Modifications, classification, and outcomes of elephant-trunk procedures

Area of Science:

• Cardiovascular Surgery
• Thoracic Surgery
• Vascular Surgery

Background:

• Modified elephant-trunk techniques, including endovascular stents, offer alternatives to the classic approach.
• Evaluating outcomes and completion rates of these modifications is essential for optimizing aortic dissection repair.

Purpose of the Study:

• To classify modifications of the elephant-trunk procedure.
• To compare outcomes between classic and alternative anastomotic sites.
• To investigate the time to second-stage elephant-trunk completion.

Main Methods:

• Analysis of 526 patients who underwent a first-stage elephant-trunk procedure between May 1992 and January 2011.
• Classification of distal aortic anastomosis locations: before brachiocephalic artery, between brachiocephalic and left common carotid artery (LCCA), between LCCA and left subclavian artery (LSCA), and beyond LSCA (classic).

Main Results:

• Stroke occurred in 8% of patients; rates were 10% in the LCCA-LSCA group and 6.8% in the classic group.
• Thirty-day mortality was 7.6% and similar between LCCA-LSCA (9.7%) and classic (6.3%) sites.
• Mortality before second-stage completion was 16% at 1 year, 22% at 4 years, and 27% at 8 years. Larger distal aorta size correlated with higher likelihood of second-stage completion (p < 0.0001).

Conclusions:

• The elephant-trunk operation is safe across various anastomotic sites, including those other than beyond the LSCA.
• Failure to complete the second stage of the elephant-trunk procedure leads to a significant increase in long-term patient mortality.
• Optimizing the timing and success of the second stage is critical for improving survival after the elephant-trunk procedure.