Modifications, Classification, and Outcomes of Elephant-Trunk Procedures

• Published in: The Annals of thoracic surgery Vol. 96; no. 2; pp. 548 - 558
• Main Authors: Svensson, Lars G., Rushing, Gregory D., Valenzuela, Edgardo Sepulveda, Rafael, Aldo E., Batizy, Lillian H., Blackstone, Eugene H., Roselli, Eric E., Gillinov, A. Marc, Sabik, Joseph F., Lytle, Bruce W.
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01.08.2013
• Subjects: Anastomosis, Surgical - methods; Aorta, Thoracic - surgery; Aortic Aneurysm, Thoracic - mortality; Aortic Aneurysm, Thoracic - surgery; Aortic Diseases - mortality; Aortic Diseases - surgery; Cardiothoracic Surgery; Carotid Artery, Common; Female; Humans; Male; Middle Aged; Risk Factors; Stents; Subclavian Artery; Surgery; Time Factors; Vascular Surgical Procedures - methods; 26
• ISSN: 0003-4975; 1552-6259; 1552-6259
• DOI: 10.1016/j.athoracsur.2013.03.082

There are a variety of modified elephant-trunk methods, including use of endovascular stents. Our objectives were to classify these modifications, compare outcomes between the classic anastomotic site and these alternatives, and investigate time to second-stage elephant-trunk completion. From May 1992 to January 2011, 526 patients underwent a first-stage elephant-trunk procedure and were the subject of analysis. Distal aortic anastomosis was located before the brachiocephalic artery in 6 patients (1.1%), between brachiocephalic and left common carotid artery (LCCA) in 1 (0.19%), between LCCA and left subclavian artery (LSCA) in 154 (29%), and beyond the LSCA (classic) in 365 (69%). Stroke occurred in 8% (n = 42) overall, 10% (n = 16) in the LCCA-LSCA group, and 6.8% (n = 25) in the classic group. Risk factors were older age and acute dissection. Thirty-day mortality was 7.6% (n = 40) and was similar for LCCA-LSCA (9.7%) and classic sites (6.3%; p = 0.7); risk factors included older age, smaller body surface area, and end-organ dysfunction. Likelihood of death before second-stage elephant trunk at 1, 4, and 8 years after operation was 16%, 22%, and 27%, respectively. The larger the distal aorta, the more likely was second-stage completion (p < 0.0001); when greater than 6 cm, 80% had second-stage completion. The elephant-trunk operation is safe for a broad population, including when anastomotic sites are other than beyond the LSCA. Without second-stage completion, patient mortality increases markedly after 4 years.