Surgical “Elephant Trunk” Arch Replacement with a Branched Arch
Prosthesis: Two Alternative Operative Techniques
Abstract
Background: Elephant trunk repair of the aortic arch cannot be performed
with a branched prosthesis. We conceived two different modifications of
the original technique to perform an arch replacement with a branched
graft, while arranging an adequate landing zone for a subsequent TEVAR,
without the need of dedicated material. Methods: Eight consecutive
patients underwent arch replacement with one of our techniques. Five
were emergency patients with acute aortic dissection, and 3 suffered
chronic expansive disease. The “modified elephant trunk” includes a
separate anastomosis of an endo-luminal prosthetic segment in the
descending aorta. Subsequently, the branched arch prosthesis is
anastomosed to the distal aortic stump with the attached trunk. In the
“prophylactic debranching”, a tail is left on the distal end of the
arch prosthesis, so that the branches for the supra-aortic vessels will
remain displaced proximally, allowing a “zone 1” available for
landing. Results: Three patients experienced transient cerebral deficits
(1 TIA and post-operative delirium in 2 cases), 1 required re-operation
for bleeding and 2 needed prolonged intubation. One died for multi-organ
failure. Conclusion: Both techniques proved to be easily reproducible,
and allow an adequate landing zone for a subsequent endovascular
procedure, while keeping the advantages of using a tetra-furcated
prosthesis. They are a viable alternative in case a hybrid prosthesis
cannot be implanted.