1. How I would want my Elephant Trunk Procedure to be done.
Prof Dr med. Malakh Shrestha
Chief Staff Surgeon and Director of Aortic Surgery
Cardio-thoracic, Transplantation and Vascular Surgery Hannover Medical School

2. Disclosures Consultant work not relevant for this presentation.
Consultant Vascutek Terumo Edwards Lifesciences Medtronic Sorin Biomedica
Consultant work not relevant for this presentation.

3. “Elephant Trunk Technique“
Stage 1
1. Aneurysm:15th March 1982
2. CADA: 28th October 1983
3. AADA: 22nd May 1989
Modifications in Classical Elephant Trunk
Borst HG et al. Extensive aortic replacement using the ‚elephant trunk prosthesis‘
Thorac Cardiovasc Surg 1983; 31 (1): 37-40

4. The second stage completion is inevitable!
METHODS:
From March 1982 to March 2012, 179 patients (112 males, age 56.4 ± 12.6 years) received an ET procedure
(91 aneurysms, 88 dissections (47 acute)).
The cerebral protection was done either by deep (till 1999) or moderate hypothermic circulatory arrest and
selective antegrade cerebral perfusion (SACP, after 1999).
RESULTS:
Among AADA Patients, the 30-day mortality during the first-stage operation was 32% (15/47)
Peri-operative stroke was 17% (n = 8/47).
Postoperative recurrent nerve palsy was present in 13% (8/47).
The second stage completion is inevitable!

5. Hannover Medical School: ET (1982-2015) n=191; FET (2001-2015), n=224.

6. Aortic arch surgery doesn‘t always result in death !
Aortic Rupture
Ischaemia/ Malperfusion:
-Myocardial
-Cerebral: stroke
-Visceral
Intra-operative Bleeding
Myocardial failure (?Long X-clamp time)
Multi-organ failure

7. Good judgment comes from experience and experience comes from bad judgment.

8. Hannover Concept Core temperature: 25°C
Bilateral cold selective antegrade cerebral perfusion (22-24°C)
‘Beating Heart‘ arch Surgery
Branched graft for aortic arch
Minimize Lower Body ischaemia
CSF Drainage
CO2 Sufflation
FET

9. Selective Antegrade Cerebrale Perfusion
Bachet J, Guilmet D, Goudot B, Dreyfus GD, Delentdecker P, Brodaty D, Dubois C
Antegrade cerebral perfusion with cold blood: a 13-year experience.
Ann Thorac Surg Jun;67(6):1874-8; discussion

10. Is BGT better than en-block technique for total aortic arch replacement?
Ann Thorac Surg Jun;77(6):
Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch.
Di Eusanio M, Schepens MA, Morshuis WJ, Dossche KM, Kazui T, Ohkura K, Washiyama N, Di Bartolomeo R, Pacini D, Pierangeli A.
Spielvogel 2005

15. Conclusion Olympics Motto Aortic arch repair Citius, Altis, Fortius!
(Higher, Faster, Further)
Safer, Simpler, Reproducible!

16. Nepal Earthquake: Please Help!