Arch Surgery and Elephant Trunk Technique and Alternatives for Second Stage

  • Michael Z. TongEmail author
  • Lars G. Svensson


The history of aortic arch surgery began in 1932 when Blalock repaired an ascending aorta that was stabbed by an ice pick. Since then, multiple advances in neuroprotection, surgical techniques and new technologies has made aortic arch surgery a safe and repeatable operation. In this chapter, we will review modern surgical techniques for the treatment of aortic arch pathologies and alternatives for second stage repair of the descending aorta.


Dissection Frozen elephant trunk Endovascular Second stage 


  1. 1.
    Svensson LG, Crawford ES. Cardiovascular and vascular diseases of the aorta. Philadelphia, PA: WB Saunders; 1997.Google Scholar
  2. 2.
    De Bakey ME, Crawford ES, Cooley DA, Morris GC Jr. Successful resection of fusiform aneurysm of aortic arch with replacement by homograft. Surg Gynecol Obstet. 1957;105:657–64.Google Scholar
  3. 3.
    Barnard CN. Surgical treatment of acquired aneurysms of the thoracic aorta. N Z Med J. 1965;64:S61–3.Google Scholar
  4. 4.
    Borst HG, Frank G, Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg. 1988;95:11–3.PubMedGoogle Scholar
  5. 5.
    Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using “elephant trunk” prosthesis. J Thorac Cardiovasc Surg. 1983;31:37–40.CrossRefGoogle Scholar
  6. 6.
    Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Card Surg. 1992;7:301–12.CrossRefGoogle Scholar
  7. 7.
    Svensson LG. Antegrade perfusion during suspended animation? J Thorac Cardiovasc Surg. 2002;124:1068–70.CrossRefGoogle Scholar
  8. 8.
    Svensson LG, Blackstone EH, Rajeswaran J, Sabik JF 3rd, Lytle BW, Gonzalez-Stawinski G, et al. Does the arterial cannulation site for circulatory arrest influence stroke risk? Ann Thorac Surg. 2004;78:1274–84.CrossRefGoogle Scholar
  9. 9.
    Coselli JS, Crawford ES, Beall AC Jr, Mizrahi EM, Hess KR, Patel VM. Determination of brain temperatures for safe circulatory arrest during cardiovascular operation. Ann Thorac Surg. 1988;45:638–42.CrossRefGoogle Scholar
  10. 10.
    Iba Y, Minatoya K, Matsuda H, Sasaki H, Tanaka H, Kobayashi J, et al. Contemporary open aortic arch repair with selective cerebral perfusion in the era of endovascular aortic repair. J Thorac Cardiovasc Surg. 2013;145:S72–7.CrossRefGoogle Scholar
  11. 11.
    Zierer A, El-Sayed Ahmad A, Papadopoulos N, Moritz A, Diegeler A, Urbanski PP. Selective antegrade cerebral perfusion and mild (28 degrees C-30 degrees C) systemic hypothermic circulatory arrest for aortic arch replacement: results from 1002 patients. J Thorac Cardiovasc Surg. 2012;144:1042–9.CrossRefGoogle Scholar
  12. 12.
    Svensson LG, Husain A, Penney DL, Swanson RA, Margolis DS, Kimmel WA, et al. A prospective randomized study of neurocognitive function and s-100 protein after antegrade or retrograde brain perfusion with hypothermic arrest for aortic surgery. J Thorac Cardiovasc Surg. 2000;119:163–7.CrossRefGoogle Scholar
  13. 13.
    Lytle BW, McCarthy PM, Meaney KM, Stewart RW, Cosgrove DM 3rd. Systemic hypothermia and circulatory arrest combined with arterial perfusion of the superior vena cava. Effective intraoperative cerebral protection. J Thorac Cardiovasc Surg. 1995;109:738–43.CrossRefGoogle Scholar
  14. 14.
