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Asian Cardiovasc Thorac Ann 1999;7:329-330
© 1999 Asia Publishing EXchange Pte Ltd

HOW TO DO IT

Modified "Elephant Trunk" Procedure for Type-A Aortic Dissection

Hitoshi Ogino, MD, Yuichi Ueda, MD, Keiji Matsubayashi, MD, Takuya Nomoto, MD

Department of Cardiovascular Surgery Tenri Hospital Nara, Japan
For reprint information contact: Hitoshi Ogino, MD Tel: 81 7436 35611 Fax: 81 7436 25576 Department of Cardiovascular Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara 632-8552, Japan.

   Abstract
TOP
 Abstract
Introduction
 Surgical Technique
 Discussion
 References
 
A modified "elephant trunk" procedure was successfully carried out in a 60-year-old female requiring double-barrel distal aortic anastomosis for chronic type-A aortic dissection. Initial rough fixation of the inserted graft to the descending aortic wall was followed by anastomosis of the graft to the descending aorta-to-arch graft with side-branches. Then aortic arch replacement was carried out with individual reconstruction of the three arch vessels.


   Introduction
TOP
 Abstract
 Introduction
Surgical Technique
 Discussion
 References
 
The "elephant trunk" procedure for multiple-stage surgery on an extensive aortic aneurysm obviates a proximal graft-to-aorta anastomosis in the second-stage of the operation.1–3 This is normally followed by aortic arch replacement with en bloc arch vessel reconstruction using a pulled-through graft. Conversely, individual arch vessel reconstruction is preferable in cases of severe pathology or dissection in the arch vessels. It is difficult to insert an arch graft with three or four side-branches into the "elephant trunk" graft. Therefore, an additional graft-to-graft anastomosis on the distal section is required. We employed a modified "elephant trunk" technique by anastomosing the inserted "elephant trunk" graft fixed roughly to the descending aorta-to-arch graft with four side-branches, to shorten the circulatory arrest time.


   Surgical Technique
TOP
 Abstract
 Introduction
 Surgical Technique
Discussion
 References
 
A 60-year-old female was referred for surgery 3 months after the onset of chronic type-A aortic dissection. Aortography demonstrated the origin of dissection in the arch and revealed that the superior and inferior mesenteric arteries arose from the false lumen, although other visceral arteries branched off the true lumen. Therefore, double-barrel aortic anastomosis on the distal section with replacement of the ascending aorta and the transverse arch was scheduled. Cardiopulmonary bypass was established with ascending aortic cannulation through the true lumen and bifurcated venous drainage. The patient was cooled for hypothermic circulatory arrest.4 During core cooling, 4 small grafts of 10 mm or 8 mm in diameter were anastomosed to a 26-mm Hemashield woven Dacron graft (Meadox Medical, Oakland, NY, USA) for individual arch vessel reconstruction and antegrade perfusion during cardiopulmonary bypass. At 18°C, hypothermic arrest was induced and retrograde cerebral perfusion through the superior vena cava was commenced.5 The ascending aorta was incised and a large intimal tear was found in the arch. Cardioplegia through the coronary orifices ensured smooth cardiac arrest. Extension of the dissection was found in the brachiocephalic artery. The ascending aorta and arch were excised completely. An 8-cm section of the thickened dissecting intima in the remaining descending aorta was excised. A 26-mm Hemashield graft of 6 cm in length was inserted into the descending aorta for an "elephant trunk" procedure. Three interrupted stitches of 3/0 polypropylene were used to roughly fix the graft to the descending aorta with a Teflon felt strip for reinforcement. The prepared graft with four small side-branches was anastomosed to the end of the descending aorta with the inserted graft using a 3/0 polypropylene running suture (Figure 1Go). The three arch vessels were reconstructed individually with the side-branches. The proximal part of the 26-mm graft was crossclamped and antegrade systemic perfusion was recommenced via a side-branch graft. The duration of hypothermic circulatory arrest was 57 minutes and the retrograde cerebral perfusion time was 49 minutes. During rewarming, proximal graft-to-aorta anastomosis was performed (Figure 2Go). No homologous blood transfusion was required. The patient recovered uneventfully, she awoke after 4 hours, and was extubated after 9 hours. Postoperative aortography re-vealed favorable well-balanced flow in the double-barrel descending aorta and the abdominal aorta.



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  		Figure 1. Distal anastomosis in a modified "elephant trunk" procedure in conjunction with graft-to-aorta anastomosis in a patient requiring individual arch vessel reconstruction.

 


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  		Figure 2. Graft replacement of the ascending aorta to the arch with a modified "elephant trunk" procedure and individual arch vessel reconstruction.

 

   Discussion
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 Abstract
 Introduction
 Surgical Technique
 Discussion
References
 
In the first-stage of replacement of the arch in chronic type-A aortic dissection, a double-barrel graft-to-aorta anastomosis was carried out in the distal section, including an "elephant trunk" graft. This double-barrel anastomosis could potentially accelerate dilatation of the false lumen of the remaining descending aorta, although it provides sufficient blood flow into the visceral arteries, even those arising from the false lumen. Therefore, an "elephant trunk" technique was employed for second-stage surgery on the descending aorta.1–3 This procedure was followed by aortic arch replacement, which is normally associated with en bloc reconstruction of the arch vessels using a pulled-through graft.2,3 Conversely, in this case of arch vessel dissection with a large intimal tear in the arch, individual arch vessel reconstruction with side-branches was essential. However, it is difficult to invaginate the arch graft with some side-branches into the "elephant trunk" graft to be inserted into the descending aorta. Therefore, additional anastomosis on the distal section between the arch graft with side-branches and the "elephant trunk" graft in the descending aorta would be required during limited hypothermic circulatory arrest. In this case, a unique and simple technique excluding this additional time-consuming graft-to-graft anastomosis was successfully employed to shorten the hypothermic cir-culatory arrest time. In fact, the duration of hypothermic circulatory arrest was less than 60 minutes, which was considered to be within the limit of cerebral safety in conjunction with retrograde cerebral perfusion.4,5


   References
TOP
 Abstract
 Introduction
 Surgical Technique
 Discussion
 References
 

  1. Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37–40.[Medline]

  2. Heinemann MK, Buehner B, Jurmann MJ, Borst HG. Use of the "elephant trunk technique" in aortic surgery. Ann Thorac Surg 1995;60:2–7.[Abstract/Free Full Text]

  3. Svensson LG. Rational and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Cardiac Surg 1992;7:301–12.[Medline]

  4. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;70:1051–63.[Abstract]

  5. Ueda Y, Miki S, Kusuhara K, Okita Y, Tahata T, Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg 1990;31:553–8.[Medline]





This Article
Right arrow Abstract Freely available
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Services
Right arrow Email this article to a friend
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Right arrow Alert me to new issues of the journal
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Right arrow Download to citation manager
Right arrow Author home page(s):
Hitoshi Ogino
Yuichi Ueda
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Ogino, H.
Right arrow Articles by Nomoto, T.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Ogino, H.
Right arrow Articles by Nomoto, T.

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