Surgical management of extensive arch pathologies involving the aortic arch, and the descending aorta remains a complex and challenging operation. The unique anatomy of the arch and descending aorta demands special attention to minimize complications to brain and distal organ function, particularly in individuals with an aneurysm or dissection that involves the aortic arch and extends to the proximal descending aorta.

The introduction of the elephant trunk technique by Borst and colleagues in 1983 promoted staged surgical repair of arch and distal aortic aneurysms. By extending a graft from the distal aortic arch into the proximal descending aorta (which gives rise to the eponymous ‘elephant trunk’ appearance), repair of descending aortic pathologies can be more easily accomplished either through a second-stage open surgical procedure or by using it as a proximal landing zone for endovascular stenting.

In the 1990s, development of new elephant trunk prostheses facilitated the treatment of aortic arch and proximal descending pathologies in a single operation while also minimizing complications associated with the conventional elephant trunk. These hybrid stent-graft prostheses (also known as the Frozen Elephant Trunk Procedure) encompass a covered stent sutured to the distal end of a conventional tube graft to provide expansive radial force on the distal portion of the elephant trunk. The combination of conventional surgery with endovascular techniques minimizes the need for a second procedure, while limiting residual patency of the false lumen and encouraging aortic wall remodelling.

Professor Yan performs the Frozen Elephant Trunk procedure, which provides the possibility of a single stage operation, addressing distal arch and proximal descending aortic pathologies. Compared to the staged approach, it has obvious advantages, with acceptable mortality and morbidity.

Video 1. This patient presented with a large distal arch and proximal descending aortic aneurysm (7 cm). He underwent a Total Arch Replacement and Frozen Elephant Trunk Procedure using the Thoraflex Hybrid Graft (Vascutek Terumo). The entire operation was performed via a hemi-sternotomy (half incision size). He was discharged home on postoperative day 6.