Commentary: Should we freeze the elephant trunk with or without stents?

Abstract

In this issue of the Journal, Neri and colleagues report their experience of arch replacement using their institutionally developed multibranch collared elephant trunk (ET) graft, known as the Siena graft. Between 2002 and 2020, arch replacement with the Siena graft was performed in 146 patients, including 37.6% with either an acute or a chronic dissection and 62.3% with diffuse aneurysmal disease. The 30-day mortality was 10.9%, the stroke rate was 5.4%, and paraplegia was seen in 1 patient (0.6%). Eleven patients died before the second-stage procedure. The second-stage operation was performed using an open surgery approach in 16 patients (14.2%) and an endovascular approach in 97 patients (85.8%). Among the patients undergoing endovascular second-stage completion, 72 (74.2%) were treated with standard straight stent grafts, using a single unit in 30 patients, with a total mean aortic coverage length of 182 mm (range, 154-214 mm). The rate of paraplegia in the patients with second-stage thoracic endovascular aortic repair (TEVAR) completion with branch grafts was comparable to that in patients operated on with an open approach but significantly higher than that in patients treated with a straight TEVAR. The ET concept as proposed by Borst and colleagues in 1983 was designed to facilitate a second-stage procedure by avoiding circulatory arrest and minimizing nerve injury during the second-stage descending aortic replacement.