The most versatile and useful appendage on earth

At first glance, this paper by Shrestha et al. [1] is a standard analysis and evaluation of a single-centre experience using the elephant trunk technique for total arch replacement. About one-third of the operations were followed by a second-stage procedure, mostly a descending thoracic replacement, only in 11 cases by a thoracoabdominal repair. The focus of this paper clearly lies in the first surgical step. When studying this paper more thoroughly, it becomes obvious that it is not just an average description and common analysis of the surgical results as we can find almost monthly in all well-respected cardiovascular journals. It is much more than that. It is a wonderful piece of history describing the evolution of the elephant trunk technique starting with its introduction three decades ago by its inventor Hans Borst. Needless to say that the idea of inserting a free-floating vascular prosthesis into the downstream aorta and that in doing so, avoid re-entering in a surgical field that is crowded with major vascular, bronchial, neurological, lymphatic and gastrointestinal structures almost merits the Nobel prize in cardiovascular surgery, if it existed. Technical modifications were later introduced by some outstanding pioneers in cardiovascular surgery (such as Crawford and Svensson) in order to facilitate the technique and to reduce complication rate. Very often, these modifications were just simplifications, which is of course characteristic of the influence of great surgeons. Of special importance are the alterations concerning cerebral protection: for 17 years, deep hypothermic circulatory arrest was the mainstay and in 1999 antegrade selective cerebral perfusion was introduced and is actually a main pillar to success. It is not a coincidence that this paper now originates from the cradle where the elephant trunk was born. If you do not possess an atlas of cardiovascular surgery, this paper will tell you the ins and outs based on the evolution of the surgical technique. For example, how you can avoid trunk impaction, how to deal with the dissection membrane in chronic situations, what should be the optimal length of the trunk, how to avoid left recurrent nerve damage …. These are all fundamental aspects that should be respected in order to obtain optimal results. Concerning these results, it should be stressed that 25% of the patients received the elephant trunk for an acute Type A dissection. Very few of us are able to perform this under these dangerous circumstances. Moreover, 30% were redos. It is obvious that these two items certainly have influenced the outcome in a negative way. Another important point that had a major impact on the results was the learning curve. As the evolution of the elephant and its trunk took millions of years, we may not expect that the surgical technique can be made perfect in 30. That is why the results should be interpreted with caution and be seen in perspective. For an elephant, its trunk is absolutely vital and indispensable; without the elephant trunk technique, no matter in which form, cardiovascular surgery certainly would loose tremendous allures and look massively different.