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Endovascular Stent Grafting to Complete “Elephant Trunk” Repairs in Patients with Extensive Thoracic Aortic Aneurysms

OBJECTIVES: Surgical treatment of extensive thoracic aortic aneurysms usually involves reconstructing the ascending aorta, aortic arch, and descending thoracic aorta in two separate operations with the “elephant trunk” technique. Many patients cannot tolerate the second-stage thoracotomy after the first-stage sternotomy, which leaves them vulnerable to aneurysm rupture. Thoracic aortic endografting may be a viable alternative to the traditional second-stage procedure. We describe our initial experience with using thoracic endografts to complete elephant trunk repairs.
METHODS: The elephant trunk technique with endovascular completion was used in 7 patients with extensive thoracic aortic aneurysms: 4 degenerative aneurysms and 3 aneurysms secondary to chronic dissection (mean diameter, 5.4±2.2 cm). After graft replacement of the ascending aorta and aortic arch via sternotomy, a descending aortic endograft was deployed into the suspended elephant trunk through a direct antegrade approach via the aortic arch graft during a single operation in 3 patients and through a retrograde approach via the femoral or iliac artery during a second operation in 4 patients.
RESULTS: : There were no deaths, no spinal cord complications, 1 postoperative stroke, and 1 early Type I endoleak that was treated with an endograft. Mean length of hospital stay was 25 days (range, 3-51 days). At a mean follow-up of 9.4 months (range, 3-12 months), all patients remain alive and well. One patient has a Type II endoleak that is being managed conservatively.
CONCLUSIONS: Combined surgical and endovascular treatment of extensive thoracic aortic aneurysms appears promising. Elephant trunk repair of the aortic arch, followed by endograft placement in the descending thoracic aorta, can be performed in high-risk patients who may not tolerate the thoracotomy needed in the traditional second-stage procedure.