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Ann Thorac Surg 2007;84:1585-1591. doi:10.1016/j.athoracsur.2007.06.045
© 2007 The Society of Thoracic Surgeons
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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?

Hirotaka Watanuki, MDa, Hitoshi Ogino, MDa,*, Kenji Minatoya, MDa, Hitoshi Matsuda, MDa, Hiroaki Sasaki, MDa, Motomi Ando, MDb, Soichiro Kitamura, MDa

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.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
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.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Acute type A aortic dissection is a potentially catastrophic event and requires surgical repair on an emergency basis. Despite recent favorable outcomes by leading centers [1, 2], the surgery still has a high mortality rate of 14% to 32.5% [3–6]. In these circumstances, limited ascending aortic or hemiarch replacement is widely accepted to permit a primary goal of immediate survival by preventing secondary cardiac events. However, the residual dissection’s behavior in the aortic arch or thoracoabdominal aorta after the limited repair is still unclear. In the long term, repeated surgery for the residual dissection of the arch, descending thoracic aorta, and abdominal aorta would be necessary in some instances [7, 8]. Extended total arch repair is then more advantageous for complete resection of the intimal tear and the massively dissected arch [9]. In particular, with a modified elephant trunk technique, total arch repair might be more beneficial to prevent late enlargement of the residual aortic dissection.

In this study, we evaluated the early and midterm 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 who would have potential for enlargement of the distal dissection.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patients
Between 2000 and 2006, a total of 98 patients underwent emergent or urgent surgery for acute type A aortic dissection in the National Cardiovascular Center, Japan. Extended total arch replacement was performed in 54 patients (55.1%) of them (Table 1). One patient had previous history of type B dissection. Another patient developing significant distal anastomotic leak immediately after emergent hemiarch replacement was also included, although patients having iatrogenic dissection were excluded. Other 40 patients underwent hemiarch replacement and 4 patients partial arch replacement with reconstruction of the innominate artery. The institutional approval for this study was obtained, and each patient within the study gave informed consent for serving as a subject.


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  		Table 1 Preoperative Patient Characteristics
 
Surgical Technique
Cardiopulmonary bypass with additional axillary artery perfusion
With standard retrograde perfusion through the femoral artery, an additional right axillary artery perfusion was used for maintaining the true channel circulation and easy shift to selective antegrade cerebral perfusion (SCP [Fig 1]) [10]. The right axillary artery was quickly exposed and easily cannulated in the axilla, to where arterial dissection hardly extends. A 10F to 16F thin-wall cannula was inserted. The femoral artery was also cannulated with a 16F to 21F cannula. Bicaval venous drainage with left ventricular venting was used.


Figure 1
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  		Fig 1. Total arch replacement with a modified elephant trunk technique using antegrade selective cerebral perfusion (SCP) with right axillary artery (AxA) perfusion. (AV = aortic valve; FA = femoral artery; GRF-glue = Gelatin-Resorcin-Formal glue.)

 
Brain protection
Patients were cooled to the range of 20°C to 28°C (Fig 1). With hypothermic circulatory arrest, SCP through the right axillary artery was quickly commenced by clamping the innominate artery. The ascending aorta was opened without aortic clamp. The site and extent of intimal tear was defined. A SCP balloon-tipped cannula was inserted into the left common carotid artery with the left subclavian artery clamped. During the SCP, the superficial temporal artery or the balloon-tip pressures were regulated in the range of 30 to 50 mm Hg by the SCP flow of approximately 10 to 12 mL · kg–1 · min–1. Since 2003, the left subclavian artery perfusion has been included with moderate hypothermia. The SCP flow was also increased to maintain the pressure at approximately 50 mm Hg.

Total arch replacement with a modified elephant trunk technique
Ascending aortic or hemiarch replacement was the procedure principally performed for our tear-oriented surgery (Fig 1) [1, 2]. With hypothermic circulatory arrest, the ascending aorta was transected proximal to the innominate artery, excising a tear. With a tear in the minor arch curvature, the arch including a tear was beveled for hemiarch replacement. The false channel was closed with internal and external Teflon felt strips. A 22 mm to 26 mm single-branched Dacron graft was anastomosed with an open aortic technique. The antegrade distal aortic perfusion was commenced using the branch graft, and the patient was rewarmed. In contrast, extended total arch replacement with a modified elephant trunk technique [11] was attempted in the following settings: (1) tear (entry) in the arch (excluding the minor curvature); (2) tear in the descending aorta ("retrograde dissection"); (3) reentry in the arch or the proximal descending aorta; (4) Marfan syndrome; (5) arch aneurysm or dilatation; (6) atheromatous arch; (7) massive arch dissection; and (8) relatively young age less than 70 years [9, 12, 13].

