Ann Thorac Surg 2007;84:1729-1734. doi:10.1016/j.athoracsur.2007.05.087
© 2007 The Society of Thoracic Surgeons
New Technology
Elephant Trunk Anastomosis Proximal to Origin of Innominate Artery in Total Arch Replacement
Kazuhiro Taniguchi, MD, PhDa,*,
Koichi Toda, MD, PhDa,
Hiroki Hata, MD, PhDa,
Yasuhiro Shudo, MDa,
Hajime Matsue, MD, PhDb,
Toshiki Takahashi, MD, PhDb,
Satoru Kuki, MD, PhDb
a Department of Cardiovascular Surgery, Osaka Rosai Hospital, Sakai, Japan
b Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
Accepted for publication May 31, 2007.
* Address correspondence to Dr Taniguchi, Department of Cardiovascular Surgery, Japan Labour Health and Welfare Organization Osaka Rosai Hospital, Sakai, 591-8025, Japan (Email: kazuhiro{at}orh.go.jp).
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Abstract
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Purpose: The purpose of this study was to describe our current technique for aortic arch replacement using a four-branched arch graft and a long elephant trunk.
Description: Using our method, the ascending aorta is replaced with a four-branched Hemashield arch graft (Hemashield Platinum, Woven Double Velour [Boston Scientific Corp, Wayne, NJ]) while cooling the patient. When 25°C is reached, selective cerebral perfusion is started and the elephant trunk is inserted under open distal conditions into the descending aorta using a catching catheter introduced through a femoral artery. A distal aortic anastomosis is then performed between the four-branched graft and distal aorta incorporating the elephant trunk at the base of the innominate artery. Arch vessels are reconstructed separately during rewarming.
Evaluation: Between October 1998 and December 2005, we performed the present technique in 52 patients with no operative deaths within 30 days after the procedure. The mean duration of hypothermic circulatory arrest was 24 ± 5 minutes, whereas that of selective cerebral perfusion was 86 ± 9 minutes.
Conclusions: The technique described herein requires a shorter circulatory arrest time and is uniformly applicable to patients with extensive thoracic aortic aneurysms.
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Introduction
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Although various modifications of surgical techniques and perfusion strategies have resulted in steady reductions in mortality and morbidity associated with aortic arch replacement [1, 2], treatment for extensive portions of the aorta located from the aortic annulus to below the mid-descending aorta remains difficult [3]. In 1998 we developed a modified technique for total arch replacement that uses a four-branched graft and long elephant trunk [4, 5]. Since that time we have consistently used the technique in a uniform fashion to repair various types of thoracic aortic aneurysms and dissections involving the aortic arch, and we have also made some improvements. The technique was designed to reduce morbidity and mortality associated with replacement of the aortic arch, as well as allow for easier performance of subsequent related operations. Herein, we present our current technique and postoperative results.
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Technique
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After the induction of anesthesia, a catching catheter (Amplatz Goose Neck Snare [ev3 Inc, Plymouth, MN]) is introduced into the aortic arch through the left femoral artery. After a median sternotomy is performed, the arch vessels are mobilized and encircled with tape. Next, the right and left axillary arteries are exposed and an 8-mm tube graft is anastomosed end-to-side to both axillary arteries. The opposite end of the left graft is introduced into the pericardial space through a retro-clavicle tunnel, which is used for perfusion of the left subclavian artery during selective cerebral perfusion and later for reconstruction of the left subclavian artery. The right axillary graft is used for systemic perfusion (Fig 1A) and later for perfusion of the innominate artery during selective cerebral perfusion (Fig 1B).
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Fig 1. (A) Systemic perfusion strategy through the right axillary artery. (B) Selective cerebral perfusion system used during hypothermic circulatory arrest. (A = artery.)
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A cardiopulmonary bypass is established with bi-caval venous drainage and a right axillary arterial return, and cooling to a nasopharyngeal temperature of 25°C is begun. During the cooling period, the ascending aorta is clamped and antegrade cold blood cardioplegia is given to obtain heart arrest. The aorta is then opened and transected proximally above the sinotubular junction (Fig 2A). Next, an appropriately sized four-branched graft (Hemashield Platinum, Woven Double Velour [Boston Scientific Corp, Wayne, NJ]) is anastomosed to the proximal aorta using the preferred suture technique of the surgeon. Our preference is multiple interrupted 4-0 pledgeted polypropylene sutures and a running 4-0 polypropylene suture (Fig 2B).
