Hybrid Management of a Giant Aortic Arch and Descending Thoracic Aortic Aneurysm Using Elephant Trunk Technique and Thoracic Endovascular Aortic Repair: A Case Report

Kumar N et al | DOI: 10.65188/nurexus.1064

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Journal of MedVerse Research & Practice

ISSN: 3107-4278

Staged Hybrid Repair of Giant Aortic Arch and Descending Thoracic

Aortic Aneurysms Using Elephant Trunk and TEVAR

Dr. Nivetha Kumar, Dr. Kushbu Ravi

Associate Professor, Professor

Department of Cardiothoracic and Vascular Surgery

Kasturba Medical College (KMC), Manipal.

Email ID: nivethakumar84@gmail.com

Submission Date: 28.12.2025

Accepted Date:25.01.2026

Published Date: 31.01.2026

DOI: 10.65188/nurexus.1064

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: Extensive thoracic aortic aneurysms involving the aortic arch and descending thoracic aorta represent

one of the most complex entities in cardiovascular surgery. Conventional open repair is associated with significant

perioperative morbidity, especially in elderly patients with multiple comorbidities. Hybrid strategies combining open

arch repair with staged endovascular treatment have emerged as a viable alternative in carefully selected patients.

Case Presentation: A 64-year-old hypertensive male with a chronic smoking history and chronic obstructive

pulmonary disease presented with progressive dyspnoea. Imaging revealed giant aneurysmal dilatation of the aortic

arch and descending thoracic aorta, along with an associated left common iliac artery aneurysm. A staged hybrid

approach was planned. Stage I involved total arch replacement with deployment of an elephant trunk graft. Stage II

consisted of thoracic endovascular aortic repair to exclude the descending thoracic aortic aneurysm. The

postoperative course was complicated by prolonged ventilatory requirement necessitating tracheostomy and a

transient generalized tonic–clonic seizure, both of which resolved with appropriate management. The patient

recovered well and was discharged in stable condition.

Conclusion: This case illustrates that staged hybrid repair using the elephant trunk technique followed by TEVAR

provides an effective and relatively safe treatment option for giant thoracic aortic aneurysms in high-risk patients.

Careful patient selection, meticulous planning, and multidisciplinary management are essential for optimal outcomes.

Keywords: Aortic arch aneurysm; Descending thoracic aortic aneurysm; Elephant trunk technique; Hybrid aortic

repair; TEVAR

Introduction

Thoracic aortic aneurysms constitute a significant proportion of aortic pathology and are associated with

considerable morbidity and mortality if left untreated [1]. Aneurysms involving the aortic arch and

descending thoracic aorta are particularly challenging due to their anatomical complexity, proximity to

major supra-aortic vessels, and the need for cerebral and spinal cord protection during intervention [2].

Giant thoracic aortic aneurysms, though rare, carry a substantially increased risk of rupture, dissection,

thromboembolism, and compressive symptoms involving the airway and esophagus [3]. Traditional open

surgical repair remains the definitive treatment; however, it is associated with prolonged cardiopulmonary

bypass, deep hypothermic circulatory arrest, and increased risk of neurological and respiratory

complications, particularly in patients with advanced age or significant comorbid conditions [4].

The elephant trunk technique was developed to facilitate staged repair of extensive thoracic aortic disease

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by creating a distal landing zone for subsequent intervention [5]. With the advent of thoracic endovascular

aortic repair, hybrid strategies combining open arch replacement and endovascular exclusion of the

descending thoracic aorta have gained widespread acceptance [6]. These approaches aim to reduce

operative trauma while maintaining durable aneurysm exclusion. We report a detailed case of a giant aortic

arch and descending thoracic aortic aneurysm managed successfully using a staged hybrid approach,

highlighting diagnostic challenges, perioperative decision-making, postoperative complications, and

outcomes in the context of contemporary evidence.

Case presentation

A 64-year-old male presented with gradually progressive dyspnoea on exertion over a period of several

months. The dyspnoea was insidious in onset and had worsened to New York Heart Association functional

class II–III at presentation. There was no associated orthopnoea or paroxysmal nocturnal dyspnoea. The

patient denied chest pain, palpitations, syncope, hemoptysis, dysphagia, hoarseness of voice, or symptoms

suggestive of cerebrovascular insufficiency. The patient had a long-standing history of systemic

hypertension for more than 15 years, which was irregularly controlled on oral antihypertensive medications.

He was a chronic smoker with a significant smoking history exceeding three decades. He was a known case

of chronic obstructive pulmonary disease and was on regular inhaled bronchodilator therapy. There was no

prior history of aortic surgery, connective tissue disorders, vasculitis, or traumatic chest injury. Family

history was negative for aortic aneurysms, sudden cardiac death, or hereditary aortopathies.

