of the descending thoracic or thoracoabdominal aorta 4.9 ± 7.5 months after the first stage.

RESULTS: Operative mortality after the proximal aortic stage was 12% (18/148). Seven patients (5%) had strokes. Among the patients who subsequently underwent distal aortic repair, operative mortality was 4% (3/76). Two patients (3%) developed paraplegia. Long-term survival after completing the second stage of repair was 70 ± 6% at 5 years and 59 ± 7% at 8 years.

CONCLUSIONS: Contemporary management of extensive thoracic aortic aneurysms using the two-stage elephant trunk technique yields acceptable short-term and long-term outcomes. This technique remains an important component of the surgical armamentarium.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
Extensive thoracic aortic aneurysms that involve the ascending, arch, and descending segments require challenging repairs associated with substantial morbidity and mortality. Since its introduction by Borst and colleagues in 1983 [1], staged repair using the elephant trunk technique has become the standard approach for managing these aneurysms. The key feature of this technique is that the distal anastomosis is constructed so that a portion of the graft is left suspended within the lumen of the proximal descending thoracic aorta; this "elephant trunk" is used during the subsequent distal aortic reconstruction, making aortic clamping safer and reducing aortic clamp time. The purpose of this report is to evaluate contemporary outcomes after open surgical repair of extensive thoracic aortic aneurysms using the two-stage approach with the elephant trunk technique.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
Study Variables and Definitions
For this retrospective review, all preoperative, intraoperative, and postoperative data were retrieved from a prospectively maintained database. Among the preoperative variables, dissection was considered acute when patients underwent surgery within 14 days of the initial event; after 14 days, dissection was considered chronic. Acute presentations were defined as patients requiring emergent or urgent operation because of acute dissection, free or contained rupture, or acute symptoms [2]. Preoperative renal failure was defined as patients receiving dialysis.

For distal aortic procedures, intraoperative variables included extent of repair, which was based on Crawford's original classification. Total clamp time was defined as the time between initial aortic clamping and the removal of all clamps, with restoration of normal blood flow to all vessels; this time was not adjusted when left heart bypass was used. Similarly, visceral and renal ischemic times were defined as the time between initial aortic clamping and the restoration of normal blood flow to the respective vessels; these times were not adjusted when left heart bypass or selective visceral-renal perfusion were used. As with all other continuous variables in this report, ischemic times are presented as mean ± standard deviation.

Regarding outcome variables, operative mortality was defined as death within 30 days of operation or during the initial hospitalization. Hospital-to-hospital transfer was not considered discharge; patients who died after being transferred were counted as operative deaths. Transfer to a nursing home or rehabilitation center was considered discharge, unless a patient died because of complications directly related to the operation [3]. Deaths and complications that occurred after distal repair but within 30 days of or during the initial hospitalization for proximal repair were counted against the second-stage procedure. All patients with postoperative neurologic deficits involving the lower extremities were included in the paraplegia category, regardless of whether the deficit was weakness (paraparesis) or paralysis, immediate or delayed, transient or permanent. This included patients with unilateral lower-extremity deficits, unless an associated deficit involving the ipsilateral upper extremity (indicating a stroke) was present. Acute renal failure was defined as a doubling of serum creatinine (relative to baseline) within 10 days of surgery or needing to initiate dialysis [4]. All cases of vocal cord paralysis were confirmed by direct laryngoscopy.

Patients
During a 15-year period, 205 consecutive patients had extensive aneurysms involving the entire thoracic aorta. Only 8 (4%) of these patients underwent single-stage repair of the ascending aorta, transverse aortic arch, and descending thoracic aorta. Forty-nine (24%) of the patients underwent staged repair using the reversed elephant trunk procedure, in which the descending thoracic component is repaired first. (These patients are the subject of a separate report and are not included in this manuscript [5].) One hundred forty-eight consecutive patients (72%) underwent total aortic arch replacement using the elephant trunk technique and are the focus of this report. The characteristics of these patients are presented in Table 1 .

