Objective: We performed total arch replacement (TAR) with the elephant trunk (ET) technique in two groups of patients. In one group, the distal end of a distal arch aneurysm was located at a point below the tracheal bifurcation. The other group required total arch replacement for acute type A aortic dissection. We reviewed the operative and long-term results of this procedure. Methods: During the period 2004–2012, we performed TAR with the ET technique in 27 patients with a true distal arch aneurysm and in 13 patients with acute type A aortic dissection. Since 2007, multidetector computed tomography has been used in all patients with a distal arch aneurysm (n = 15) to identify the Adamkiewicz artery (AKA). Results: There was one (2.5%) operative death within 30 days of the operation. The average length of the ET for all patients was 11.4 cm (7–22 cm). Paraplegia occurred in 4 (27%) of 15 patients in whom the ET was > 15 cm, whereas no paraplegia occurred in 25 patients in whom the ET was < 12 cm (p < 0.01). All 4 of the patients who developed paraplegia had a distal arch aneurysm, with no AKA detected. In contrast, no paraplegia developed in patients in whom the AKA was detected and preserved. Among the patients with a distal arch aneurysm, thromboexclusion around the ET and shrinkage of the aneurysm occurred in 16 (76.2%) of 21 patients in whom thromboexclusion was expected. In the patients with acute type A aortic dissection, the length of the ET ranged from 7 to 10 cm. Complete thrombosis of the false lumen was obtained in two patients and partial thrombosis of the false lumen to the level of T8 (T7–T12) in 8 patients. There was no thrombosis of the false lumen in three patients. Conclusions: TAR with ET effectively repaired distal arch aneurysms in patients in whom the distal end of the aneurysm was deeply located. Although thromboexclusion and shrinkage of the aneurysm could be expected with this technique, the risk of paraplegia was high when the ET was > 15 cm. Patients with acute type A aortic dissection exhibited good thrombosis of the false lumen with no paraplegia when the ET measured 7–10 cm.

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