On physical examination, the patient was conscious, oriented, and hemodynamically stable. Blood pressure

recordings showed controlled systolic and diastolic values on admission. Oxygen saturation was mildly

reduced on room air, consistent with underlying pulmonary disease. Cardiovascular examination revealed

normal heart sounds without murmurs, rubs, or gallops. There were no signs of heart failure such as raised

jugular venous pressure, peripheral edema, or hepatomegaly. Respiratory system examination demonstrated

bilateral expiratory wheeze and prolonged expiratory phase, consistent with chronic obstructive pulmonary

disease. Peripheral pulses were palpable and symmetrical in all extremities, with no evidence of limb

ischemia or blood pressure differential.

Baseline laboratory investigations, including complete blood count, renal function tests, liver function tests,

coagulation profile, and inflammatory markers, were within normal limits. There was no biochemical

evidence of infection or systemic inflammatory disease. Arterial blood gas analysis showed mild

hypoxemia without significant hypercapnia. A chest radiograph revealed marked widening of the

mediastinum with abnormal aortic contour, raising suspicion of thoracic aortic pathology. Subsequently,

contrast-enhanced computed tomography angiography of the chest, abdomen, and pelvis was performed

for definitive evaluation. Imaging demonstrated a giant aneurysmal dilatation involving the aortic arch with

extension into the descending thoracic aorta. The aneurysm was large enough to exert mass effect on

adjacent mediastinal structures. The aortic arch branches were displaced but patent. No features of acute

dissection, intramural hematoma, or contained rupture were identified. In addition, computed tomography

angiography revealed an associated aneurysm of the left common iliac artery. The abdominal aorta and

visceral branches were otherwise unremarkable.

Pulmonary evaluation confirmed moderate to severe chronic obstructive pulmonary disease, placing the

patient at increased risk for prolonged mechanical ventilation following extensive open thoracic surgery.

Cardiac evaluation did not reveal significant coronary artery disease or valvular pathology. Given the

extensive involvement of the thoracic aorta, the size of the aneurysm, and the presence of significant

pulmonary comorbidity, the case was discussed in detail in a multidisciplinary heart team meeting

comprising cardiothoracic surgeons, vascular surgeons, anesthesiologists, cardiologists, pulmonologists,

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and radiologists. Considering the high operative risk associated with a single-stage extensive open repair

and the need to minimize physiological stress, a staged hybrid approach was deemed the most appropriate

treatment strategy. The patient and family were counseled extensively regarding the nature of the disease,

the planned staged hybrid repair, potential risks including neurological and respiratory complications, and

the need for long-term surveillance. Written informed consent was obtained prior to proceeding with

surgical intervention.

Management and Surgical Technique

Stage I: Total arch replacement with elephant trunk technique

Following comprehensive preoperative evaluation and multidisciplinary planning, the patient was taken up

for elective open surgical repair. General anesthesia was administered with invasive hemodynamic

monitoring, including arterial and central venous pressure monitoring. Neuromonitoring with near-infrared

spectroscopy was employed to continuously assess cerebral oxygenation throughout the procedure. A

standard median sternotomy was performed. After careful pericardial opening, cardiopulmonary bypass

was established using central arterial and venous cannulation. Systemic cooling was initiated to facilitate

cerebral protection. Selective antegrade cerebral perfusion was employed to maintain adequate cerebral

blood flow during arch reconstruction. This strategy was chosen to minimize the risk of neurological injury

while allowing safe replacement of the aortic arch.

Following cross-clamping and controlled circulatory arrest, the aneurysmal aortic arch was opened and

excised. A prosthetic vascular graft was used to replace the aortic arch, with meticulous reconstruction of

the supra-aortic vessels. An elephant trunk segment was intentionally deployed into the descending thoracic

aorta and secured distally. This free-floating graft extension was positioned to provide a stable proximal

landing zone for the planned second-stage endovascular intervention. Hemostasis was achieved carefully,

and the patient was gradually rewarmed and weaned off cardiopulmonary bypass without hemodynamic

instability. After satisfactory restoration of cardiac rhythm and stable cerebral oximetry readings, the

sternum was closed in layers, and the patient was transferred to the cardiac intensive care unit for

postoperative management.

