Ann Thorac Surg 2005;79:2159
© 2005 The Society of Thoracic Surgeons
Images in cardiothoracic surgery
Complete Replacement of the Supraaortic Branches and of the Aortic Arch Facilitated by a "Reversed" Elephant Trunk
Thierry P. Carrel, MD*,
Friedrich S. Eckstein, MD,
Jürg Schmidli, MD
Clinic for Cardiovascular Surgery, University Hospital, Berne, Switzerland
* Address reprint requests to Dr Carrel, Clinic for Cardiovascular Surgery, University Hospital, CH-3010 Berne, Switzerland (E-mail: thierry.carrel{at}insel.ch).
A 33-year-old female with Marfan syndrome presented in 1996 with acute peripartal aortic dissection. A composite graft was performed and intestinal resection had to be performed a few days later because of malperfusion-related ischemia. Recovery of the mother and the child was uneventful. In 2000, complete thoracoabdominal replacement was necessary because of expanding aneurysm Crawford type II, but the aortic arch was normal sized. The proximal anastomosis was performed at the level of the left subclavian artery by invaginating a piece of the graft into the descending prosthesis (reversed elephant trunk) to facilitate ulterior aortic arch replacement [1–3].
Three years later, the patient presented with severe pains in the right neck region. Computed tomographic scan illustrated the cause to be large aneurysms of the innominate artery, including the right subclavian and carotid arteries (Fig 1). Note in Figure 1 that both carotid arteries present a persistent dissection. The aortic arch was 4.2 cm. Complete replacement of the supraaortic branches and of the aortic arch was performed under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. A Vaskutek Plexus prosthetic graft (Vaskutek, Renfreswire, Scotland) was inserted, using separate reconstruction of the supraaortic vessels and the sidearm prosthesis for arterial return (Fig 2). The distal aortic arch anastomosis was greatly facilitated and accelerated by the fact that the "reversed" elephant trunk could be unfolded very easily out of the descending prosthesis and exposure was very comfortable (Fig 2). Little clot material was found. The period of total circulatory arrest was 19 minutes only, while carotid reperfusion was started after 20 minutes on the left and 33 minutes on the right side. Proximal anastomosis was performed between the composite graft and the arch prosthesis using running monofilament suture.
In this particular patient, the "reversed" elephant trunk technique was very useful and considerably facilitates the separate attachment of the supraaortic branches. A conventional approach with the classic elephant trunk requiring invagination of a multiside-branched graft or aortic arch replacement followed by revascularization of the supraaortic branches with additional small-sized grafts would have been technically more demanding and time consuming.
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References
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- Carrel T, Althaus U. Extension of the "elephant trunk" technique in complex aortic pathologythe bidirectional option. Ann Thorac Surg 1997;63:1755-1758.[Abstract/Free Full Text]
- Coselli JS, Oberwalder P. Successful repair of mega aorta using the reversed elephant trunk procedure J Vasc Surg 1998;27:183-188.[Medline]
- Carrel T, Berdat P, Kipfer B, Eckstein F, Schmidli J. The reversed and bidirectional elephant trunk technique in the treatment of complex aortic aneurysms J Thorac Cardiovasc Surg 2001;122:587-591.[Abstract/Free Full Text]
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