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Ann Thorac Surg 1997;63:1755-1758
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Extension of the "Elephant Trunk" Technique in Complex Aortic Pathology: The "Bidirectional" Option

Clinic for Thoracic and Cardiovascular Surgery, University Hospital, Berne, Switzerland

Accepted for publication December 30, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. The "elephant trunk" technique, using a free-floating vascular prosthesis, was originally described to facilitate a subsequent operation on the downstream aorta. We developed an additional refinement of this technique, called the "bidirectional elephant trunk." This option may represent an interesting tool in more complex aortic operations, especially when the descending aorta has to be replaced first in patients with concomitant pathology of the ascending aorta or of the aortic arch.

Methods. The initial operation is performed through a left thoracotomy. The proximal elephant trunk is created by invaginating the future aortic arch graft into the descending aortic graft. The proximal anastomosis between the doubled graft and the proximal descending aorta is performed first. During construction of the distal anastomosis, a distal elephant trunk may be inserted likewise. If the aortic arch and ascending aorta have to be replaced later, this second step is performed through a median sternotomy. The free-floating arch graft is pulled out of the proximal descending aorta with a nerve hook, unfolded, and used for total arch replacement.

Results. This technique was used successfully in 3 patients without mortality. No major complications were observed excepted persistent hoarseness in a patient with preoperative paresis of the recurrent nerve. No perfusion problems due to the unfolding of the free-floating graft occured during the second operation.

Conclusions. The bidirectional elephant trunk technique is an interesting option that may be suitable for patients presenting with a complex pathology of the whole thoracic aorta when the descending segment has to be replaced first.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The "elephant trunk" technique using an intraaortic free-floating vascular prosthesis was originally described to facilitate a subsequent operation on the downstream aorta [1, 2]. We developed an additional refinement called the "bidirectional technique," which may help decision-making and represent an interesting option in complex aortic pathology. This technique may be useful in patients needing urgent replacement of the descending aorta and demonstrating concomitant pathology in a more proximal aortic segment and in patients referred for elective replacement of the descending aorta in whom subsequent development of a pathology of the arch or ascending aorta may be expected (Fig 1).

View larger version (108K): [in this window] [in a new window]   Fig 1. . Schematic representation of the bidirectional elephant trunk graft after positioning in the proximal segment of the descending aorta, before unfolding the distal part in the downstream aorta. The proximal trunk remains invaginated in the cranial part of the graft and can be pulled out from a sternotomy approach when aortic arch replacement is required.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

View larger version (135K): [in this window] [in a new window]   Fig 2. . Magnetic resonance imaging in a patient with operated type A dissection and symptomatic dilation of the descending aorta. Note the incidental finding of more proximal pathology at the origin of the innominate artery.

View larger version (109K): [in this window] [in a new window]   Fig 3. . Computed tomogram demonstrating contained rupture of the proximal descending aorta. There are severe atherosclerotic alterations of the aortic arch, but the caliber of the latter seems rather normal. No dissection was visualized by computed tomographic scan.

View larger version (99K): [in this window] [in a new window]   Fig 4. . Transesophageal echocardiography allowed us to demonstrate the presence of a dissecting membrane in the transverse aortic arch. In the absence of a typical entry in the ascending aorta, a type B aortic dissection with retrograde extension in the aortic arch was suspected.

In a second step, subsequent aortic arch and, if necessary ascending aortic replacement is performed through median sternotomy, using femoral-right atrial cannulation and deep hypothermic circulatory arrest. During the cooling phase with its retrograde perfusion in the descending aorta, special attention should be paid to detect an unfolding of the floating elephant trunk itself. This can be monitored easily by transesophageal echocardiography. During circulatory arrest, the free-floating arch graft is pulled out of the proximal part of the descending aortic graft using a nerve hook; it is unfolded and used for total arch replacement (Fig 5). The supraaortic vessels are inserted into the aortic arch graft and the operation proceeds like conventional aortic arch-ascending aortic replacement, depending on the proximal extent of the disease.

