Hybrid Elephant Trunk Procedure

Elephant procedure

Anatomic Illustration of Two-Staged Procedure

The hybrid elephant trunk procedure is one commonly used complex aortic operation recommended for patients who have extensive aortic aneurysms as well as several coexisting medical conditions, particularly respiratory problems. The elephant trunk procedure is a two-stage procedure used to treat extensive aneurysms involving both the ascending aorta and aortic arch, and the descending thoracic or thoracoabdominal aorta.

The elephant trunk procedure was used to treat a 65-year-old woman who had a leaking aneurysm, severe emphysema, and a leaky aortic valve.

In the first stage, Cleveland Clinic surgeons used a traditional incision in the sternum to replace the aortic valve, ascending aorta and arch, and placed an “elephant trunk” graft that hangs in the descending aorta. Shaped in a tubular form, the elephant trunk graft is made from Dacron, which is a synthetic material that is used to replace or repair blood vessels. The aorta was then wrapped at the diaphragm, and superior mesenteric arteries were bypassed.

During the second-stage procedure, a stent graft was placed by using an endovascular approach through the femoral artery to connect the elephant trunk to the lower wrap graft.

In other cases, an additional incision may be required to place an extra graft to another part of the aorta.

While a high-risk staged procedure, the current techniques used by Cleveland Clinic surgeons has resulted in a 98% survival rate for 142 patients having the first stage of the elephant trunk procedure and 92% survival for the second stage. Late survival was excellent with very low risk of reoperation.



Stage 1 Elephant Trunk Procedure

Stage 1: Elephant Trunk Procedure for complex aortic aneurysm

Stage 2: Elephant Trunk Procedure

Stage 2: Elephant Trunk Procedure for complex aortic aneurysm

The Valve-sparing Aortic Root Procedures

What is an aortic root aneurysm?

Aortic Root Aneurysm

Occurring at the aortic root (the section of the aorta that is attached to the heart), an aortic root aneurysm can cause a life-threatening condition called aortic dissection. In this condition, blood flows through a tear in the inner layer of the aorta, causing the layers to separate. Blood flow becomes interrupted and causes the arterial wall to burst.

How is it treated?

The David’s valve-sparing aortic root replacement method is a surgical treatment for aortic root aneurysms. With this method, the aneurysm is repaired while the patient’s own aortic valve is preserved. If the patient’s aortic valve is diseased or cannot be used during the surgery, a bioprosthetic valve may be used.

What is the Modified David’s Reimplantation Procedure?

The Modified David’s Reimplantation Procedure, developed by Dr. Lars G. Svensson, Director of the Center for Aortic Surgery, Cardiovascular Marfan & Connective Tissue Clinic at Cleveland Clinic, is used to treat an aortic root aneurysm. While the David’s valve-sparing aortic root replacement method has many benefits, it is also a technically difficult procedure. Dr. Svensson’s Modified David’s procedure helps the surgeon determine the appropriately sized aorta graft, maintain the left ventricular outflow tract (the passageway out of the left ventricle), and improve outcomes when using the valve-sparing method.

With the Modified David’s approach, the surgeon uses a special piece of equipment called a Hegar’s dilator to ensure the outflow tract size of the aortic root is maintained, a more normal aortic root is established, and valve function is improved.

Cleveland Clinic Surgeons have performed over 120 Modified David Reimplantation procedures with no deaths and 97% freedom from reoperation at 10 years.

Endovascular Repair

Cleveland Clinic surgeons are now able to treat some thoracic and thoracoabdominal aneurysms with a promising, new procedure called an endovascular stent graft.

What is an endovascular stent graft?

Endovascular means that surgery is performed inside the body using thin, long tubes called catheters. Through small incisions in the groin, the catheters are used to guide a stent graft through the blood vessels to the site of the aneurysm.

An endovascular stent graft is a small, wire mesh tube (also called a scaffold) that reinforces the weak spot in the aorta. By sealing the area tightly with the artery above and below the aneurysm, the graft allows blood to pass through it without pushing on the aneurysm.

What are the benefits of endovascular repair?

Endovascular repair of thoracic aneurysms is generally less painful and has a lower risk of complications than traditional open-chest surgery because the incisions are smaller.

The use of endovascular stent grafts is particularly beneficial for those patients who are not candidates for open-chest surgery, due to the risks it presents.

While a new and evolving approach, Cleveland Clinic surgeons are paving the way for successful use of endovascular repair of thoracic aneurysms, with careful attention to technique and type of stent graft used through various clinical trials.

Ascending and Descending Aortic Aneurysm Repair

Complex aortic procedures treat patients with aneurysms that need replacement of the aorta from the aortic valve down to the aortic bifurcation (where the aorta separates into two).

Axillary artery

The axillary artery is used to provide ongoing blood perfusion to organs during aortic aneurysm repair and when atherosclerosis (plaque) is present in the ascending aorta.

Cleveland Clinic surgeons offer an innovative approach for ascending and descending aortic aneurysm repair through a single operation that uses combined incisions in the chest and mid-abdomen. During the procedure, the axillary artery (the part of the main artery of the arm) is used to provide ongoing blood perfusion to the body’s organs, and is also used when atherosclerotic plaque is present in the ascending aorta.

Protecting the Brain

A recent study of 403 patients who underwent ascending and aortic arch minimally invasive operations over a 10-year period at Cleveland Clinic showed that blood conservation during surgery is beneficial for the prevention of stroke and neurocognitive outcome.

By following a preoperative protocol that includes patients donating 1 unit of autologous (their own) blood and fresh frozen plasma weekly before surgery (usually 3 to 4 units in total), and donating platelets 3 to 6 days before surgery to be used during the procedure, there was a 98.5% 30-day survival with only 2.0% occurrence of stroke.

While studies are ongoing as to the direct link that blood conservation has on brain function following replacement of the entire aortic arch or an endarterectomy (surgical removal of the lining of an artery), evidence from Cleveland Clinic studies and ongoing experience supports its use.

Last reviewed by a Cleveland Clinic medical professional on 04/29/2019.

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