Print this pageThe Hybrid Elephant Trunk Procedure: A Single Stage Repair of an Ascending, Arch, and Descending Thoracic Aortic Aneurysm
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Ali Azizzadeh, MD, Anthony L. Estrera, MD, Eyal E. Porat, MD, Kenneth R. Madsen, MD, Hazim J. Safi, MD.
University of Texas Health Science Center, Houston, TX, USA.
BACKGROUND: Treatment of extensive aortic aneurysms traditionally requires a staged surgical approach. We report a case of simultaneous repair of the ascending, transverse arch, and descending thoracic aorta using a hybrid procedure.
METHODS: A 71-year-old woman was referred to our center for treatment of an extensive aortic aneurysm. A CT angiogram demonstrated a 6 cm ascending and a 7 cm descending thoracic aneurysm (Figure 1). After preoperative workup, the patient underwent a single stage repair. Through a median sternotomy, the ascending and transverse aortic arch was repaired using a 30 mm Dacron tube graft with cardiopulmonary bypass, profound hypothermia, circulatory arrest, and retrograde cerebral perfusion. A modified elephant trunk technique was used in the proximal descending thoracic aorta. Next, an endovascular repair of the descending thoracic aorta was performed using the TAG device (WL Gore, Flagstaff, AZ) placed in an antegrade fashion thru a side branch of the ascending graft. Two devices were placed, a 31mm x 15 cm distal piece, followed by a 34 mm x 20 cm proximal graft (Figure 2). Angiographic guidance thru the femoral approach was used to deploy the device inside the elephant trunk. The descending thoracic aortic aneurysm was successfully excluded without any evidence of endoleak or extravasation. The left subclavian and celiac arteries remained patent.
RESULTS: The patient tolerated the procedure well. The early postoperative course was complicated by hypotension. The patient developed delayed paraplegia on the morning of postoperative day #1. A cerebrospinal fluid drainage catheter was placed. The patient regained complete neurological function later that day. She was discharged home neurologically intact two weeks postoperatively.
CONCLUSION: Simultaneous repair of the ascending and descending thoracic aorta using the hybrid technique is an alternative to the traditional staged procedure in selected patients with extensive aortic aneurysms. The long term durability of these combined reconstructions remains unknown. Further research regarding the role of cerebrospinal fluid drainage in this setting is warranted. 