In total arch replacement, the descending aorta was transected distal to the left subclavian artery. A modified elephant trunk technique was used for secure anastomosis with less anastomotic bleeding and early thrombosed closure of the distal false channel [12, 13] . Depending on the size and condition of the true channel in the descending aorta, a prosthetic graft of 16 mm to 24 mm in diameter and 3 cm to 10 cm in length was carefully inserted into the distal true channel. The proximal end of the elephant trunk graft was attached to the completely divided descending aorta using a 4-0 polypropylene continuous suture. The anastomosis was reinforced by an external Teflon felt strip. Another quadrifurcated Dacron arch graft of 20 to 24 mm in diameter was anastomosed to this aortic stump with a 4-0 polypropylene continuous suture. The antegrade distal aortic perfusion was commenced with a branch graft of the arch graft.

By transesophageal echocardiography, good shape of the inserted elephant trunk graft without kinking was confirmed. The left subclavian artery was reconstructed using a branch graft with the reinforcement of an external felt. The patient was then rewarmed. At the proximal site, the ascending aorta was transected just around the sinotubular junction. The proximal false channel was closed with internal and external Teflon felt strips. When the commissures of aortic valve detached, they were attached using 5-0 polypropylene pledgeted mattress sutures in 25 patients. In most, the proximal false channel was fixed using Gelatin-Resorcin-Formal glue (Cardial, Sainte-Etienne, France) [3]. In a recent 5 patients, an adventitial inversion technique was used without Gelatin-Resorcin-Formal glue. The main graft was anastomosed to this end with a 4-0 polypropylene continuous suture. Finally, the other two arch vessels were reconstructed using branch grafts with 5-0 polypropylene continuous suture under SCP.

Data Collection and Statistical Analysis
Medical records were reviewed. All patients have been followed at our outpatient clinic at intervals of 3 to 12 months. The follow-up rate was 100%, and the mean duration was 2.9 ± 1.8 years. We reviewed the early and midterm outcomes and investigated risk factors for in-hospital mortality and for reoperation of the distal dissection by univariate and multivariate analyses, which were carried out using SPSS software (SPSS, Chicago, Illinois). Values are expressed as the mean ± SD or medians (range), with p values less than 0.05 considered significant. Univariate analysis was carried out using the {chi}2 test or Fisher exact test. Stepwise logistic regression was used for multivariate analysis. A logistic regression model was used with p less than 0.10 as the limit for selecting variables for entry into the model. Kaplan-Meier estimates were used to calculate long-term survival and reoperation-free rates.

In the follow-up, enhanced computed tomography (CT) scanning of the entire aorta was undertaken annually to assess late enlargement of the distal dissection and the fate of the distal false channel. The diameter of the dissected aorta was measured on the short-axis view at four points of the proximal, middle, and distal descending aorta, and the abdominal aorta around the origin of the superior mesenteric artery. The conditions of the false lumen were evaluated using three grades: (1) thrombosed closure, (2) nearly closed with most of parts thrombosed, and (3) patent. The authors had full access to the data and take responsibility for its integrity. All authors have read and agree to the manuscript as written.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Total arch replacement was performed in certain patients with the following settings: tear in the arch (n = 18), tear in the descending aorta (13), massive arch dissection (17), Marfan syndrome (2), arch aneurysm (1), atheromatous arch (1), distal end of dissection in the arch (2), arch rupture (1), and descending aortic rupture (1). Concomitantly, aortic valve resuspension (n = 25), composite root replacement (2), valve-sparing root surgery (3), aortic valve replacement (1), mitral valve plasty (1), coronary artery bypass grafting (5), and ascending aorta to external iliac or femoral artery bypass for limb ischemia (2) were performed. The median duration of open distal anastomosis, cardiac arrest, SCP, cardiopulmonary bypass, and surgery was 55.5 minutes (range, 34 to 130), 136.5 minutes (84 to 379), 167.5 minutes (50 to 455), 236 minutes (124 to 789), and 462.5 minutes (237 to 1,375). The stay in the intensive care unit and the hospital was 5 days (range, 1 to 52) and 31.5 days (16 to 130), respectively. The amount of transfusion was 3,780 mL (range, 0 to 20,000 mL).