Figure 1: Imaging CT in Ascending & descending aorta

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Postoperative course after stage I

The immediate postoperative period was notable for prolonged ventilatory dependence, attributed primarily

to the patient’s underlying chronic obstructive pulmonary disease and reduced pulmonary reserve. Despite

aggressive pulmonary care and physiotherapy, extubation was not feasible in the early postoperative period,

and a tracheostomy was performed to facilitate prolonged ventilatory support and gradual weaning. During

the postoperative recovery phase, the patient experienced a transient generalized tonic–clonic seizure.

Urgent neurological assessment was undertaken. Computed tomography of the brain did not reveal any

evidence of acute ischemia, intracranial hemorrhage, or space-occupying lesion. Electrolyte abnormalities

were excluded. The seizure was managed with antiepileptic medication, following which no further seizure

activity was observed. The patient remained neurologically intact on serial examinations. Gradual clinical

improvement was noted over the subsequent days, with stabilization of respiratory parameters and

hemodynamic status. After successful ventilator weaning through the tracheostomy, the patient was

transferred to the step-down unit. Once adequate recovery from the first stage was achieved, he was

reassessed for completion of the second stage of repair.

Stage II: Thoracic endovascular aortic repair

After an interval of clinical stabilization, the patient underwent the planned second-stage thoracic

endovascular aortic repair. The procedure was performed under fluoroscopic guidance. Vascular access

was obtained, and angiographic evaluation confirmed appropriate positioning and patency of the previously

deployed elephant trunk graft. A thoracic stent graft was advanced and deployed with the elephant trunk

serving as the proximal landing zone. Care was taken to ensure optimal alignment and complete coverage

of the aneurysmal segment of the descending thoracic aorta. Completion angiography demonstrated

successful exclusion of the aneurysm with no evidence of endoleak, graft migration, or compromise of

major branch vessels. The procedure was well tolerated, and the patient was transferred to the intensive

care unit for routine post-endovascular monitoring.

Figure 2: Hemiarch and Innominate Artery Reconstruction

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Outcome and follow-up

Following the second stage of repair, the patient demonstrated steady clinical improvement. Respiratory

function improved significantly, allowing gradual downsizing and eventual decannulation of the

tracheostomy. The patient remained neurologically stable, with no recurrence of seizures or focal deficits.

Postoperative imaging using contrast-enhanced computed tomography angiography confirmed satisfactory

positioning of both the surgical graft and the endovascular stent graft. The aortic arch and descending

thoracic aorta were effectively excluded from circulation, with no evidence of endoleak, graft kinking, or

distal malperfusion.

The patient was discharged in stable condition with advice for strict blood pressure control, continuation of

bronchodilator therapy, complete smoking cessation, and regular follow-up. A structured surveillance plan

was instituted, including periodic clinical evaluation and serial imaging to monitor graft integrity and detect

any late complications. At follow-up, the patient remained asymptomatic with good functional recovery,

highlighting the effectiveness of the staged hybrid approach in managing extensive thoracic aortic

aneurysms in high-risk individuals.

Discussion

Giant aneurysms involving the aortic arch and descending thoracic aorta represent one of the most complex

and high-risk entities in thoracic aortic surgery. Their management requires careful assessment of aneurysm

morphology, patient comorbidities, and procedural risk. The present case illustrates the successful

application of a staged hybrid strategy in a patient with significant pulmonary comorbidity, highlighting

contemporary principles in the management of extensive thoracic aortic disease.Thoracic aortic aneurysms

often remain clinically silent until they reach a critical size or produce compressive symptoms. Large

aneurysms involving the aortic arch and descending thoracic aorta are associated with a substantially

increased risk of rupture, dissection, thromboembolism, and sudden death. Johnston and Soltesz [7]

emphasized that giant thoracic aneurysms carry particularly poor natural history outcomes and warrant

timely elective intervention. Involvement of the arch further increases complexity due to the need for

cerebral protection during surgical repair.

Extensive single-stage open repair of combined arch and descending thoracic aneurysms requires prolonged

cardiopulmonary bypass, deep hypothermic circulatory arrest, and extended operative times, all of which

contribute to increased perioperative morbidity and mortality. These risks are amplified in patients with

advanced age or significant systemic comorbidities. Bavaria et al. [8] demonstrated that hybrid arch repair

strategies significantly reduce operative mortality and neurological complications in appropriately selected

high-risk patients. Similarly, Shrestha et al. [9] reported favorable early and mid-term outcomes with staged

hybrid approaches compared to extensive open reconstruction.

