Two-Stage Elephant Trunk approach for open management of distal aortic arch and descending aortic pathology in patients with Marfan syndrome

Background: Extensive pathology involving the aortic arch and descending aorta traditionally has been treated with two open procedures. We report our institutional experience with a single stage frozen elephant trunk procedure for treatment of extensive aortic pathology. Methods: Between June 2018 and October 2019, nine patients (eight males, 89%, mean age 61 ± 6 years) with extensive aortic pathology were operated using the frozen elephant trunk procedure. Five (56%) patients underwent primary operation for chronic arch and proximal descending aneurysm in two (22%) patients, chronic type B aortic dissection in two (22%) patients and penetrating aortic ulcer in one (11%) patient. The other four (44%) patients received reoperative surgery for chronic post-dissection aneurysms. For organ protection during the aortic arch procedure, we used selective antegrade cerebral perfusion and mild systemic hypothermia at 28°C. Results: Early mortality was not observed. A single (11%) patient developed focal stroke. Unilateral vocal cord palsy was present in two (22%) patients. Spinal cord injury was not observed. Reexploration for bleeding was required in two (22%) patients. Prolonged ventilation, liver and kidney failure as well as cardiac morbidity were not observed. Two patients (22%) with anticipated Endoleak type Ib received TEVAR extension at follow up. Mid-term mortality was observed in two (22%) patients, due to pneumonia. Conclusion: The frozen elephant trunk procedure can be used for a single-stage treatment of patients with extensive aortic pathology, due to chronic degenerative aneurysms or post-dissection aneurysms involving the aortic arch and the descending aorta, with acceptable mortality and morbidity.

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Surgery for patients with Marfan syndrome with type A dissection involving the aortic arch using total arch replacement combined with stented elephant trunk implantation: The acute versus the chronic

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/j.jtcvs.2011.01.038 ◽

2011 ◽

Vol 142 (3) ◽

pp. e85-e91 ◽

Cited By ~ 21

Author(s):

LiZhong Sun ◽

Ming Li ◽

JunMing Zhu ◽

YongMin Liu ◽

Qian Chang ◽

...

Keyword(s):

Aortic Arch ◽

Marfan Syndrome ◽

Type A ◽

Total Arch Replacement ◽

Elephant Trunk ◽

Type A Dissection

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Comprehensive treatment of pathology of the ascending, arch and descending thoracic aorta by performing operations of the hybrid "elephant trunk"

Bukovinian Medical Herald ◽

10.24061/2413-0737.xxv.3.99.2021.7 ◽

2021 ◽

Vol 25 (3 (99)) ◽

pp. 42-47

Author(s):

V. Kravchenko ◽

I. Dytkivski ◽

V. Lybavka

Keyword(s):

Hospital Mortality ◽

Aortic Arch ◽

Thoracic Aorta ◽

Postoperative Blood Loss ◽

Comprehensive Treatment ◽

Descending Thoracic Aorta ◽

Elephant Trunk ◽

Surgical Equipment ◽

Complete Replacement ◽

Aortic Pathology

The purpose of the study – study and demonstration of the possibilities of the technique of complete replacement of the ascending, arch, vessels of the arch and descending thoracic aorta "elephant trunk" surgery in patients with aortic arch aneurysms.Material and methods. The paper describes the technique and demonstrates the results of the first 29 operations of prosthetics of the ascending, arch, vessels of the arch and descending thoracic aorta, which were performed by the staff of the Department of Surgical Treatment of Aortic Pathology National M.Amosov ICVS of the NAMS of Ukraine" in 2016-2020. Results. Hospital mortality was 10.3%, three patients died. The causes of death were: the following acute cardiovascular failure, uncontrolled bleeding, and multiple organ failure in each case. In none of the operated patients the level of postoperative blood loss did not require rethoracotomies.Conclusions. The optimal way to correct aneurysms of the aortic arch is the operation of prosthetics of the ascending, arch and descending thoracic aorta - "elephant trunk". Improvement of preoperative diagnostics, surgical equipment, optimization of methods of protection of the brain, spinal cord and visceral organs, the possibility of using hybrid / endovascular techniques to treat patients with complex lesions of the aortic arch pool with hospital mortality within 10.3%.

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Whole body perfusion for hybrid aortic arch repair: evolution of selective regional perfusion with a modified extracorporeal circuit

Perfusion ◽

10.1177/0267659116673444 ◽

2016 ◽

Vol 32 (3) ◽

pp. 230-237 ◽

Cited By ~ 2

Author(s):

Philip Fernandes ◽

Graham Walsh ◽

Stephanie Walsh ◽

Michael O’Neil ◽

Jill Gelinas ◽

...

Keyword(s):

Aortic Arch ◽

Regional Perfusion ◽

Whole Body ◽

Acute Type ◽

Lower Body ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Aortic Pathology ◽

Aortic Arch Reconstruction ◽

Arch Reconstruction

Background: Patients undergoing hybrid aortic arch reconstruction require careful protection of vital organs. We believe that whole body perfusion with tailored dual circuitry may help to achieve optimal patient outcomes. Methods: Our circuit has evolved from a secondary circuit utilizing a cardioplegia delivery device for lower body perfusion to a dual-oxygenator circuit. This allows individually controlled regional perfusion with ease of switching from secondary to primary circuit for total body flow. The re-design allows for separate flow and temperature regulation with two oxygenators in parallel. All patients underwent a single-stage operation for simultaneous treatment of arch and descending aortic pathology via a sternotomy, using a hybrid frozen elephant trunk technique. Results: We report six consecutive patients undergoing hybrid arch and frozen elephant trunk reconstruction using a dual-oxygenator circuit. Five patients underwent elective surgery and one was emergent. One patient had an acute dissection while three underwent concomitant procedures, including a Ross procedure and two valve-sparing root reconstructions. Three cases were redo sternotomies. The mean pump time was 358 ± 131 min, the aortic cross clamp time 243 ± 135 min, the cardioplegia volume of 33,208 ml ± 16,173, cerebral ischemia 0 min, lower body ischemia 76 ± 34 min and the average lower body perfusion time was 142 min. Two patients did not require any donor blood products. The median intensive care unit (ICU) and hospital lengths of stay (LOS) were two days and 10 days, respectively. The average peak serum lactate on CPB was 7.47 mmol/L and, at admission to the ICU, it was 3.37 mmol/L. Renal and respiratory failure developed in the salvage acute type A dissection patient. No other complications occurred in this series. Conclusions: Whole body perfusion as delivered through individually controlled dual-oxygenator circuitry allows maximum flexibility for hybrid aortic arch reconstruction. A modified circuit perfusion strategy may help to limit intra-operative metabolic derangements, providing improved clinical outcomes.

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