The following complications occurred: bleeding in 5.6% (n = 3), cardiac in 5.6% (3), respiratory in 13.0% (7), renal in 1.9% (1), hepatic in 1.9% (1), gastrointestinal tract in 1.9% (1), limb (leg) ischemia in 3.7% (2), infection in 1.9% (1), and wound in 1.9% (1). Cerebral deficits occurred in 11.1% (6): temporary neurologic dysfunction in 5.6% (3) and permanent dysfunction in 5.6% (3). One severe permanent neurologic dysfunction was due to preoperative cardiac arrest in the anesthetic induction owing to rupture, and cardiac massage was required until the establishment of cardiopulmonary bypass. The other 2 permanent dysfunctions were presumably due to preoperative serious cerebral malperfusion caused by extended dissection of the innominate artery to the right common carotid artery. The surgery needed to be rushed for cardiac tamponade, although both of the patients were unconscious. These 2 patients rehabilitated eventually.

There were two 30-day deaths (3.7%) due to low cardiac output. Both of these 2 female patients with preoperative deep shock had fallen into cardiac arrest during the anesthetic induction owing to ascending aorta to aortic arch rupture in 1 patient or to coronary malperfusion in 1 patient. For the first patient, hemiarch replacement was initially attempted because all of the three intimal tears were located in the ascending aorta. However, rupture of the transverse arch close to the arch vessels was found after the proximal anastomosis so that total arch replacement was performed after recooling the patient. This patient had severe edema of the whole body and abdominal distension associated with severe acidosis; she did not recover despite cardiopulmonary support using femorofemoral circuit. In the second patient, having deep shock and severe pulmonary congestion due to left coronary malperfusion preoperatively, severe hypokinesis of the anteroseptal wall with left ventricular dilatation and mitral regurgitation of grade IV due to left coronary malperfusion were revealed on transthoracic echocardiography. Total arch repair was carried out because of the primary tear located in the transverse arch just close to the left common carotid artery. After that, at the proximal site, routine supracoronary anastomosis was done with Gelatin-Resorcin-Formal glue. However, after the anastomosis, rupture of the right coronary artery due to extension of the dissection was noticed. Full root repair was carried out using a porcine stentless valved graft. However, cardiac function did not recover despite intra-aortic balloon pumping and percutaneous cardiopulmonary support using a femorofemoral circuit.

On the univariate analysis, significant risk factors for 30-day mortality were cardiac arrest before surgery, coronary malperfusion, and the duration of cardioplegic cardiac arrest more than 180 minutes (Table 2). In the following multivariate analysis, no independent predictors for mortality were found.


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  		Table 2 Univariate Analysis of Risk Factors for In-Hospital Mortality
 
During the mean follow-up period of 2.9 ± 1.8 years, 4 late deaths (7.8%) occurred from nonaortic events such as pneumonia (n = 2), cancer (1), and suicide (1; Fig 2). The actuarial survival including hospital deaths was 87.8% ± 1.2% at 3 years. Five patients (9.6%) required reoperation: root replacement for recurrent aortic regurgitation (n = 2), ascending aortic replacement for proximal anastomotic stricture due to the internal felt strip (1), and descending replacement (2; Fig 3). Regarding the reoperation of the distal dissection with the incidence of 3.8%, 1 of the 2 patients had suffered from type B aortic dissection before acute type A dissection. In the total arch replacement for new type A dissection, the previous tear of old dissection in the descending aorta was not resected, resulting in the enlargement of the descending aorta. Another patient had the tear in the descending aorta, which was not noticed through a median approach. The tear was not resected in the total arch repair, resulting in the descending aortic dilatation. The overall reoperation-free rate was 88.4% ± 11.7% at 3 years. On univariate analysis, no resection of the tear in the descending aorta was a risk factor for distal aortic reoperation (Table 3).


Figure 2
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  		Fig 2. Midterm survival, Kaplan-Meier method. (Pt = patients.)

