Ann Thorac Surg 2007;84:659-661
© 2007 The Society of Thoracic Surgeons
Case Reports
Successful Total Arch Replacement With Long Elephant Trunk for Chronic Aortic Dissection (DeBakey IIIb)
Yasuhiro Shudo, MDa,
Kazuhiro Taniguchi, MD, PhDa,*,
Hajime Matsue, MD, PhDb,
Toshiki Takahashi, MD, PhDb,
Koichi Toda, MD, PhDa,
Hiroki Hata, MD, PhDa,
Yoshiki Sawa, MD, PhDb
a Department of Cardiovascular Surgery, Japan Labour Health and Welfare Organization, Osaka Rosai Hospital, Osaka, Japan
b Division of Cardiovascular Surgery, Department of Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
Accepted for publication December 11, 2006.
* Address correspondence to Dr Taniguchi, 1179-3 Nagasone, Sakai, Osaka 591-8025, Japan (Email: yasuhiro-shudo{at}s5.dion.ne.jp).
 |
Abstract
|
|---|
A 68-year-old man presenting with abdominal distention was found on enhanced computed tomography to have a dilated ascending aorta and aortic dissection (DeBakey IIIb). Through a median sternotomy, we performed a total arch replacement using a four-branched Hemashield graft (Meadox Medical, Oakland, NJ) and a long elephant trunk anastomosis at the base of the innominate artery. Postoperatively, a pseudolumen of the descending aorta was effectively thrombo-excluded to the T12 level. Visceral blood flow was preserved, and the patient’s postoperative course was uneventful.
|
Introduction
|
|---|
Surgical intervention for chronic aortic dissection (DeBakey IIIb type) is a challenging operation. Borst and colleagues [1] introduced the elephant trunk procedure, after which a number of others adopted the technique. For the present case, we performed total arch replacement using a four-branched arch graft (Hemashield Platinum, Meadox Medical, Oakland, NJ) and a long elephant trunk anastomosis at the base of the innominate artery through a median sternotomy with selective antegrade cerebral perfusion [2]. Postoperatively, a pseudolumen of the descending aorta was effectively thrombo-excluded to the T12 level. Visceral blood flow was preserved and the postoperative course was uneventful.
A 68-year-old man with an abdominal distension came to us in November 2004. He had a history of hypertension. Enhanced computed tomography (CT) revealed a dilated ascending aorta and an aortic dissection (DeBakey IIIb) extending from the distal arch to the level of the inferior mesenteric artery. Enhanced CT, magnetic resonance imaging, and angiogram findings showed that the primary entry site was the distal aortic arch, with no lack of visceral blood flow (Fig 1). Blood flow in the superior mesenteric and bilateral renal arteries was from a true lumen, whereas that in the celiac and inferior mesenteric arteries was from a pseudolumen. Further, the common hepatic artery was supplied from the superior mesenteric artery and the splenic artery from the collateral arteries. The pseudolumen was not thrombosed. The diameter of the aorta was 48 mm at the level of the distal arch and 50 mm at the level of the descending aorta (Fig 2).
View larger version (65K):
[in this window]
[in a new window]
|
Fig 1. Preoperative evaluation of chronic aortic dissection (DeBakey IIIb). The primary entry site was found to be the distal aortic arch. The pseudolumen was not thrombosed.
|
|
View larger version (101K):
[in this window]
[in a new window]
|
Fig 2. Preoperative evaluation of chronic aortic dissection (DeBakey IIIb). (A) Blood flow in the superior mesenteric and bilateral renal arteries was from the true lumen. (B) Blood flow in the celiac and inferior mesenteric arteries was from the pseudolumen. The common hepatic artery was supplied from the superior mesenteric artery and the splenic artery from the collateral arteries.
|
|
We performed a total arch replacement, using a four-branched Hemashield graft through a median sternotomy with a modified elephant trunk technique, under a moderately hypothermic cardiopulmonary bypass (25°C) and selective antegrade brain perfusion. A distal anastomosis was performed at the base of the innominate artery using an open distal method, and a long elephant trunk was inserted into the descending aorta with a 7F forceps catheter through the femoral artery. Cardiac arrest time was 168 minutes, selective brain perfusion time was 80 minutes, and open distal time was 22 minutes.
The tip of the elephant trunk was located at the T10 level, as shown by a chest roentgenogram. The entry site was closed, and the pseudolumen of the descending aorta was effectively thrombo-excluded to the T12 level (Fig 3). Visceral blood flow was preserved, and the patient’s postoperative course was uneventful.
