title: Elephant trunk procedure: newer indications and uses.
abstract: BACKGROUND
  The elephant trunk procedure is used for extensive aortic aneurysms. We evaluated its safety, newer indications, and influence of second-stage completion on survival.
  
  
  METHODS
  Records were reviewed for 94 consecutive patients (age 67 +/- 11 years, 47% men) who underwent the procedure between November 1990 and February 2003. The trunk was implanted as an extension of the ascending aorta and arch graft in 83 of 94 (88.3%) patients, distal arch graft in 8 of 94 (8.5%) patients, and in 3 distal to the left subclavian artery (3 of 94 patients [3.2%]). Aortic dissection was present in 37 (39.4%) patients and Marfan syndrome was present in 7 (7.4%). Twenty-three were reoperations (24.5%). In 9 patients, the trunk procedure was adjunctive in preparation for the second operation. In 15 patients, the anastomosis was completed between the left subclavian and common carotid arteries. Coronary artery bypass was performed in 36 (38.4%) and aortic valve operation in 55 (58.5%; 20 root sparing repairs, 16 composite grafts and 19 replacements) patients.
  
  
  RESULTS
  There were two early 30-day in-hospital deaths (2.1%) and 5 permanent strokes (5.3%). Eleven died before the second-stage procedure. Forty-seven (57%) underwent second-stage procedures; 40 by thoracotomy and 7 by stent graft insertion, including 2 thoracoabdominal aneurysm repairs with visceral bypasses before stent grafting with 4 early deaths (8.5%). Five-year survival was 34% without a second-stage procedure versus 75% 3-year survival with it.
  
  
  CONCLUSIONS
  With a current total of 142 elephant trunk procedures, we found it is safe and should be used more with initial cardiac surgery before descending or thoracoabdominal aorta repair.
authors.affiliation: Center for Aortic Surgery, Marfan Syndrome and Connective Tissue Disorders Clinic and Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA. svenssl@ccf.org
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.forename: Kyung-Hwan
authors.initials: KH
authors.lastname: Kim
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
authors.forename: Joan M
authors.initials: JM
authors.lastname: Alster
authors.forename: Patrick M
authors.initials: PM
authors.lastname: McCarthy
authors.forename: Roy K
authors.initials: RK
authors.lastname: Greenberg
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.forename: Richard S
authors.initials: RS
authors.lastname: D'Agostino
authors.forename: Bruce W
authors.initials: BW
authors.lastname: Lytle
authors.forename: Delos M
authors.initials: DM
authors.lastname: Cosgrove
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D000784:Aortic Dissection / Q000209:etiology / Q000601:surgery; D001011:Aorta / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D001014:Aortic Aneurysm / Q000209:etiology / Q000601:surgery*; D001021:Aortic Valve / Q000601:surgery; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D017536:Carotid Artery, Common / Q000601:surgery*; D001026:Coronary Artery Bypass; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008382:Marfan Syndrome / Q000150:complications; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D011183:Postoperative Complications / Q000209:etiology; D012086:Reoperation; D012189:Retrospective Studies; D020521:Stroke / Q000209:etiology; D013348:Subclavian Artery / Q000601:surgery*; D015996:Survival Rate