View larger version (73K): [in this window] [in a new window]   Fig 1. This drawing illustrates the first stage of repair of an extensive thoracic aortic aneurysm (A) using the elephant trunk technique. After initiating hypothermic circulatory arrest and opening the aortic arch, the invaginated graft is inserted into the descending aorta (B) and the folded edge is used to construct the distal anastomosis (C). The invaginated portion of the graft is then pulled back into the field, and an opening in the graft is created adjacent to the brachiocephalic vessels for the arch anastomosis (D).

After opening the aortic arch longitudinally, the aortic graft was invaginated enough so that approximately 10 cm of graft remained suspended within the descending thoracic aorta. The graft was inserted into the descending aorta, and the folded edge was used to construct the distal anastomosis. We routinely avoid transecting the aorta at the level of this anastomosis. As advocated by Heinemann and colleagues [6] for patients with chronic aortic dissection, a large enough section of dissecting membrane was excised from the descending thoracic aorta to accommodate the graft and to prevent its entrapment. In 78% of cases, this anastomosis was performed just beyond the left subclavian artery. In 21% of cases, the aorta was particularly large at this level; therefore, the distal anastomosis was performed between the left common carotid and subclavian arteries in an attempt to reduce anastomotic tension [7]. The invaginated portion of the graft was then pulled back into the field. The brachiocephalic vessels were reattached to one or more openings made in the graft or, less commonly, replaced with separate smaller grafts if they were aneurysmal or damaged by dissection, as in the one patient with a distal anastomosis proximal to the innominate artery. After thorough removal of air, the graft was clamped and cardiopulmonary bypass was resumed. In 36% of cases, the proximal portion of the repair required only graft replacement of the ascending aorta. Aortic valve repairs using resuspension or annuloplasty techniques were performed in 24% of patients, and aortic valve replacement was performed in 28% of patients. Concomitant coronary artery bypass grafting was required in 30% of patients. There were no mitral procedures in this series. Before weaning from cardiopulmonary bypass, correct positioning of the elephant trunk within the descending thoracic aorta was confirmed using transesophageal echocardiography.

Distal Aortic Repairs (Stage 2)
Thus far, 79 patients have undergone the second-stage distal aortic repair; 76 of these procedures were performed at Baylor College of Medicine and will be the focus of this report. Three repairs were performed at outside institutions, and these patients have been excluded from our distal aortic repair analyses. Clinical characteristics are presented in Table 3. The demographics for these 76 patients were similar to those of the initial group, except that far fewer had coronary artery disease.

View larger version (68K): [in this window] [in a new window]   Fig 2. This drawing illustrates the second stage of repair of an extent II thoracoabdominal aortic aneurysm (A) after aortic arch replacement using the elephant trunk technique. After starting left heart bypass, the upper descending thoracic aorta is clamped beyond the previous distal anastomosis. The aorta is opened, and the elephant trunk graft is retrieved (B). After completing the proximal graft-to-graft anastomosis, left heart bypass is stopped and the remainder of the aneurysm is opened. Selective blood perfusion of the visceral vessels and cold perfusion of the renal arteries are delivered through balloon perfusion catheters (C). The reattachment of intercostal, visceral, and renal arteries is followed by the distal anastomosis, completing the repair (D).

	Results

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
Proximal Aortic Repairs (Stage 1)
Early mortality and complications after the first stage of repair are presented in Table 5. Operative mortality was 12% (18/148). Concomitant coronary artery bypass grafting during elephant trunk repair was significantly associated with 30-day mortality (8/11, 73%; p = 0.003) and stroke (5/7, 71%; p = 0.025). Details of the 18 early deaths are presented in Table 6.

Seven patients (5%) had strokes. There was no difference in neurologic outcome between the various cerebral protection strategies. Five patients (3%) underwent reoperation for bleeding and 14 (9%) developed acute renal failure requiring dialysis. None of the patients with renal failure received femoral cannulation (0/14; p < 0.0005); all were cannulated through the ascending-transverse arch aorta or the right axillary artery. Pulmonary complications were the most common and were often exacerbated by vocal cord paralysis, which occurred in 37 patients (25%). One patient had bilateral vocal cord paralysis requiring permanent tracheostomy. No patients experienced paraplegia or paraparesis after proximal aortic repair.