    Juvonen T, Weisz DJ, Wolfe D, Zhang N, Bodian CA, McCullough JN, et al. Can retrograde perfusion mitigate cerebral injury after particulate embolization? A study in a chronic porcine model. J Thorac Cardiovasc Surg. 1998;115:1142–59.CrossRefGoogle Scholar
  15. 15.
    Svensson LG, Blackstone E, Apperson C, Ruggieri P, Sun Z, Naugle R, et al. Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial. J Thorac Cardiovasc Surg. 2015;150:1140–7.CrossRefGoogle Scholar
  16. 16.
    Milewski RK, Pacini D, Moser GW, Moeller P, Cowie D, Szeto WY, et al. Retrograde and antegrade cerebral perfusion: results in short elective arch reconstructive times. Ann Thorac Surg. 2010;89:1448–57.CrossRefGoogle Scholar
  17. 17.
    Spielvogel D, Kai M, Tang GH, Malekan R, Lansman SL. Selective cerebral perfusion: a review of the evidence. J Thorac Cardiovasc Surg. 2013;145:S59–62.CrossRefGoogle Scholar
  18. 18.
    Sugiura T, Imoto K, Uchida K, Minami T, Yasuda S. Comparative study of brain protection in ascending aorta replacement for acute type A aortic dissection: retrograde cerebral perfusion versus selective antegrade cerebral perfusion. Gen Thorac Cardiovasc Surg. 2012;60:645–8.CrossRefGoogle Scholar
  19. 19.
    Usui A, Miyata H, Ueda Y, Motomura N, Takamoto S. Risk-adjusted and case-matched comparative study between antegrade and retrograde cerebral perfusion during aortic arch surgery: based on the Japan Adult Cardiovascular Surgery Database: the Japan Cardiovascular Surgery Database Organization. Gen Thorac Cardiovasc Surg. 2012;60:132–9.CrossRefGoogle Scholar
  20. 20.
    Williams ML, Ganzel BL, Slater AD, Slaughter MS, Trivedi JR, Edmonds HL, et al. Antegrade versus retrograde cerebral protection in repair of acute ascending aortic dissection. Am Surg. 2012;78:349–51.PubMedGoogle Scholar
  21. 21.
    Svensson LG, Rushing GD, Valenzuela ES, Rafael AE, Batizy LH, Blackstone EH, et al. Modifications, classification, and outcomes of elephant-trunk procedures. Ann Thorac Surg. 2013;96:548–58.CrossRefGoogle Scholar
  22. 22.
    Safi HJ, Miller CC 3rd, Estrera AL, Huynh TT, Rubenstein FS, Subramaniam MH, et al. Staged repair of extensive aortic aneurysms: morbidity and mortality in the elephant trunk technique. Circulation. 2001;104:2938–42.CrossRefGoogle Scholar
  23. 23.
    Svensson LG, Kaushik SD, Marinko E. Elephant trunk anastomosis between left carotid and subclavian arteries for aneurysmal distal aortic arch. Ann Thorac Surg. 2001;71:1050–2.CrossRefGoogle Scholar
  24. 24.
    Xiao Z, Meng W, Zhu D, Guo Y, Zhang E. Treatment strategies for left subclavian artery during total arch replacement combined with stented elephant trunk implantation. J Thorac Cardiovasc Surg. 2014;147:639–43.CrossRefGoogle Scholar
  25. 25.
    Lee CW, Beaver TM, Klodell CT Jr, Hess PJ Jr, Martin TD, Feezor RJ, et al. Arch debranching versus elephant trunk procedures for hybrid repair of thoracic aortic pathologies. Ann Thorac Surg. 2011;91:465–71.CrossRefGoogle Scholar
  26. 26.
    Svensson LG, Nadolny EM, Kimmel WA. Multimodal protocol influence on stroke and neurocognitive deficit prevention after ascending/arch aortic operations. Ann Thorac Surg. 2002;74:2040–6.CrossRefGoogle Scholar
  27. 27.
    Karck M, Chavan A, Hagl C, Friedrich H, Galanski M, Haverich A. The frozen elephant trunk technique: a new treatment for thoracic aortic aneurysms. J Thorac Cardiovasc Surg. 2003;125:1550–3.CrossRefGoogle Scholar
  28. 28.