View larger version (114K):
[in this window]
[in a new window]
|
Fig 3. (A) Postoperative results after total arch replacement with a long elephant trunk. (B) Schematic illustration of the present total arch replacement with long elephant trunk method. The pseudolumen in the descending aorta was effectively thrombo-excluded to the T12 level. Visceral blood flow was preserved.
|
|
|
Comment
|
|---|
Borst and colleagues [1] introduced the elephant trunk procedure in 1983 for aneurysms of the aortic arch and proximal descending aorta, and it has since been modified by several groups [3]. A staged elephant trunk technique has been widely used for extensive ascending, arch, descending, and thoracoabdominal aneurysms. Ando and colleagues [4] adopted the technique for aortic dissection in which a distal anastomosis is performed at the descending aorta just below the left subclavian artery under retrograde cerebral perfusion. Although progress has been made recently in modifying the method, results for surgical repair of an aortic dissection (DeBakey IIIb type) generally remain unsatisfactory, because it is associated with considerable mortality and morbidity, especially in elderly patients or those with preoperative complications.
In the present case, we applied a total arch replacement using a four-branched Hemashield graft and a long elephant trunk anastomosis at the base of the innominate artery through a median sternotomy under selective antegrade cerebral perfusion. The technique was easy to perform and less invasive, and it enabled the pseudolumen to be thrombo-excluded by closing the primary entry site. Further, a second-stage operation could be rapidly initiated, if necessary.
It is essential to anticipate the likelihood of visceral ischemia after thrombotic closure of a pseudolumen. To prevent ischemic complications, it is important to know the entry and reentry sites of the false lumen and elucidate blood flow in the abdominal branches preoperatively. In the present patient, the celiac artery trunk was already thrombosed; however, the common hepatic artery was supplied from the superior mesenteric artery and the splenic artery from the collateral arteries. It is not necessary to preserve blood flow in the celiac artery trunk after thrombotic closure of a pseudolumen, thus we are confident that perfusion of the celiac artery was preserved. In addition, no sign of visceral ischemia was detected postoperatively.
We determined the appropriate length of the elephant trunk using preoperative aortography and CT examinations and confirmed that the tip was located at the level of T7-8. In our patient, the tip of the elephant trunk was located at the T10 level, which was two vertebral bodies lower than expected. Fortunately, there was no evidence of paraplegia. Additional study will be necessary to determine the ideal length of the elephant trunk for this technique.
It was considered essential to predict whether complete thrombo-exclusion of the pseudolumen would be obtained in this case. Our results showed that thrombo-exclusion of the pseudolumen was completely obtained to the level of T12, and the diameter of the descending aorta didn’t increase, while the diameter at the level of T12 remained at 42 mm.
In conclusion, total arch replacement with a long elephant trunk is an alternative method for chronic aortic dissection (DeBakey IIIb type), and the present results were satisfactory. We found that it was essential to evaluate the area of dissection, visceral flow, and the location of entry and reentry preoperatively.
|
References
|
|---|
- Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis Thorac Cardiovasc Surg 1983;31:37-40.[Medline]
- Kuki S, Taniguchi K, Masai T, Endo S. A novel modification of elephant trunk technique using a single four-branched arch graft for extensive thoracic aortic aneurysm Eur J Cardiothorac Surg 2000;18:246-248.[Abstract/Free Full Text]
- Kazui T, Washiyama N, Muhammmad BA, et al. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion Ann Thorac Surg 2000;70:3-8discussion 8–9.[Abstract/Free Full Text]
- Ando M, Takamoto S, Okita Y, et al. Elephant trunk procedure for surgical treatment of aortic dissection Ann Thorac Surg 1998;66:82-87.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
J. Wei, C.-Y. Chang, Y.-C. Chuang, S.-H. Sue, K.-C. Lee, C.-W. Wu, and C.-H. Chang
Midterm results of vascular ring connector in open surgery for aortic dissection
J. Thorac. Cardiovasc. Surg.,
January 1, 2012;
143(1):
72 - 77.e3.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. Toda, K. Taniguchi, T. Masai, T. Takahashi, S. Kuki, Y. Sawa, and Osaka Cardiac Surgery Research (OSCAR) Group
Arch Aneurysm Repair With Long Elephant Trunk: A 10-Year Experience in 111 Patients
Ann. Thorac. Surg.,
July 1, 2009;
88(1):
16 - 22.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
