Single-Stage Treatment of Extensive Aortic Pathology Using the Frozen Elephant Trunk Procedure


  • Petar Risteski Department of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
  • Vasil Papestiev University Clinic for Cardiac Surgery, Skopje, North Macedonia
  • Stefanija Hadzievska University Clinic for Cardiac Surgery, Skopje, North Macedonia
  • Nadica Mehmedovic University Clinic for Cardiac Surgery, Skopje, North Macedonia
  • Nikola Lazovski University Clinic for Cardiac Surgery, Skopje, North Macedonia
  • Zan Zimbakov University Clinic for Cardiology, Skopje, North Macedonia
  • Venko Filipce University Clinic for Neurosurgery, Skopje, North Macedonia
  • Marjan Shokarovski University Clinic for Cardiac Surgery, Skopje, North Macedonia



Frozen elephant trunk, Aortic arch, Aneurysm, Aorta, aortic dissection


Background: Extensive pathology involving the aortic arch and descending aorta traditionally has been treated with two open procedures. We report our institutional experience with a single stage frozen elephant trunk procedure for treatment of extensive aortic pathology.

Methods: Between June 2018 and October 2019, nine patients (eight males, 89%, mean age 61 ± 6 years) with extensive aortic pathology were operated using the frozen elephant trunk procedure. Five (56%) patients underwent primary operation for chronic arch and proximal descending aneurysm in two (22%) patients, chronic type B aortic dissection in two (22%) patients and penetrating aortic ulcer in one (11%) patient. The other four (44%) patients received reoperative surgery for chronic post-dissection aneurysms. For organ protection during the aortic arch procedure, we used selective antegrade cerebral perfusion and mild systemic hypothermia at 28°C.

Results: Early mortality was not observed. A single (11%) patient developed focal stroke. Unilateral vocal cord palsy was present in two (22%) patients. Spinal cord injury was not observed. Reexploration for bleeding was required in two (22%) patients. Prolonged ventilation, liver and kidney failure as well as cardiac morbidity were not observed. Two patients (22%) with anticipated Endoleak type Ib received TEVAR extension at follow up. Mid-term mortality was observed in two (22%) patients, due to pneumonia.

Conclusion: The frozen elephant trunk procedure can be used for a single-stage treatment of patients with extensive aortic pathology, due to chronic degenerative aneurysms or post-dissection aneurysms involving the aortic arch and the descending aorta, with acceptable mortality and morbidity.


Borst HG, Walterbusch G, Shaps D, et al. 1983. Extensive aortic replacement using “elephant trunk” prosthesis. Thorac Cardiovasc Surg 31:37-40.

Castrovinci S, Murana G, de Maat GE, et al. 2015. The classic elephant trunk technique for staged thoracic and thoracoabdominal aortic repair: long-term results. Thorac Cardiovasc Surg 149(2):416-22.

De Rango P, Cao P, Ferrer C, et al. 2014. Aortic arch debranching and thoracic endovascular repair. J Vasc Surg 59(1):107-14.

Doss M, Woehleke T, Wood JP, Martens S, Greinecker GW, Moritz A. 2003. The clamshell approach for the treatment of extensive thoracic aortic disease. J Thorac Cardiovasc Surg 126(3):814-7.

El-Sayed Ahmad A, Risteski P, Ay M, Papadopoulos N, Moritz A, Zierer A. 2019. Moderate hypothermic circulatory arrest (≥ 28°C) with selective antegrade cerebral perfusion for total arch replacement with frozen elephant trunk technique. Thorac Cardiovasc Surg 67(5):345-350.

Erbel R, Aboyans V, Boileau C, et al. 2014. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. European Heart Journal 35: 2873-2926.

Estrera AL, Sandhu HK, Miller CC, et al. 2014. Repair of extensive aortic aneurysms: a single center experience using elephant trunk technique over 20 years. An Surg 260(3):510-6

Etz CD, Plestis KA, Kari FA, et al. 2008 Staged repair of thoracic and thoracoabdominal aortic aneurysms using the elephant trunk technique: a consecutive series of 215 first stage and 120 complete repairs. Eur J Cardiothorac Surg 34:605-615.

Grabenwoger M, Alfonso F, Bachet J, et al. 2012. Thoracic Endovascular Aortic Repair TEVAR for treatment of aortic diseases: a position statement from European Association for Cardio-Thoracic Surgery EACTS and the European Society of Cardiology ESC, in collaboration with European Association of Percutaneous Cardiovascular Interventions EAPCI. EUR J Cardiothorac Surg 42(1);17-24.

Luehr M, Peterss S, Zierer A, Pacini D, et al. 2018. Aortic events and reoperations after elective aortic arch surgery: incidence, surgical strategies and outcomes. Eur j Cardiothorac Surg 1;53(3):519-524.

Preventza O, Price MD, Simpson KH, et al. 2015. Hemiarch and total arch surgery in patients with previous repair of acute type I aortic dissection. Ann Thorac Surg 100:833-9.

Risteski P, El-Sayed Ahmad A, Monsefi N, et al. 2017. Minimally invasive aortic arch surgery: Early and late outcomes Int J Surg 45 113-117.

Shrestha M, Bachet J, Bavaria J, et al. 2015. Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular Domain of EACTS. Eur J Cardiothorac Surg 47(5):759-69.

Shrestha M, Beckmann E, Krueger H, et al. 2015. The elephant trunk is freezing: The Hannover experience. J Thorac Cardiovasc Surg 149(5):1286-93.

Shrestha M, Martens A, Krüger H, et al. 2014. Total aortic arch replacement with the elephant trunk technique: single-center 30-year results. Eur J Cardiothorac Surg 45:289-96.

Zierer A, El Sayed Ahmad A, Papadopoulos N, et al. 2017. Fifteen years of surgery for acute type A dissection in moderate to mild systemic hypothermia Eur J Cardiothorac Surg 51 (1): 97-103.



How to Cite

Risteski, P., Papestiev, V., Hadzievska, S., Mehmedovic, N., Lazovski, N., Zimbakov, Z., Filipce, V., & Shokarovski, M. (2020). Single-Stage Treatment of Extensive Aortic Pathology Using the Frozen Elephant Trunk Procedure. The Heart Surgery Forum, 23(5), E606-E610.