In the present case, the presence of chronic obstructive pulmonary disease and limited pulmonary reserve

made a single-stage open repair particularly hazardous. A staged hybrid approach was therefore chosen to

minimize physiological stress while achieving effective aneurysm exclusion. The elephant trunk technique

remains a cornerstone in the staged management of extensive thoracic aortic disease. By creating a free-

floating graft segment within the descending thoracic aorta during arch replacement, it facilitates

subsequent distal repair and reduces manipulation of aneurysmal tissue. Phan et al. [10] highlighted the

continued relevance of the elephant trunk technique in the modern era, particularly in combination with

endovascular technology. The availability of thoracic endovascular aortic repair has further enhanced the

utility of this technique by allowing less invasive completion of distal aneurysm exclusion, as demonstrated

by Moulakakis et al. [11].

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Neurological injury remains one of the most feared complications of aortic arch surgery. Advances in

cerebral protection strategies, including selective antegrade cerebral perfusion and continuous

neuromonitoring, have significantly reduced the incidence of permanent neurological deficits. Etz et al.

[12] emphasized that optimized cerebral protection is critical in reducing stroke and cognitive dysfunction

following arch surgery. The transient generalized tonic–clonic seizure observed in the present patient

underscores the neurological vulnerability associated with complex aortic procedures. Importantly,

neuroimaging revealed no structural brain injury, and the episode resolved completely with medical

management. Werner and Czerny [13] reported that transient neurological events may occur after hybrid

aortic repair and do not necessarily correlate with permanent cerebral injury when promptly recognized and

treated.

Pulmonary complications are common following major thoracic aortic surgery, particularly in patients with

pre-existing lung disease. Czerny et al. [14] demonstrated that hybrid repair strategies may be especially

advantageous in patients with compromised pulmonary reserve by reducing operative trauma and

facilitating staged recovery. In this case, prolonged ventilatory dependence necessitated tracheostomy,

which ultimately enabled successful weaning and recovery. Early anticipation and proactive management

of respiratory complications were essential in achieving a favorable outcome.

Recent evidence supports the use of staged hybrid repair in selected patients with extensive thoracic aortic

aneurysms. Krishnan et al. [15] reported acceptable early mortality and reduced neurological complications

following staged hybrid thoracic aortic repair. Comparative studies by Yamabe et al. [16] demonstrated

that limited arch replacement combined with endovascular completion is associated with shorter operative

times and comparable mid-term outcomes when compared with more extensive open procedures.

The favorable postoperative course and effective aneurysm exclusion observed in the present case are

consistent with these findings and further support the role of hybrid strategies in complex thoracic aortic

pathology.

Successful management of extensive thoracic aortic disease requires a multidisciplinary approach involving

cardiothoracic surgeons, vascular surgeons, anesthesiologists, intensivists, pulmonologists, and

radiologists. Akintoye et al. [17] emphasized that outcomes of complex thoracic aortic surgery are

significantly improved in high-volume centers with coordinated multidisciplinary care. Long-term

surveillance is equally critical, as late complications such as endoleaks, graft migration, or disease

progression in untreated segments may occur. Borger et al. [18] highlighted the importance of lifelong

imaging follow-up and aggressive risk factor modification following thoracic aortic interventions.

Limitations: This report represents a single-case experience and therefore, may not be generalizable to all

patients with extensive thoracic aortic aneurysms. Outcomes are influenced by patient selection, anatomical

complexity, and institutional expertise. Nevertheless, the case provides valuable insight into contemporary

hybrid management strategies for high-risk patients.

Summary

This case report describes the successful staged hybrid management of a giant aortic arch and descending

thoracic aortic aneurysm in a high-risk patient with significant pulmonary comorbidity. The patient

underwent elective total arch replacement with deployment of an elephant trunk graft, followed by thoracic

endovascular aortic repair to exclude the descending thoracic aortic aneurysm. Despite postoperative

respiratory and transient neurological complications, timely multidisciplinary management resulted in

complete recovery and effective aneurysm exclusion. This case highlights the importance of individualized

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treatment planning, the role of the elephant trunk technique in facilitating staged repair, and the value of

hybrid strategies in reducing operative risk while maintaining durable outcomes in complex thoracic aortic

pathology.

Conclusion

Giant aneurysms involving the aortic arch and descending thoracic aorta present substantial surgical

challenges, particularly in patients with significant comorbidities. This case demonstrates that a staged

hybrid approach combining total arch replacement with the elephant trunk technique and subsequent

thoracic endovascular aortic repair can be performed safely and effectively in carefully selected patients.

Meticulous preoperative planning, advanced cerebral protection strategies, proactive management of

respiratory complications, and coordinated multidisciplinary care are essential for favorable outcomes.

Lifelong imaging surveillance and aggressive risk factor modification remain critical to ensure long-

term graft durability and prevent late complications following hybrid thoracic aortic repair.

Conflict of interest: Nil

Source Of Fund: Nil

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