Aortic arch replacement: the conventional 'elephant trunk' technique.

Pathology of the aorta starting into the ascending aorta or aortic arch and extending downstream into the descending thoracic or thoracoabdominal aorta requiring surgical therapy, can be treated in two steps. At the first stage, via median sternotomy, the ascending aorta and arch are repaired, if necessary in combination with the aortic root or other cardiac interventions (such as bypass grafting or mitral valve repair). During this stage a free-floating extension of the arch prosthesis, the so-called elephant trunk, is left behind in the proximal descending aorta. Later, at the second stage via left thoracotomy, thoracophrenolaparatomy or endovascular repair, the descending aorta or thoracoabdominal aorta can be replaced. The most important advantage of leaving behind an elephant trunk is the avoidance of a difficult and hazardous dissection in the region of the distal aortic arch where arterial, venous, nervous, bronchial, gastro-intestinal and lymphatic structures cross. Doing so, the risk of damage to one of these structures can be completely avoided.