Navigating the two-stage elephant trunk procedure (CET): A nursing case study on postoperative vigilance and multidisciplinary care

Bharathi1*, Monisha1, Ramya2

1Registered Nurse, CTICU, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

2Nursing Supervisor Registered Nurse, CTICU, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

*Correspondence

Abstract

Background: Complex aortic aneurysms involving both the arch and descending aorta present significant surgical challenges. The Conventional Elephant Trunk (CET) procedure, a two-stage surgical approach, offers definitive repair but places patients at high risk for postoperative complications due to the extensive nature of the surgery and the patient’s comorbid burden.

Objective: To illustrate the complex nursing management of a patient undergoing a two-stage CET procedure, emphasizing the critical assessments and interventions required to detect and manage life-threatening complications, particularly in the interval between surgical stages.

Methods: This case study presents a 62-year-old male with a massive, multi-segment aortic aneurysm. It details his clinical course from the initial CET surgery through the secondary endovascular repair and subsequent recovery. The nursing care plan, focusing on hemodynamic, neurological, and respiratory systems, is analyzed.

Results: The patient successfully completed both stages of the repair. Key nursing contributions included the early identification of acute neurological decline post-second stage, proactive respiratory management to prevent failure, and coordinated rehabilitation efforts. These interventions were pivotal in stabilizing the patient and facilitating a safe transfer out of the intensive care unit.

Conclusion: The CET procedure, while lifesaving, demands a highly skilled nursing approach. Success hinges on the nurse’s ability to perform nuanced neurological assessments, implement aggressive pulmonary hygiene, and coordinate early mobilization to optimize patient outcomes in this high-acuity population.

Keywords: Aortic Aneurysm; Thoracic; Elephant Trunk Procedure; Postoperative Care; Nursing Assessment; Patient Care Planning

Introduction

The Elephant Trunk (ET) procedure is a sophisticated surgical technique reserved for patients with extensive aneurysmal disease of the thoracic aorta, involving the arch and the descending segment. The “classic” or Conventional Elephant Trunk (CET) is a planned two-stage procedure. The first stage, performed via median sternotomy, replaces the ascending aorta and aortic arch, leaving a segment of the graft (the “trunk”) suspended in the proximal descending aorta. This trunk serves as a landing zone for the second stage, which is often an endovascular repair (TEVAR) or a separate open thoracotomy to address the distal aneurysm. While the Frozen Elephant Trunk (FET), a hybrid single-stage approach, is gaining popularity, the CET remains a vital option. However, the two-stage nature of the CET introduces unique risks. The interval between stages is a period of high vulnerability, where the patient remains at risk for rupture of the residual aneurysm, as well as the typical complications of major cardiothoracic surgery. This case study underscores the critical role of the nurse in navigating this complex trajectory, from the immediate postoperative period after the first stage, through the high-risk second intervention, and into recovery.

Case presentation

Patient profile and history

Mr. X, a 62-year-old male, presented to the cardiothoracic surgery service. His medical history was significant for long-standing systemic hypertension, a 40-pack-year smoking history, and newly diagnosed type 2 diabetes mellitus. He presented with complaints of intermittent back pain and hoarseness, which prompted diagnostic imaging.

Diagnostic findings

A computed tomography (CT) angiogram revealed life-threatening aortic pathology:

  • A 9.8 cm fusiform aneurysm of the distal aortic arch and proximal descending thoracic aorta.
  • An 11 cm saccular aneurysm in the mid-descending thoracic aorta with a large mural thrombus.
  • Incidental findings included aortic valve sclerosis and occlusion of the celiac artery with collateral circulation.

The sheer size of these aneurysms (far exceeding the typical 5.5 cm surgical threshold) and their multi segmental nature necessitated a complex, staged surgical approach.

Surgical Course

Stage I: Conventional Elephant Trunk Procedure

On May 20, 2025, Mr. X underwent his first surgery. The procedure included:

ApproachMedian sternotomy.
Cardiopulmonary Bypass (CPB)Established with cooling to 22°C.
Cerebral ProtectionAntegrade cerebral perfusion (ACP) was used to maintain cerebral blood flow during arch repair, minimizing the risk of stroke.
RepairThe ascending aorta and arch were replaced with a 24 mm Siena Gel soft graft, with the distal end left free-floating in the descending aorta the "elephant trunk."
Additional ProcedureAn extra-anatomical bypass to the left axillary artery was performed to ensure upper extremity perfusion.

Stage II: Endovascular Completion

Four days later, on May 24, 2025, the second stage was performed. A trans catheter endovascular aortic repair (TEVAR) was conducted via femoral access. A Valiant Thoracic Stent Graft was deployed, extending from the elephant trunk graft to just above the celiac axis, successfully excluding the large thoracoabdominal aneurysm.

Nursing Management and Postoperative Course

The nursing care for Mr. X can be divided into three distinct phases, each with specific priorities.

Phase 1: Immediate Post-Stage I Recovery (POD 1-3) – The Foundation of Stability

Following Stage I, Mr. X was admitted to the Cardiovascular Intensive Care Unit (CVICU). The immediate goals were to support the transition from CPB, manage hemodynamics, and prevent early complications.

