Clinical Experience with "Stand-Alone" Elephant Trunk Procedure for Descending Aortic Aneurysms

Both open and endovascular treatments of descending thoracic aortic aneurysms require a secure proximal landing zone. This may be difficult to achieve when the dilatation extends proximally to the left subclavian level. Clamping above the aneurysm may be difficult. In the case of an endovascular approach, achieving a suitable landing zone may require extensive extra-anatomic debranching, which is not without complications and limitations.

We describe a modification of the traditional elephant trunk procedure that represents a "stand-alone" elephant trunk. Under deep hypothermic circulatory arrest, the aorta is transected between the left carotid and left subclavian arteries. A simple, noninverted elephant trunk is placed through the distal cut aorta. The two ends are sewn back together, incorporating the lip of the elephant trunk in the anastomosis. We review our experience in five patients who underwent this procedure.

All 5 patients (4 males, 1 female) aged 41 to 68 (mean, 57 years) tolerated the Stage 1 stand-alone elephant trunk procedure well, without mortality, stroke, or bleeding. The Stage 2 descending aortic replacements were performed at a mean of 6.7 months after Stage 1. There was no Stage 2 mortality, stroke, or bleeding. One patient died 8 years later of cardiac cause, and the remaining are alive and well.

A stand-alone elephant trunk procedure is safe and straightforward and provides an excellent proximal foundation for subsequent open (or potentially endovascular) descending aortic replacement.