Asian Cardiovasc Thorac Ann 2004;12:168-170
© 2004 Asia Publishing EXchange Ltd
Modified Elephant Trunk Technique for Distal Reconstruction of Ragged Descending Thoracic Aorta
Masato Nakajima, MD,
Kouji Tsuchiya, MD,
Hidenori Inoue, MD,
Kensuke Kobayashi, MD,
Koki Takizawa, MD
Department of Cardiovascular Surgery, Yamanashi Central Hospital, Yamanashi, Japan
For reprint information contact: Masato Nakajima, MD Tel: 81 55 253 7111 Fax: 81 55 253 8011 Email: m-nakajima2a{at}ych.pref.yamanashi.jp Department of Cardiovascular Surgery, Yamanashi Central Hospital, 1-1-1 Fujimi, Kofu City, Yamanashi 400-0027, Japan.
 |
ABSTRACT
|
|---|
We present a modified elephant trunk technique with a novel indication for aortic arch aneurysm with ragged, undilated descending thoracic aorta. Our modification is simple and effective for minimizing bleeding from the distal anastomosis and has the possibility of preventing distal embolization of atheromatous plaque by ensuring sufficient contact area between the graft and the aortic wall.
|
INTRODUCTION
|
|---|
The elephant trunk procedure was introduced by Borst et al. for a staged approach in extensive aortic disease.1 This technique has been applied in various situations including distal aortic dissection, entire aortic replacement, proximal aortic aneurysm, proximal aortic dissection, and Marfan’s syndrome.2–4 We have modified this technique and present a novel indication for aortic arch aneurysm with ragged, undilated descending thoracic aorta (Figure 1
) that minimizes bleeding from the distal anastomosis and potentially prevents distal embolization of atheromatous plaque.
View larger version (95K):
[in this window]
[in a new window]
|
Figure 1. Computed tomography showing aneurysm of the distal aortic arch and undilated ragged descending thoracic aorta.
|
|
|
OPERATIVE TECHNIQUE
|
|---|
The aortic arch was approached through a median sternotomy in all patients. Cardiopulmonary bypass was instituted with right atrial drainage and ascending aortic return with right upper pulmonary vein venting. The brachiocephalic, left carotid, and left subclavian arteries were carefully dissected and looped with umbilical tape. Meanwhile, the patient was cooled down, the aneurysm surface carefully dissected and circulatory arrest was induced after rectal temperature reached 25°C. The aneurysm was incised and the three neck vessels were perfused selectively at 20°C using a soft balloon cannula. The descending thoracic aorta was carefully transected and its inner dimensions were examined so as to select a graft that properly fit the ragged aortic wall. This step was very important for minimizing bleeding and preventing the hematoma formation between a floating graft and the aortic wall that would otherwise result from minor leakage. Four horizontal mattress stitches were placed, while applying a Tefl on felt strip on the outside of the transected aorta, and passed through the side of a four-branched arch graft (Hemashield Gold® woven double velour, Meadox, USA) (Figure 2A). About 3 to 5 cm of the graft were carefully located inside the descending thoracic aorta and the four stitches were tied down (Figure 2B). A circular ridge was constructed and used to form a continuous, over-and-over distal anastomosis (Figure 2C). Additional Tefl on felt pledgets with mattress stitches were applied all around the anastomosis for reinforcement. After the distal anastomosis, systemic perfusion was started from the 4th branch of the graft with rewarming and the proximal anastomosis was performed. The left subclavian, left carotid, and brachiocephalic arteries were reconstructed in order.
From February 2002 to July 2002, eight patients underwent total aortic arch replacement with this technique. The group was comprised of six men and two women whose mean age was 74.1 years (69 to 77 years). The underlying aortic pathology was atherosclerotic aneurysm in all patients. Two patients required coronary artery bypass grafting concomitantly. Operation time, cardiopulmonary bypass time, selective cerebral perfusion time, aortic cross clamp time, and open distal time were 303 ± 34, 173 ± 22, 93 ± 13, 91.5 ± 18 and 52 ± 9 min, respectively. Intraoperative bleeding amounted to 840±354 mL. The mean duration of mechanical ventilation, intensive care unit stay, and hospitalization were 112±246 hours, 6.125 ± 10.5 days and 31.25 ± 15.9 days, respectively. There were no hospital deaths, but multiple lacuna cerebral infarctions occurred in one patient, requiring long-time ventilatory support with tracheotomy. There were no bleeding or peripheral embolic complications.
|
DISCUSSION
|
|---|
The elephant trunk procedure is employed in aneurysms and chronic dissections of the aortic arch and descending thoracic aorta involving the respective downstream portions of the vessels, for staged surgical approach.1,2 The advantages of this technique are widely accepted, having been applied in various situations including distal aortic dissection, entire aortic replacement, proximal aortic aneurysm, proximal aortic dissection, and Marfan’s syndrome.3–6 Furthermore, technical modifications such as distal reconstruction using horizontal interrupted buttressed sutures and use of a single four-branched graft with a "collar" and a long "elephant trunk", have been reported.7,8
We indicated this modification for aortic arch aneurysm with ragged, undilated descending thoracic aorta. We believe this is very useful for minimizing bleeding from the distal anastomosis because the continuity of the woven graft is maintained and because the graft is expanded by the blood pressure so as to fit more snugly to the aortic wall. Technically, the distal anastomosis is not easy, but good visibility can be achieved by retracting four pairs of stitches, and the ridge made by these stitches provides a good suture line. Once the distal reconstruction is completed, graft to graft anastomosis is not required.
In addition, it was considered this modification potentially has the advantage of preventing distal embolization of atheromatous plaque by creating an adequate and effective contact area between the graft and ragged aortic wall. In all of our cases, no complications related to distal embolization occurred and postoperative computed tomography showed good coaptation between the graft and the aortic wall. However, as this is a small series of patients without comparing data and long term follow-up, further investigation is required for referring to this advantage.
In cases with a small descending thoracic aorta, the use of this technique would be limited because the available graft sizes exceed 20 mm. However, even in cases with descending thoracic aortic aneurysm requiring a second stage operation, we consider our modification to be useful.
|
ACKNOWLEDGMENTS
|
|---|
We thank Dr Fuminaga Suetsugu for providing fine illustrations.
|
REFERENCES
|
|---|
- 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]
- Heinemann MK, Buehner B, Jurmann MJ, Borst HG. Use of the "elephant trunk technique" in aortic surgery. Ann Thorac Surg
1995;60:2–6.[Abstract/Free Full Text]
- Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Card Surg
1992;7:301–12.[Medline]
- Schepens MA, Dossche KM, Morshuis WJ, van den Barselaar PJ, Heijmen RH, Vermeulen FE. The elephant trunk technique: operative results in 100 consecutive patients. Eur J Cardiothorac Surgery
2002;21:276–81.
- Safi HJ, Miller CC 3rd, Estrera AL, Huynh TT, Rubenstein FS, Subramanian MH et al. Staged repair of extensive aortic aneurysms: morbidity and mortality in the elephant trunk technique. Circulation
2001;104:2938–42.[Abstract/Free Full Text]
- Kanagasabay RR, Matalanis G. A novel approach to reconstructing the distal aortic arch. Eur J Cardiothorac Surgery
2002;21:544–45.
- Kuki S, Taniguchi K, Masai T, Endo S. A novel modification of elephant trunk technique using a single four-branched arch graft for extensive thoracic aortic aneurysm. Eur J Cardiothorac Surgery
2000;18:246–8.
TOP
ABSTRACT
INTRODUCTION
