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,

How I would want my Elephant Trunk Procedure to be done.

Prof Dr med. Malakh ShresthaChief Staff Surgeon and Director of Aortic SurgeryCardio-thoracic, Transplantation and Vascular SurgeryHannover Medical School

Cardio-Thoracic,Transplantation and Vascular Surgery

Disclosures

Consultant Vascutek TerumoEdwards LifesciencesMedtronicSorin Biomedica

Consultant work not relevant for this presentation.

Cardio-Thoracic,Transplantation and Vascular Surgery

Stage 1

Borst HG et al. Extensive aortic replacement using the ‚elephant trunk prosthesis‘ Thorac Cardiovasc Surg 1983; 31 (1): 37-40

Modifications in Classical Elephant Trunk

“Elephant Trunk Technique“

1. Aneurysm:15th March 19822. CADA: 28th October 19833. AADA: 22nd May 1989

Cardio-Thoracic,Transplantation and Vascular Surgery

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!

Cardio-Thoracic,Transplantation and Vascular Surgery

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

Cardio-Thoracic,Transplantation and Vascular Surgery

Aortic arch surgery doesn‘t always result in death !

Aortic Rupture Ischaemia/ Malperfusion:

-Myocardial-Cerebral: stroke-Visceral

Intra-operative BleedingMyocardial failure (?Long X-clamp time)Multi-organ failure

Cardio-Thoracic,Transplantation and Vascular Surgery

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

Cardio-Thoracic,Transplantation and Vascular Surgery

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

Hannover Concept

Cardio-Thoracic,Transplantation and Vascular Surgery

Selective Antegrade Cerebrale Perfusion

Bachet J, Guilmet D, Goudot B, Dreyfus GD, Delentdecker P, Brodaty D, Dubois CAntegrade cerebral perfusion with cold blood: a 13-year experience.Ann Thorac Surg. 1999 Jun;67(6):1874-8; discussion 1891-4.

Cardio-Thoracic,Transplantation and Vascular Surgery

Spielvogel 2005

Is BGT better than en-block technique for total aortic arch replacement?

Ann Thorac Surg. 2004 Jun;77(6):2021-8.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.

Cardio-Thoracic,Transplantation and Vascular Surgery

Cardio-Thoracic,Transplantation and Vascular Surgery

Cardio-Thoracic,Transplantation and Vascular Surgery

Cardio-Thoracic,Transplantation and Vascular Surgery

Cardio-Thoracic,Transplantation and Vascular Surgery

Citius, Altis, Fortius!(Higher, Faster, Further)

Safer, Simpler, Reproducible!

Olympics Motto

Aortic arch repair

Conclusion

Cardio-Thoracic,Transplantation and Vascular Surgery

Nepal Earthquake: Please Help!