Asian Cardiovasc Thorac Ann 2002;10:374-375
© 2002 Asia Publishing EXchange Pte Ltd
Simplified Elephant Trunk Graft Technique for Aortic Arch Replacement
Shinji Miyamoto, MD,
Tetsuo Hadama, MD,
Hirofumi Anai, MD,
Hidenori Sako, MD,
Tomoyuki Wada, MD,
Iwata Eriko, MD,
Hirotsugu Hamamoto, MD
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Department of Cardiovascular Surgery Oita Medical University Oita, Japan
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For reprint information contact: Shinji Miyamoto, MD Tel: 81 97 586 6732 Fax: 81 97 586 6739 email: smiyamot{at}oita-med.ac.jp Department of Cardiovascular Surgery, Oita Medical University, 1-1 Hasama-machi, Oita 879-5593, Japan.
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ABSTRACT
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We refined the elephant trunk graft to facilitate and reinforce the distal anastomosis in aortic replacement operations. A cuff is created in a single four-branch graft, which is used for the distal anastomosis; the trunk below the cuff is inserted into the distal aortic stump. This method is feasible for repairing extensive aortic aneurysm with a fragile wall and for treating acute aortic dissection where thromboocclusion of the remaining false lumen is desired.
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INTRODUCTION
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The elephant trunk graft originally was developed to facilitate the second stage of aortic replacement operations. We have refined the technique using a single four-branch graft and used it not only to facilitate second-stage operations but also to strengthen the distal anastomosis, which is the most critical maneuver in aortic arch replacement. Our technique prevents blood leakage from the anastomosis into the false lumen and facilitates thromboocclusion of the false lumen in aortic dissection.
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TECHNIQUE
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The graft is prepared while the patient is being cooled and the aneurysm is being exposed. The graft size used is based on the diameter of the distal aorta as measured by computed tomography or transesophageal echocardiography. The distal end of the prosthesis, a four-branch graft impregnated with gelatin, is pushed back into itself, and a hem is made by sewing the inner and outer walls together 1 cm from the new end (Figure 1
). The inside end is then pulled out from the prosthesis, turning the hem into a 1-cm cuff. The position of the cuff depends on how deep the distal aortic stump is. Usually, the cuff is created 5 cm from the last branch of the graft. The trunk after the cuff is 5 cm in length.
Cardiopulmonary bypass is established by cannulation of the right subclavian artery, the femoral artery, and the right atrium. The patient is cooled to a rectal temperature of 20°C. Under selective cerebral perfusion and systemic circulatory arrest, the aorta is transected and the aneurysm excised. Cardiac arrest is achieved by selective antegrade cold blood cardioplegia. To create the distal anastomosis, about 12 stay sutures are inserted through a Teflon felt strip placed around the end of the distal aortic stump and through the stump, as in aortic valve replacement. These sutures are then inserted through the cuff of the graft (Figure 2A). After tying the graft down and pushing its trunk into the aortic stump, the anastomosis is secured with a 3/0 continuous suture (Figure 2B). Systemic perfusion is resumed, and the femoral cannula is switched to graft perfusion. The proximal portion of the graft is anastomosed to the proximal aortic stump, and the brachiocephalic branches are reconstructed.
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Figure 2. (A) About 12 stay sutures are inserted through a Teflon felt strip, the distal aortic stump, and the cuff of the graft. (B) After tying the stay sutures, the anastomosis is secured with a 3/0 continuous suture.
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DISCUSSION
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From June 1995 to July 2000, we performed 72 aortic replacements, and the simplified elephant trunk graft was used in 24 cases, including 10 cases of acute dissection. A fragile distal aortic wall was the primary surgical indication in half of our patients. Seven of the 10 cases of acute dissection had a false lumen in the descending aorta, which was expected to be closed by thromboocclusion promoted by the graft. In 5 cases, this technique was used so that the trunk could serve as the proximal stump for the second-stage operation. Operation time, the duration of extracorporeal circulation, crossclamping time, and the duration of distal circulatory arrest were 482 ± 62, 254 ± 41, 127 ± 35, and 79 ± 19 minutes, respectively. The stem sizes of the grafts used were 22 mm (8 patients), 24 mm (12 patients), and 26 mm (4 patients). There were 3 deaths. One patient was unconscious when she was transferred to the operating room and became brain dead after surgery. Another patient, who had preexisting liver cirrhosis, developed hepatic failure and died 6 months after the operation. The third patient developed methicillin-resistant Staphylococcus aureus mediastinitis and died of sepsis 6 months postoperatively. The trunk in the descending aorta was fully patent in all the patients, except for one patient with acute dissection, in which a discrepancy of 25 mm Hg was found between the blood pressures in the upper arm and the lower limb because of constriction of the trunk in a small lumen.
Borst and colleagues1,2 created the elephant trunk graft to repair extensive aortic aneurysm as the first stage of a two-stage operation. In the second stage, the residual aneurysm of the descending aorta was replaced. Ando’s team3 used the elephant trunk technique in cases of acute aortic dissection to ensure thromboocclusion of the false lumen. In our series, satisfactory thromboocclusion of the false lumen in the descending aorta was achieved in all patients who had a patent trunk. We began to use stay sutures prior to insertion of the continuous suture after we experienced bleeding from the anastomosis made with a 3/0 continuous suture alone. Securing the graft to the stump with stay sutures facilitates insertion of the continuous suture. Unlike the original elephant trunk technique, which involves the insertion of a tube graft into the descending aorta, there is no fear of bleeding from the anastomosis in our technique with the creation of a cuff. Previously, using a different technique of graft preparation, we used only knitted Dacron grafts because of their elasticity.4 However, with the present technique, a cuff can be created easily in any type of prosthesis, including woven Dacron graft, which we are now using.
The simplified elephant trunk graft reduces hemorrhagic complications and promotes thrombotic closure of the false lumen in the descending aorta. However, this technique is contraindicated when the distal aorta is small and does not allow the graft to open fully.
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REFERENCES
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- Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg
1983;31:37–40.[Medline]
- Borst HG, Frank G, Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg
1988;95:11–3.[Abstract]
- Ando M, Takamoto S, Okita Y, Morota T, Matsukawa R, Kitamura S. Elephant trunk procedure for surgical treatment of aortic dissection. Ann Thorac Surg
1998;66:82–7.[Abstract/Free Full Text]
- Hadama T, Mori Y, Shigemitsu O, Miyamoto S, Anai H, Sako H, et al. Postoperative dilation of gelatin impregnated knitted Dacron prostheses and technical contrivance as reversed-end insertion anastomosis. Jpn J Vasc Surg
1997;6:399–404.
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ABSTRACT
INTRODUCTION
