The reversed and bidirectional elephant trunk technique in the treatment of complex aortic aneurysms

Background: The elephant trunk technique with a free-floating vascular pros thesis was originally developed to facilitate a subsequent operation on the downstream aorta. We present here our experience with further developments of this technique, which we call the reversed elephant trunk and bidirecti onal elephant trunk: Methods: Between January 1, 1995, and December 31, 2000, 505 adult and adol escent patients underwent operations of the thoracic aorta. A reversed elep hant trunk procedure in 13 patients and a bidirectional elephant trunk proc edure in 4 patients was performed to facilitate either subsequent proximal or proximal and distal aortic replacement. Nine patients underwent subseque nt aortic arch replacement with the reversed prosthetic portion after a mea n interval of 8 +/- 5.5 months, and 2 patients received distal extension by use of the distal portion of the free-floating graft. Results: There was no hospital mortality (30 days) in this small group of p atients, and no patient had aortic rupture, malperfusion caused by the tech nique itself, or thromboembolic complications during the waiting interval b etween the first and the second operations. Five patients are still being o bserved until the contiguous aortic size is large enough to require an oper ation, and one 74-year-old patient declined a second-stage operation. Conclusion: The reversed and bidirectional elephant trunk techniques are in teresting options that may be suitable for patients having complex abnormal ities of the thoracic aorta and thoracoabdominal aorta when the proximal po rtion of the descending aorta has to be replaced before the aortic arch wit h or without the ascending aorta or the distal descending aorta with or wit hout the thoracoabdominal aorta.