View larger version (105K): [in this window] [in a new window]   Fig 5. . (A) Intraoperative view of the proximal elephant trunk still invaginated in the proximal segment of the descending aorta; the aortic arch has been completely resected and the supraaortic vessels excised with a generous patch of aortic wall. (B) Same view after unfolding the elephant trunk with the aid of a nerve hook; only minor clots were observed on the external layer of the prosthesis.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Within the last decade, substantial improvement in operative techniques and perioperative management of complex lesions of the thoracic aorta has been achieved. It includes major advances in extracorporeal circulation (heparin-bonded systems), cerebral (retrograde perfusion) and myocardial protection (blood cardioplegia), and refinements in surgical (zero-porosity vascular grafts) and hemostatic techniques (aprotinin). Therefore, there has been a shift from limited to extended procedures in aortic dissection and in extensive true aortic aneurysms [2–4].

Some dissections involving the ascending aorta may present an atypical pattern, with the site of intimal tear located in the distal transverse arch or even in the proximal descending aorta; in these cases, involvement of the ascending aorta occurs through a retrograde extension of the dissecting process. In this situation, the operation should focus on prevention of potentially life-threatening complications; therefore, the repair of the aortic arch or descending aorta can be postponed until after the life-saving operation on the ascending aorta [5]. However, in some rare instances, the major problem may be situated in the descending aorta and require emergency or urgent replacement of this portion first. For this particular situation, we have developed a further refinement of the classic elephant trunk technique, described originally by Borst and associates in 1983 [1] and modified by Svensson [6], the so-called bidirectional elephant trunk. The first step is performed on the downstream aorta (through a left thoracotomy) and the second step addresses the proximal aortic replacement. The proper localization of the proximal elephant trunk can be monitored by transesophageal echocardiography. Should an unfolding of the free-floating graft occur, antegrade perfusion through the diseased ascending aorta or the apex of the left ventricle can be accomplished. Clot formation may be a matter of concern in elephant trunks, but we did not observe any important clots in or around the trunk itself. Because the ideal management of acute type B dissection with retrograde extension into the aortic arch and ascending aorta and of chronic type A dissection with a rapidly expanding aneurysm or a contained rupture located in the descending aorta is still controversial, the bidirectional elephant trunk option may be a valuable alternative to one-step replacement of the whole thoracic aorta.

Like every elephant trunk procedure, this refinement avoids a hazardous dissection in areas of previous operation and allows a substantial shortening of the period of deep hypothermic circulatory arrest, because it eliminates the construction of the distal arch anastomosis during the second step of the procedure. Therefore it usually facilitates a subsequent operation and substantially shortens the operating time.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Prof Carrel, Clinic for Thoracic and Cardiovascular Surgery, University Hospital, CH-3010 Berne, Switzerland.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement with the "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37–41.[Medline]
2. Borst HG, Walterbusch G, Schaps D. Treatment of extensive aortic arch aneurysm by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988;95:11–6.[Abstract]
3. Heinemann MK, Bühner B, Jurmann MU, Borst HG. Use of the elephant trunk technique in aortic surgery. Ann Thorac Surg 1995;59:2–7.
4. Crawford ES. Diffuse aneurysmal disease (chronic aortic dissection, Marfan and mega aorta syndrome) and multiple aneurysms. Treatment by subtotal and total aortic replacement emphasizing the elephant trunk technique. Ann Surg 1990;211:521–30.[Medline]
5. Carrel T, Pasic M, Vogt P, et al. Retrograde ascending aortic dissection: a diagnostic and therapeutic challenge. Eur J Cardiothorac Surg 1993;7:146–52.[Abstract]
6. Svensson LG. Rationale and technique for replacement of the ascending aorta, aortic arch and distal aorta using a modified elephant trunk procedure. J Card Surg 1992;7:301–5.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Thierry Carrel Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Carrel, T. Articles by Althaus, U. Search for Related Content PubMed PubMed Citation Articles by Carrel, T. Articles by Althaus, U.