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Cardiac, Thoracic, and Vascular Surgery, Inc, 3009 N. Ballas Rd, Suite 360C, St. Louis, MO 63131
(Email: ntkouch{at}aol.com).
LeMaire and colleagues [1] report an extensive experience with the elephant trunk procedure for staged repair of complex aneurysms of the entire thoracic aorta and conclude that this procedure yields acceptable short-term and long-term outcomes.
Their rationale for use of the procedure rests principally with the benefits achieved during the distal repair as follows: avoiding dissection near the distal arch anastomosis, a shorter aortic clamp time for the graft to graft anastomosis, and eliminating the need for clamping of the aorta proximal to the left subclavian artery, which reduces the risk of stroke and paraplegia. Their results with the second stage procedure (ie, low rates of operative mortality, stroke, paraplegia, and renal failure) lend support to this hypothesis.
Balanced against these results however are complications and outcomes that are relatively unique to the elephant trunk procedure and warrant serious consideration. These include a relatively high prevalence of left recurrent nerve injury resulting in vocal cord paralysis (25%, 37 patients), aortic rupture early after the operation (4 patients), and aortic rupture during the interval before the second stage of the operation (3 known deaths and possibly more among the remaining 29 patients, because the cause of death was unknown in most cases). Only 61% (79 out of 148 patients) underwent the second-stage aortic repair. These results are not unique to this series. Similar complication rates and outcomes have been reported among other large series reporting use of the elephant trunk procedure [2, 3].
Suitable alternatives to the elephant trunk technique are available and perhaps they should be used more frequently. These include the single-stage approach, which is applicable to patients whose disease is confined to the thoracic aorta. The authors cited two references that reported substantial morbidity and mortality with this procedure. However, they did not provide references for two more recent series that report outcomes comparing favorably with the results of their study [4, 5]. Performing the distal aortic anastomosis to a more distal segment of the descending thoracic aorta would substantially reduce the prevalence of left recurrent nerve injury (2% in our series of 46 patients with single-stage repair) [5]. An end-to-end anastomosis to a more normal-sized segment of the descending aorta would also eliminate the risk of rupture that exists when the aortic graft is sutured to a dilated or dissected segment that is not completely transected, as is often the case with the elephant trunk procedure. This would not preclude a subsequent distal procedure, if indicated, and would be the definitive procedure for some patients.
Another concern relates to the substantial number of patients (39%) who did not undergo the second procedure. Some patients simply refused, and this has been noted in other series [2, 3]. In the present series, the distal disease was described as not being substantial enough to require immediate operation in some of the patients, and the elephant trunk procedure was done in anticipation of later development of aneurysmal disease that would require intervention. Given that aortic rupture has been consistently observed in all of the large reported series and the risk of left recurrent nerve injury is not insignificant, should such patients undergo the elephant trunk procedure?
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  S. A. LeMaire and J. S. Coselli Reply Ann. Thorac. Surg., February 1, 2008; 85(2): 691 - 692. [Full Text] [PDF]
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