Long-term survival after the proximal operation was 55 ± 4% at 4 years and 31 ± 5% at 10 years (Fig 3). Late outcome data for the 130 patients who survived the first stage are summarized in Table 7. Thirty-two patients (25%) died without undergoing distal aortic repair at a mean time of 2.2 ± 2.2 years since their proximal aortic repair. In most cases cause of death was unknown. There were 3 deaths due to distal aortic rupture at 2.4 months, 6.3 months, and 7.6 years after proximal repair; the last patient refused to have distal aortic repair. Nineteen patients (15%) are alive and have not undergone the second stage of repair. In most cases, the remaining aneurysm has not yet reached sufficient size to warrant repair. Thus far, 79 patients (61%) have undergone the second-stage distal aortic repair.

View larger version (20K): [in this window] [in a new window]   Fig 3. Kaplan-Meier curve demonstrating long-term survival after 148 stage 1 elephant trunk repairs (bold line) and 76 stage 2 completion repairs (broken line).

	Comment

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

The results presented herein compare favorably with other large series in the literature [6, 11–15]. After the proximal stage of repair, early mortality ranges between 8% and 20% in other series; a recent report by Svensson and colleagues [15] is notable for a 2% 30-day mortality rate among 94 patients. The incidence of stroke after the proximal stage of repair ranges between 2% and 8%. After second-stage distal repair, both mortality and paraplegia rates range up to 9%.

After surviving the first stage, the risk of death before undergoing the completion procedure can be up to 15%, with aortic rupture being the most common cause of death [6, 12, 13]. Because of this risk, several authors have advocated single-stage repairs of the entire thoracic aorta [16, 17]. Total thoracic aortic replacement can be accomplished using a variety of approaches, including sternotomy alone, bilateral thoracotomy, and sternotomy plus thoracoabdominal incision. While the single-stage approach eliminates the interval period, with its attendant risk of aortic rupture, these operations carry substantial morbidity and mortality despite being used in a relatively younger patient population. Massimo and colleagues [17], for example, report risks of 15% for early mortality, 9% for spinal cord deficits, 3% for stroke, 12% for bleeding requiring reoperation, and 12% for renal failure; long-term survival was 62% at 9 years. Our experience with the single-stage approach is limited to 8 patients. Nearly all of those procedures were performed on an emergent basis in patients with acute symptoms and (1) prior ascending aortic repair and large aneurysms involving the transverse arch and descending thoracic segments, or (2) aneurysms that involved the entire ascending and transverse arch but were limited distally to a short segment of proximal descending thoracic aorta.

Recent endovascular innovations have created alternative approaches to complex aortic arch pathology. For example, several groups have reported using descending thoracic aortic endografts to complete the second stage in patients who have had elephant trunk repairs of the arch [18–21]. In this approach, the elephant trunk is used as the landing zone for the endograft. In light of this evolving development, we currently place metal clips at the distal end of the graft to facilitate future radiographic localization. Further advances in endovascular techniques are certain to affect our approach to managing extensive thoracic aortic aneurysms [22–25]. Careful assessment of the safety and efficacy of these alternative approaches will require comparison with standard open surgical repair.

Specific anatomic criteria for when to employ the elephant trunk technique have not been established. During the early portion of this series, we tended to reserve this technique for patients with descending thoracic aortic aneurysms that were already large enough to warrant repair (5-6 cm in diameter). With increasing experience, however, we have liberalized our indications for using the elephant trunk technique. We now commonly perform stage-1 repairs in patients who do not yet meet criteria for descending repair (4-5 cm in diameter) but are likely to require repair in the future (because of young age, presence of Marfan syndrome, etc). These patients are then reassessed annually with imaging studies to determine whether they have developed indications for proceeding with stage 2. Fifteen patients are currently in this surveillance phase. The relative benefits of this approach will require future analysis.

