Ann Thorac Surg 2001;71:705-707
© 2001 The Society of Thoracic Surgeons
Case report
Stented elephant trunk method for multiple thoracic aneurysms
Shinji Miyamoto, MDa,
Tetsuo Hadama, MDa,
Hirofumi Anai, MDa,
Hidenori Sako, MDa,
Osamu Shigemitsu, MDa
a Department of Cardiovascular Surgery, Oita Medical University, Oita, Japan
Accepted for publication May 2, 2000.
Address reprint requests to Dr Miyamoto, Department of Cardiovascular Surgery, Oita Medical University, Hasama-machi, Oita 879-5593, Japan
e-mail: smiyamot{at}oita-med.ac.jp
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Abstract
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Stent-grafting and open graft replacement was introduced to reduce the complications of suture anastomosis in the descending aorta. We applied this technique in the treatment of a patient with multiple thoracic aneurysms. The elephant trunk procedure was used for thromboexclusion. A single branched graft was placed easily without twisting. In patients with aneurysms at both the proximal and distal thoracic aorta, combined stent-grafting and open graft replacement is an excellent approach.
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Introduction
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Creation of an anastomosis in the descending aorta through a median sternotomy is a technically challenging procedure, and the recurrent laryngeal nerve palsy is a risk during dissection of the aortic arch. Aneurysms of the distal arch often require total arch replacement because of involvement of the cervical vessels or aneurysmal changes in the proximal aorta. We successfully treated a patient with multiple discrete thoracic aneurysms using the stented elephant trunk method and a single branched graft.
A 69-year-old woman was referred to our hospital with a diagnosis of multiple thoracic aneurysms. Computed tomography showed a protruding aneurysm in the ascending aorta, two aneurysms with mural thrombus in the distal arch, and aneurysmal changes in the innominate and left subclavian artery origins. The patient had chronic obstructive pulmonary disease with a forced expiratory volume in 1 second (FEV1) that was 50% of expected. Routine preoperative coronary angiography revealed significant stenosis of the left anterior descending (LAD) artery and the right coronary artery (RCA). We decided that a minimally invasive method would be used to minimize the dissection that might cause recurrent nerve palsy and to avoid entering the pleural space. A simplified elephant trunk method was employed in which the distal end of the graft was fixed with a stent.
A 22-mm gelatin-impregnated Dacron graft with four branches (Gelweave, Vasctek, Renfrewshire, Scotland) was used. After pushing the distal end of the prosthesis back into itself, the inner and outer walls were sewn together 1 cm from the new end (Fig 1A). Pulling the end out from the prosthesis changed this hem into a cuff. A Gianturco stent (Cook, Bloomington, IN) with a diameter of 30 mm and a length of 50 mm was inserted and fixed to the distal trunk (Fig 1B). The appropriate trunk length (15 cm) was determined by measuring the aorta on three-dimensional computed tomography. The stented graft was then bound to a curved tube with a chain stitch.
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Fig 1. Preparation of the stented graft with a cuff. The inner and outer wall were sewn together (A). The distal end was pulled out and a Z stent was fixed to it (B).
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The ascending aorta and aortic arch were exposed through a median sternotomy. Cardiopulmonary bypass was established by cannulation of the right subclavian artery, femoral artery, and right atrium. The patient was cooled to a rectal temperature of 20°C. During the cooling process, saphenous vein grafts were anastomosed to the RCA and LAD. Under systemic circulatory arrest with selective cerebral perfusion, the aorta was transected at the level of the left carotid artery. Cardiac arrest was obtained with selective antegrade cold blood cardioplegia. First the root of the left subclavian artery was closed. The stented graft was inserted into the descending aorta under transesophageal echocardiographic guidance (Fig 2). The stent was then expanded by releasing the chain stitch, which fixed the distal end of the trunk in position. The cuff was sutured to the distal aortic stump with a continuous 4-0 polypropylene suture. Flow (2 L/min for 30 seconds) was established in the graft through the femoral cannula to remove loose atheromatous plaque after sewing of the cuff. Systemic perfusion was resumed by switching the femoral cannula into a graft perfusion branch. The proximal portion of the graft was anastomosed to the proximal aortic stump and the cephalobracheal branches were reconstructed. The times of ECC, selective cerebral perfusion, and the whole operation were 212, 98, and 344 minutes, respectively. The patient was weaned from bypass without difficulty and was extubated on postoperative day 1. The postoperative course was uneventful, with no distal embolic episodes. Both CT and angiography showed the fully expanded stent in the ideal position and complete thromboexclusion of the residual aneurysms in the distal arch aorta.
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Fig 2. Operative procedure. The graft bound to a tube with a chain stitch was inserted into the descending aorta under selective cerebral perfusion.
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Comment
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Open surgery combined with stent-grafting of thoracic aneurysms was introduced in 1996 to reduce the complications associated with suture anastomosis in the descending aorta. Suto and colleagues [1] first reported the stented elephant trunk procedure for extensive aneurysms involving the distal aortic arch and descending aorta. They inserted a stented tube graft constricted by pursestring sutures under endoscopic guidance. Kato and associates [2] described the sutureless distal anastomotic technique in which a compressed stented graft in a catheter sheath was inserted into the descending aorta. We made the procedure simpler without compromising anastomotic security by using a single branched graft with a cuff. The chain stitch that bound the graft tightly was unlaced easily. Binding the graft to a curved tube prevented twisting between the cuff and the distal end. Although the original elephant trunk method proposed by Borst and associates [3] also allows the possibility of spontaneous thrombosis in the dead space around the trunk, stent insertion brings about more complete obliteration of the residual aneurysm. Palma and coworkers [4] performed an elephant trunk procedure for acute type B aortic dissection and used a stented Dacron prosthesis in the last two patients for more certain thromboexclusion of the false lumen.
Endovascular stent-grafting techniques have been shown to be safe alternatives for the treatment of thoracic aneurysms [5]. However aneurysms involving the ascending or proximal arch aorta still require an open surgical procedure. These aneurysms often extend distally or are associated with other aneurysms in the distal aorta. In such cases combined stent-grafting and open graft replacement is an excellent approach, particularly in high-risk patients. As there is a considerable risk of paraplegia in this procedure, it is quite important to avoid a needlessly long elephant trunk by careful preoperative measurement.
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References
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Suto Y., Yasuda K., Shiiya N., et al. Stented elephant trunk procedure for an extensive aneurysm involving distal aortic arch and descending aorta. J Thorac Cardiovasc Surg 1996;112:1389-1390.[Free Full Text]
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Kato M., Ohnishi K., Kaneko M., et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996;94(Suppl II):188-193.
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Borst H.G., Frank G., Schapes D. Treatment of extensive aortic aneurysm by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988;95:113.
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Palma J.H., Almeida D.R., Carvalho A.C., Andrade J.C.S., Buffolo E. Surgical treatment of acute type B aortic dissection using an endoprosthesis (elephant trunk). Ann Thorac Surg 1997;63:1081-1084.[Abstract/Free Full Text]
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Mitchel R.S., Miller D.C., Dake M.D., Semba C.P., Moore K.A., Sakai T. Thoracic aortic aneurysm repair with an endovascular stent graft: the "first generation". Ann Thorac Surg 1999;67:1971-1974.[Abstract/Free Full Text]
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Abstract
Introduction