  • Hemodynamic Monitoring: Invasive arterial and central venous pressures were monitored continuously. The primary goal was to maintain a mean arterial pressure (MAP) between 70-80 mmHg. This range is critical: too low risks hypo perfusion of vital organs and the new graft; too high increases stress on the fresh suture lines and the risk of bleeding. The nurse titrated vasoactive medications (e.g., nitroglycerin for afterload reduction, vasopressin for blood pressure support) as per protocol.
  • Respiratory Management: Mr. J was initially mechanically ventilated. The nursing team employed a lung-protective strategy, monitoring peak and plateau pressures. Sedation was weaned according to a daily interruption protocol to allow for neurological assessment. He was successfully extubated to CPAP and then to 6 L/min oxygen via face mask by POD 2.
  • Neurological Vigilance: Hourly GCS and pupillary checks were performed. Once sedation was lifted, the nurse confirmed equal limb movement and strength, a baseline assessment crucial for detecting future spinal cord ischemia.
  • Drain and Wound Care: The mediastinal and pleural drains were closely monitored for output. A sudden increase could indicate hemorrhage. Output decreased to less than 50 mL over 6 hours by POD 1, allowing for safe drain removal. The sternal incision was assessed for signs of infection.

Phase 2: Post-Stage II Instability (POD 4-5) – A Sentinel Event

The second stage, while less invasive, carries its own risks, including embolic stroke and spinal cord ischemia from coverage of intercostal arteries. Within hours of returning to the ICU, the nursing team identified a sentinel change in Mr. J’s condition.

  • Assessment Finding: The nurse noted new-onset lower extremity weakness, hip instability, and loss of bladder control. Concurrently, Mr. X became acutely disoriented with confused speech. His vital signs remained stable, but the neurological changes were profound.
  • Nursing Diagnosis: Acute confusion and impaired physical mobility related to potential cerebral emboli or spinal cord ischemia secondary to TEVAR.
  • Intervention and Collaboration: The nurse’s immediate action was to perform a full neurological assessment and notify the surgical and critical care team’s stat. This prompt recognition triggered an urgent neurology consultation and an MRI of the brain and spine. The MRI revealed small embolic infarcts but no major stroke or spinal cord hematoma, suggesting a combination of micro emboli and possible spinal cord stunning.
  • Outcome: While alarming, the deficits were non-permanent. The nurse implemented a patient safety protocol, including frequent reorientation, a low-stimulus environment, and falls prevention measures.

Phase 3: Recovery and Rehabilitation (POD 5-10) – The Long Road Back

On POD 5, Mr. X developed acute respiratory distress, presenting with tachypnea (respiratory rate > 30), tachycardia, and oxygen desaturation to 88%. He was emergently re-intubated.

  • Assessment: Chest auscultation revealed diminished breath sounds and coarse crackles at the right base. A chest X-ray confirmed right lower lobe pneumonia.
  • Nursing Diagnosis: Ineffective airway clearance and impaired gas exchange related to ventilator-associated pneumonia and underlying smoking history.

Interventions

  • Aggressive Pulmonary Toilet: The nurse coordinated with respiratory therapy for frequent nebulized bronchodilators, chest physiotherapy (percussion and vibration), and suctioning. In-line spirometry was used to monitor lung mechanics.
  • Nutritional Support: Given the hyper metabolic state of sepsis and surgery, a consult to dietetics was placed. A high-protein, high-calorie enteral feeding regimen was initiated to support weaning from the ventilator and muscle repair.
  • Sedation Management: A light sedation protocol was used to allow for spontaneous breathing trials and maintain some circadian rhythm.
  • Mobilization: Once hemodynamically stable and extubated (POD 9), the focus shifted to recovery. The nursing team collaborated with physiotherapy to initiate a graded mobility program, beginning with bed exercises, progressing to sitting on the edge of the bed, and finally, ambulating with a walker.
  • Outcome: With aggressive intervention, Mr. X’s respiratory status improved. He was successfully transferred from the CVICU to the step-downward on June 1, 2025, with a plan for continued rehabilitation.

Discussion: The Indispensable Role of the Nurse

This case highlights three critical domains where nursing expertise directly impacted patient outcomes in a CET procedure:

Neurological Stewardship: The aortic arch and descending aorta are intimately related to cerebral and spinal cord perfusion. Nurses must possess a high index of suspicion for neurological complications, particularly after the second stage. Differentiating between delirium, embolic stroke, and spinal cord ischemia requires astute assessment skills. Our prompt recognition of limb weakness and confusion led to immediate imaging, ruling out a catastrophic event and allowing for appropriate supportive care.

Pulmonary Risk Mitigation: Mr. X’s significant smoking history placed him at extreme risk for postoperative pulmonary complications. The nursing team’s proactive approach early extubation, aggressive chest physiotherapy, and nutritional optimization were essential. When pneumonia did develop, the swift, coordinated response with respiratory therapy prevented progression to septic shock and multi-organ failure. This underscores the need for ventilator-associated pneumonia prevention bundles in this high-risk population.

Coordinating the Multidisciplinary Trajectory: The CET patient’s journey is not linear. It involves surgeons, intensivists, neurologists, physiotherapists, and dietitians. The bedside nurse is the constant, the central hub of communication and coordination. From initiating a neurology consult to ambulating the patient with a walker, the nurse ensures that all members of the team are working toward the unified goal of recovery, transforming the patient from a passive recipient of care to an active participant in their own rehabilitation.

Conclusion

The Elephant Trunk procedure, whether conventional or frozen, is a testament to the advancements in cardiothoracic surgery. However, this case demonstrates that the hardware of the procedure the grafts and stents is only half the story. The “software” of success is the vigilant, continuous, and holistic care provided by the nursing team. For the patient undergoing this lifesaving but arduous journey, the nurse is not just a caregiver, but the critical link between a complex surgical plan and a successful human recovery. The key takeaways for nursing practice are the imperative for meticulous neurological surveillance, an aggressive and proactive approach to respiratory care, and the seamless coordination of a multidisciplinary rehabilitation effort.

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