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Original Articles: Cardiovascular

Is Emergency Total Arch Replacement With a Modified Elephant Trunk Technique Justified for Acute Type A Aortic Dissection?

^a Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
^b Department of Thoracic Surgery, Fujita Health University, Osaka, Japan

Accepted for publication June 15, 2007.

^_* Address correspondence to Dr Ogino, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan (Email: hogino{at}hsp.ncvc.go.jp).

Presented at the Poster Session of the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.

Background: We assess the outcome of emergency total arch replacement with a modified elephant trunk technique for acute type A aortic dissection to clarify whether our aggressive approach is justified in certain patients.

Methods: Between 2000 and 2006, 54 patients (55.1% of all) underwent emergency total arch replacement for acute type A aortic dissection. The surgery was performed using open distal anastomosis with selective antegrade cerebral perfusion under hypothermia. Total arch replacement with individual arch-vessel reconstruction was applied in the following settings: the intimal tear in the transverse arch or the proximal descending aorta, massive arch dissection, Marfan syndrome, arch aneurysm, and atheromatous arch. At the distal anastomosis, a modified elephant trunk procedure was added for secure anastomosis and early thrombosed closure of the false channel in the descending aorta.

Results: Only 2 patients (3.7%) died of low cardiac output, in whom cardiac arrest had developed preoperatively owing to rupture of the arch or to left coronary artery malperfusion. There were 4 late deaths from nonaortic events. On the follow-up computed tomographic scanning, a high incidence of early thrombosed closure of the false channel in the dissected descending aorta was found. Only 2 patients, whose tear had not been resected in the first surgery, required reoperation of the descending aorta.

Conclusions: Total arch replacement with an elephant trunk procedure, which permits immediate survival and provides early thrombosed closure of the distal false channel, is justified in certain patients with acute type A dissection.