 

Figure 3
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  		Fig 3. Freedom from reoperation, Kaplan-Meier method. (Open circles = replacement of root [2] or ascending aorta [1]; solid circles = replacement of descending aorta [2]; Pt = patients.)

 

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  		Table 3 Univariate Analysis of Risk Factors for Reoperation of the Descending Aorta
 
The follow-up CT scans showed early thrombosed closure of the distal false channel (Fig 4). Particularly, in the proximal, middle, and distal descending aorta, the complete thrombosis was demonstrated at the incidence of 43.2%, 45.5%, and 43.2% immediately after the surgery (n = 49); 84.6%, 73.1%, and 77.8% in 1 year (n = 34); and 100%, 77.8%, and 66.7% in 3 years (n = 21). Including the condition of nearly closed with most of parts thrombosed, the rate of thrombosed closure of the distal false channel was 88.6%%, 84.1%, and 79.5% immediately after the surgery; 92.3%, 84.6%, and 84.6% in 1 year; and 100%, 88.9%, and 77.8% in 3 years.


Figure 4
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  		Fig 4. Behavior of distal false channels after total arch replacement with a modified elephant trunk technique on the follow-up computed tomography scans. Numbers in parentheses indicate median diameter of the distal dissected aorta including true and false channels. (Postop = postoperative, before discharge.)

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
The outcome of total arch replacement with a modified elephant trunk under SCP with axillary artery perfusion was satisfactory, with a low in-hospital mortality rate. The primary goal of emergency surgery for acute type A aortic dissection is to save patients’ lives. Limited ascending aortic or hemiarch replacement is then widely recommended [1–6]. With recent advances of diagnosis and surgery, the outcome has improved to less than 10% mortality in the leading centers [1, 2]. In our institution, the overall mortality in emergency surgery for acute type A aortic dissection, including ascending or hemiarch repair, was 2.9% during the same period. The in-hospital mortality rate in extended total arch replacement was 3.7%, which did not increase dramatically. This satisfactory outcome is, we believe, based on our surgical background consisting of a large number of arch surgeries [10, 14, 15]. During the same period, a total of 458 patients underwent total arch replacement for a variety of aortic pathologies including chronic dissecting and nondissecting aneurysms. The in-hospital mortality rate for elective total arch replacement for nondissecting aneurysm in 305 patients was 2.3% [15].

For arch surgery, we have established an integrated circulatory support system consisting of axillary artery perfusion for cardiopulmonary bypass coupled with femoral artery or ascending aortic perfusion and of SCP [10, 14, 15]. In particular, we have advocated routine use of axillary artery perfusion [10]. The exposure of the distal part of axillary artery in the axilla is quicker and easier than that in the subclavicular region. Arterial dissection rarely extends to this portion of the axillary artery. Secure perfusion of the true channel can be commenced quickly, improving cardiac and cerebral safety. Furthermore, easy shift to the SCP is feasible by clamping the innominate artery without cannulation. Our increasing experiences with arch replacement using SCP with the axillary artery perfusion has led to our growing confidence in the safe application of this prompt approach of total arch replacement even on an emergency basis [10, 13–15].

Previous reports identified various risk factors for mortality such as early year operation, increasing age, history of aortic valve replacement, high New York Heart Association class, diabetes mellitus, shock, cardiac tamponade, rupture, coronary malperfusion, visceral malperfusion, limb malperfusion, root replacement, arch replacement, coronary artery bypass graft surgery, or longer circulatory arrest [4–6]. In the presented series, cardiac arrest before surgery as well as coronary malperfusion was a risk factor for in-hospital mortality in the univariate analysis. It was extremely difficult to rescue these 2 critical patients having serious coronary malperfusion or aortic arch rupture. Given a larger number of such critical patients, the outcome might have been much worse with a higher mortality.

