Thread by @DrZeigler1

1/n Basically, if there is an arch aneurysm and a descending aneurysm, it’s pretty hard to get exposure to fix both. So, if you leave an “elephant trunk” behind, it dangles into the descending aneurysm. On return for DTA repair,

First described by Hans Borst in 1983.
#AortaEd

https://twitter.com/DrZeigler1/status/1369977735943184386

2/n When it’s time to do the descending aorta via left thoracotomy, you can easily clamp the free floating elephant trunk, and stretch it down past the aneurysm. Once the distal anastomosis is sutured in place, the aneurysm is excluded. Simple.

#AortaEd #Aneurysm #dtaa #TAAD

3/n Of course, with this approach, the patient still needs two highly invasive open operations.

Enter #TEVAR, in the early 1990s. First pioneered by Mike Dake, Scott Mitchell, and Craig Miller @StanfordCTSurg in 1992, these home-brewed devices were quickly refined.

4/n In 2003, Karch and Haverich described deployment of a custom built stent-graft through the opened arch into the descending aorta, under conditions of circulatory arrest. The “elephant trunk” was now frozen in place distally, completing seal and exclusion of the aneurysm!

5/n The whole procedure can be done through a sternotomy, or via via staged femoral access. In either case, one midline sternotomy treats the whole thoracic aorta.

The technique has been applied to #AorticDissection and #AorticAneurysm.

6/6 here, ascending and arch branches have been replaced. The divot past the LSCA (3rd pigtail mark) is the “elephant trunk” anastomosis. The ET extends 10cm. The TEVAR overlaps the ET by 5cm for good seal, but freezes it to aortic wall to exclude the aneurysm. #AortaEd