A central issue in the staged approach is the difficulty with selecting an appropriate interval between operations. The decision requires weighing the potential benefits of waiting, optimizing physiologic reserve by allowing recovery from the first operation, against the risk of interval rupture. Factors such as the presence of Marfan syndrome, maximum aortic diameter, and problematic medical compliance are carefully weighed in the analysis for each patient. While recognizing the need for an individualized target based on specific patient factors, we have advocated a 6-week recovery period between operations. Recent data from Estrera and Safi and colleagues [13, 14], however, suggest that a shorter period may be warranted; they report that rupture caused 70% of the deaths that occurred during the short period between 31 days and 6 weeks after the proximal operation. As a result, whenever the patient's condition allows it, they currently recommend performing the second-stage repair 4 weeks after the first stage.

In our series, 7 patients had distal aortic rupture after the stage-1 repair; rupture occurred during the early postoperative period in 4 patients and during the late period in 3. Rupture was fatal in 5 of the 7 patients. Although rupture was the documented cause of death in only 3% of the overall series (5/148), it is likely that fatal aortic rupture occurred in several of the patients in whom the specific cause of death could not be ascertained. The inability to obtain objective data regarding many of the late deaths is a limitation of this study.

In conclusion, contemporary management of extensive thoracic aortic aneurysms using the two-stage elephant trunk technique yields acceptable short-term and long-term outcomes. This technique certainly remains an important option in our armamentarium. We hope these data will serve as a basis for comparison as alternative approaches evolve.

	Discussion

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
DR JAMES A. QUINTESSENZA (St. Petersburg, FL): I have a technical question. How long do you make the elephant trunk compared to the rest of the graft?

DR LEMAIRE: That is something that has evolved over this time period. There certainly have been situations where, upon opening the aorta in the second stage, we wished we had a bit longer graft. We are reticent to leave too long of a graft because there have been cases of paraplegia related to thrombosis of the thoracic aorta due to too long of a trunk. We typically leave about 10 cm of graft, and occasionally we will mark the distal end with a clip to get a sense of where it is located either during the next operation or in preparation for an endovascular approach to the distal part.

DR JOHN W. HAMMON (Winston-Salem, NC): Scott, that was a very nice presentation, a lot of data, and some very interesting and very, very good results. Maybe this is a medical illustration problem, but I recall Dr. Crawford teaching us that you shouldn't leave a little segment of aorta containing the coronaries between the valve and the ascending aortic graft in people with ascending aortic aneurysmal disease. You showed that in your illustration. Have you changed the technique or do you need to hire a new medical illustrator?

DR LEMAIRE: No. In most cases when we replace the valve, we do leave a segment there; this seems to be alright in patients without Marfan syndrome. It is primarily the patients with the connective tissue disorders or with preexisting annuloaortic ectasia that need to have a concomitant root replacement. But a lot of these patients just have degenerative aneurysms related to atherosclerotic disease and are older; so, as a way of limiting the extent of operation, particularly in the setting of an elephant trunk, we will often limit the proximal repair and just do separate valve and aortic replacements.

DR ROBERT POSTON (Baltimore, MD): Have you looked at graft patency or noticed clinical problems that suggest early graft failure in those patients that required coronary bypass using a vein graft off of their ascending aortic graft?

DR LEMAIRE: We have not studied that formally, certainly not with postoperative imaging studies, but we haven't noticed any problems. Direct reattachment of the vein grafts to the Dacron graft has been used for years and doesn't seem to cause any particular problem.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
The authors gratefully acknowledge Scott Weldon, who created the medical illustrations.

	References

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Scott A. LeMaire Joseph S. Coselli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by LeMaire, S. A. Articles by Coselli, J. S. Search for Related Content PubMed PubMed Citation Articles by LeMaire, S. A. Articles by Coselli, J. S. Related Collections Great vessels