Complete resection of the primary tear is a key to good early and long-term outcomes. In previous reports, no differences were recognized in mortality or reoperation rate whether the tear was resected or not [16, 17]. However, subsequent reports noted that the reoperation rate was significantly higher without tear resection [3, 18–20]. Since then, "tear-oriented surgery" has been widely recommended [1–6]. In previous studies, anastomotic leakage, no tear resection, younger age, Marfan syndrome, and severe aortic regurgitation were significant determinants for reoperation [3, 18–22]. Given a tear in the arch excluding the minor curvature site or in the proximal descending aorta, total arch replacement is then reasonable [3, 13, 18, 19, 21, 22]. Furthermore, in cases with massive arch dissection, complete arch replacement would be more beneficial to avoid bleeding, anastomotic leak, progression of aneurysmal dilatation, rupture, reoperation, and cerebral malperfusion [3, 18, 19]. Recently, the Mount Sinai group [22] described that repeated surgical intervention was most frequently required in the aortic arch and abdominal aorta in a large series. We believe our aggressive total arch replacement for complete resection of massive arch dissection as well as the primary tear can reduce the incidence of distal reoperation, in particular, for arch dilatation.

Coupled with the total arch repair, a modified elephant trunk technique was used for secure anastomosis and for early thrombosed closure of the distal false channel [11, 12]. Without the internal reinforcement by elephant trunk graft, the distal anastomosis would be more troublesome with bleeding because of a fragile dissected descending aorta. Literally, the patent false channel was recognized in the incidence of approximately 50% to 80% after the conventional ascending aortic replacement. In our series, having total arch repair with a modified elephant trunk, early thrombosed closure or obliteration of the false channel in the descending aorta was recognized frequently on the follow up CT scans. From this point of view, we believe this unique technique plays an important role or is essential for total arch replacement for acute type A dissection [12]. It does, however, have some shortcomings. The true channel in the descending aorta is generally too small to accept a large-size graft, making necessary the use of another smaller-size graft. With such a size mismatch, the inserted elephant trunk graft might be kinked or wrinkled, resulting in stenosis or hemolysis. Its adequate length is also unknown. The longer the graft is, the greater the impact of elephant trunk on closure or obliteration of the distal false channel is. However, with a too-long elephant trunk, the potential risk of spinal cord injury or new tear formation would increase [23]. Regardless, we propose as another advantage, with the elephant trunk, that the reoperation of the descending aorta would be much easier [11, 12]. The elephant trunk procedure should be coupled with total arch replacement.

The aim of the elephant trunk procedure was to reduce the reoperation rate by preventing enlargement of the distal dissected aorta. However, 2 patients, whose tear had not been resected in the first surgery, required descending aortic replacement in the late stage. In 1 patient having the tear in the descending aorta that was not noticed intraoperatively, the elephant trunk was 5 cm in length. It was subsequently too short to cover the tear. If the tear had been identified, we could have closed the tear using a longer elephant trunk. Kato and colleagues [24] and Ishihara and associates [25] reported greater impact of stent graft as an elephant trunk on closing the false channel, instead of standard prosthetic graft. However, in the use of stent graft for acute aortic dissection, a potential risk of new intimal tear formation exists [26]. More flexible stent graft might be preferable for such fragile aortic wall of acute dissection. For reoperation of the descending aorta, patent false channel, anastomotic leakage, no tear resection, younger age, and Marfan syndrome were reportedly risk factors [3, 18, 19]. In this series, reoperation of the descending aorta was required only in the 2 cases without resection of the tear in the descending aorta. For such patients having a potential risk of distal dilatation, meticulous follow up using CT scans is mandatory.

Postoperative cerebral morbidity remains one of the critical complications, particularly in total arch repair requiring longer SCP. Generally, the incidence is higher compared with ascending or hemiarch repair. In total, 3 patients had strokes due to brain damage during cardiac resuscitation or to preoperative cerebral malperfusion. Although 2 patients having cerebral malperfusion were unconscious before surgery, the surgery was indicated because brain CT scans did not reveal any infarction.

This retrospective study has some limitations. The number of patients might be too small to reach definitive conclusions. For that, a larger number of patients is necessary. There was no appropriate control group having ascending or hemiarch replacement, because the limited repairs were performed in the patient group having different conditions including the site of the primary tear. For definitive conclusions, a randomized controlled study is required between the extended and limited repairs in patients having homogenous aortic lesions.

In conclusion, total arch replacement with a modified elephant trunk procedure under SCP with right axillary artery perfusion, which permits immediate survival and can reduce the distal aortic reoperation rate, would be justified in certain patients with acute type A aortic dissection.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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Hitoshi Ogino
Kenji Minatoya
Hitoshi Matsuda
Motomi Ando
Soichiro Kitamura
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