Elephant Trunk Procedures

Abstract

Major advances in aortic arch surgery have generally occurred through refinement of technique. The elephant trunk is a concept originally devised by Borst. This involves leaving a piece of tube graft floating in the descending aorta while repairing the ascending aorta and aortic arch. Over time, the concept was expanded to include inverting the graft within itself. The elephant trunk procedure has proven to be reliably successful and become the mainstay of treatment in aortic arch disease. Despite this relatively simple algorithm, the inconsistent and variable anatomy of the aortic arch and its neighboring aorta, coupled with brain protection issues, result in surgery being highly complex and challenging. Successful management of aortic arch disease requires appropriate patient selection, preoperative assessment, and tailoring the treatment for the individual patient with close posttreatment surveillance. Globally, endovascular modalities are also leveraged to expand the therapeutic window of the elephant trunk procedure. The inherent advantages of endovascular therapies are especially appealing when treating patients unable to tolerate conventional surgery. Significant progress has been made in both open and interventional treatment for aortic arch disease. If the elephant trunk procedure is undertaken, consideration of aortic arch principles, understanding brain protection, and the limitations of available surgical corridors is essential. This chapter focuses on the techniques of the elephant trunk in terms of the unique fundamentals and describes a contemporary approach to the management of patients with complex aortic arch pathology.