Complex aortic pathology, especially in patients having aneurysm involving the aortic arch and proximal descending aorta, has been approached with either a one-stage or two-stage procedure [1,2]. In the latter case, the aortic arch was replaced first, followed by the remaining affected aorta during the second operation 4 to 12 weeks later [1]. Both approaches presented technical challenges; the one-stage procedure due to its long duration and hypothermic circulatory arrest, and the two-stage procedure due to the need of a second operation, which sometimes required another period of circulatory arrest to perform anastomosis to the distal aortic arch. Moreover, the access to the distal aortic arch, usually via the left thoracotomy, was associated with surgical complications related to the densely adherent tissue surrounding the transverse aortic arch prosthesis and vital anatomical structures such as the pulmonary artery, left recurrent laryngeal and vagus nerves, and the esophagus [4].

In 1983, Borst introduced a significant modification to the two-stage technique. In two patients affected by aneurysms involving the ascending aorta, arch and descending aorta, the prosthesis was sutured to the proximal transected descending aorta downstream from the left subclavian artery during the first stage. This had been left, reaching antegradely into the descending aorta over 7 or 8 cm, giving the appearance of an ‘elephant trunk’. The second prosthesis was then sutured proximally to the first graft and descending aorta and employed to reconstruct the aortic arch. During the second stage performed a few weeks later, the remaining dilated descending aorta was replaced using the elephant trunk prosthesis for clamping and suturing another graft [3].

Soon thereafter, to avoid the risk of tearing the aorta along the fragile distal suture line during the first stage and to reduce the circulatory arrest time required to suture the additional graft in order to reconstruct the aortic arch, Svensson modified the original Borst technique. He inverted the tubular graft, placed it into the descending aorta, and sutured a double-layer head onto the descending aortic wall. The inner segment could then be retrieved and used for the arch reconstruction as usual, leaving an elephant trunk in the descending aorta. The modification allowed tightening of the distal suture line, a greater surface area between the graft and aortic wall, and reduction of circulatory arrest times, making one of the anastomoses redundant [5].

The presence of a significant interval of mortality between the two stages ranging from 3% to 13%, the fact that only 45% of patients who underwent the first-stage elephant trunk procedure returned for the second-stage completion, and the complications related to the second-stage procedure have convinced some surgeons to perform, whenever possible, the one-stage repair through the clamshell [6-8], trans-mediastinal [9] or left posterolateral thoracotomy approach [10].

However, the longer operation times associated with extensive one-stage or total replacements of the entire aorta [11,12], higher pulmonary complication rates ranging from 15% to 50%, the need to sacrifice both internal mammary arteries, the postoperative pain, and inability to extend resection to the segments downstream from the diaphragm have considerably limited their applicability and acceptance. At present, only one-stage repair is performed in a small number of centers.

To shorten the interim interval between the stages, other surgeons have propagated hybrid approaches with endovascular completion of the first-stage elephant trunk, implanting covered stent grafts in both the antegrade [13] and retrograde fashion [14-16]. This option has been considered particularly appealing, as the elephant trunk thus functions as a landing zone for such stent grafts.

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In our case, after a successful replacement of the ascending aorta and aortic arch, the patient underwent a second-stage procedure on postoperative day 20, which involved an endovascular stent graft insertion to the descending aorta where the elephant trunk functioned as a landing zone for the stent graft. As the largest commercially available aortic Dacron graft is 40 mm wide, in cases of very large aortic aneurysmal dimensions where the elephant trunk procedure is required, it might be technically difficult to perform anastomosis between the relatively small Dacron graft and a very large aortic aneurysm.

In this report, we have described a novel technique of “V” type aortoplasty of the proximal descending aorta in order to decrease the aortic aneurysmal dimension and to facilitate the performing of anastomosis between the Dacron graft and aortic aneurysm.