    Roselli EE, Rafael A, Soltesz EG, Canale L, Lytle BW. Simplified frozen elephant trunk repair for acute DeBakey type I dissection. J Thorac Cardiovasc Surg. 2013;145:S197–201.CrossRefGoogle Scholar
  29. 29.
    Schoenhoff FS, Schmidli J, Eckstein FS, Berdat PA, Immer FF, Carrel TP. The frozen elephant trunk: an interesting hybrid endovascular-surgical technique to treat complex pathologies of the thoracic aorta. J Vasc Surg. 2007;45:597–9.CrossRefGoogle Scholar
  30. 30.
    Kouchoukos NT, Masetti P, Mauney MC, Murphy MC, Castner CF. One-stage repair of extensive chronic aortic dissection using the arch-first technique and bilateral anterior thoracotomy. Ann Thorac Surg. 2008;86:1502–9.CrossRefGoogle Scholar
  31. 31.
    LeMaire SA, Carter SA, Coselli JS. The elephant trunk technique for staged repair of complex aneurysms of the entire thoracic aorta. Ann Thorac Surg. 2006;81:1561–9.CrossRefGoogle Scholar
  32. 32.
    Svensson LG, Kim KH, Blackstone EH, Alster JM, McCarthy PM, Greenberg RK, et al. Elephant trunk procedure: newer indications and uses. Ann Thorac Surg. 2004;78:109–16.CrossRefGoogle Scholar
  33. 33.
    Schepens MA, Dossche KM, Morshuis WJ, van den Barselaar PJ, Heijmen RH, Vermeulen FE. The elephant trunk technique: operative results in 100 consecutive patients. Eur J Cardiothorac Surg. 2002;21:276–81.CrossRefGoogle Scholar
  34. 34.
    Safi HJ, Miller CC 3rd, Estrera AL, Villa MA, Goodrick JS, Porat E, et al. Optimization of aortic arch replacement: two-stage approach. Ann Thorac Surg. 2007;83:S815–8.CrossRefGoogle Scholar
  35. 35.
    Etz CD, Plestis KA, Kari FA, Luehr M, Bodian CA, Spielvogel D, et al. Staged repair of thoracic and thoracoabdominal aortic aneurysms using the elephant trunk technique: a consecutive series of 215 first stage and 120 complete repairs. Eur J Cardiothorac Surg. 2008;34:605–14.CrossRefGoogle Scholar
  36. 36.
    Fann JI, Dake MD, Semba CP, Liddell RP, Pfeffer TA, Miller DC. Endovascular stent-grafting after arch aneurysm repair using the “elephant trunk”. Ann Thorac Surg. 1995;60:1102–5.CrossRefGoogle Scholar
  37. 37.
    Roselli EE, Subramanian S, Sun Z, Idrees J, Nowicki E, Blackstone EH, et al. Endovascular versus open elephant trunk completion for extensive aortic disease. J Thorac Cardiovasc Surg. 2013;146:1408–16.CrossRefGoogle Scholar
  38. 38.
    Kitagawa A, Greenberg RK, Eagleton MJ, Mastracci TM, Roselli EE. Fenestrated and branched endovascular aortic repair for chronic type B aortic dissection with thoracoabdominal aneurysms. J Vasc Surg. 2013;58:625–34.CrossRefGoogle Scholar
  39. 39.
    Greenberg R, Eagleton M, Mastracci T. Branched endografts for thoracoabdominal aneurysms. J Thorac Cardiovasc Surg. 2010;140:S171–8.CrossRefGoogle Scholar
  40. 40.
    Svensson LG. Options for exposure: from minimal access to total aortic replacement. In: Coselli JS, LeMaire SA, editors. Aortic arch surgery: principles, strategies and outcomes. Hoboken, NJ: Wiley-Blackwell; 2008. p. 102–3.Google Scholar
  41. 41.
    Roselli EE, Sepulveda E, Pujara AC, Idrees J, Nowicki E. Distal landing zone open fenestration facilitates endovascular elephant trunk completion and false lumen thrombosis. Ann Thorac Surg. 2011;92:2078–84.CrossRefGoogle Scholar
  42. 42.
    Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008;85:S1–41.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Heart and Vascular Institute, Cleveland ClinicClevelandUSA

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