Surgical “Elephant Trunk” Arch Replacement with a Branched Arch Prosthesis: Two Alternative Operative Techniques

Background: Elephant trunk repair of the aortic arch cannot be performed with a branched prosthesis. We conceived two different modifications of the original technique to perform an arch replacement with a branched graft, while arranging an adequate landing zone for a subsequent TEVAR, without the need of dedicated material. Methods: Eight consecutive patients underwent arch replacement with one of our techniques. Five were emergency patients with acute aortic dissection, and 3 suffered chronic expansive disease. The “modified elephant trunk” includes a separate anastomosis of an endo-luminal prosthetic segment in the descending aorta. Subsequently, the branched arch prosthesis is anastomosed to the distal aortic stump with the attached trunk. In the “prophylactic debranching”, a tail is left on the distal end of the arch prosthesis, so that the branches for the supra-aortic vessels will remain displaced proximally, allowing a “zone 1” available for landing. Results: Three patients experienced transient cerebral deficits (1 TIA and post-operative delirium in 2 cases), 1 required re-operation for bleeding and 2 needed prolonged intubation. One died for multi-organ failure. Conclusion: Both techniques proved to be easily reproducible, and allow an adequate landing zone for a subsequent endovascular procedure, while keeping the advantages of using a tetra-furcated prosthesis. They are a viable alternative in case a hybrid prosthesis cannot be implanted.