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Fig 2. (A) Cardiopulmonary bypass is established. The ascending aorta is clamped and opened. (B) The proximal anastomosis is performed first. Of note, the four-branched graft is sutured in such a way so that the three branches of the graft exit from the right anterolateral aspect of the graft, which corresponds to the commissure between the right coronary and noncoronary cusps.
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Once the proximal anastomosis is completed and the target temperature is reached, a right-angled 9-French cannula (3.0 mm, Stoeckert, Pediatric Aortic Cannula [Sorin Group Deutschland GMBH, Munchen, Germany]) is inserted into both the left common carotid artery and the left axillary artery graft. Then selective cerebral perfusion is started with a flow rate of 10 mL/kg/minute, and systemic perfusion is discontinued. Next, the aortic clamp is removed and the ascending aorta is transected just proximal to the origin of the innominate artery. A divided, non-stented tube graft ("elephant trunk," 15 to 20 cm) is inserted into the descending aorta by pulling the edge of the lesser curvature of the graft with the aid of a catching catheter under an open distal condition. The distal end of the graft is marked with metal clips, which are later used to identify the distal end of the elephant trunk during follow-up examinations (Fig 3). A distal anastomosis is then performed at the base of the innominate artery between the four-branched graft and the distal aorta, incorporating the elephant trunk using a 4-0 polypropylene running suture. Any debris or air is flushed out by retrograde perfusion through the right femoral cannula before completing the distal anastomosis (Fig 4A). Antegrade systemic perfusion is then resumed through the fourth side-branch of the graft connected to the second arterial line while selective cerebral perfusion is maintained and rewarming is begun. Finally, the arch vessels are reconstructed by an end-to-end anastomosis using a 5-0 polypropylene suture to each individual branch graft during the rewarming period. Selective cerebral perfusion flow is proportionately reduced as the branch is reconstructed. The left subclavian artery can be simply ligated or closed with clips or sutures at its origin (Fig 4B).
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Fig 3. A divided tube graft ("elephant trunk") is inserted into the descending aorta (inset, arrow) with the aid of a catching catheter under an open distal condition. A 2-0 or 3-0 Tevdek suture (polyester; Akiyama Medical Manufacturing Co Ltd, Tokyo, Japan) is placed onto the lesser curvature of the elephant trunk so that the graft is not stretched while pulling it down. The distal end of the elephant trunk in this case was marked with metal clips.
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Fig 4. (A) A distal anastomosis is performed at the base of the innominate artery. (B) The arch vessels are reconstructed sequentially while rewarming the patient.
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Design of a Four-Branched Arch Graft and Elephant Trunk
With the present procedure, the ascending aorta is replaced in the limited space between the aortic root and origin of the innominate artery by a four-branched graft. Thus, the proximal side of the graft is divided at a short distance (usually 1 to 1.5 cm) from the lowest branch to ease the distal anastomosis done later.
The length and diameter of the elephant trunk is determined by preoperative computed tomographic angiography, with the goal that the distal end of the elephant trunk becomes located at the level of the sixth to eighth thoracic vertebra (T6 to T8 level). Postoperative examinations have demonstrated that when the distal contact zone obtained between the elephant trunk and uninvolved aortic wall at the T6 to T8 level is 3 cm or more in length, the aneurysmal lumen around the elephant trunk becomes obliterated by thrombus formation, and the elephant trunk is expected to become permanent and not require a second-stage distal aortic repair. The graft diameter is always undersized by 10% to 20% (range, 22 to 28 mm) of the distal aortic diameter, because the graft dilates postoperatively. In patients with distal descending aortic aneurysms, a second-stage procedure through a left thoracotomy or an endovascular elephant trunk completion is planned during the follow-up period.
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Clinical Experience
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The Institutional Ethics Committee approved this study. Informed consent for the procedures and subsequent follow-up evaluations was obtained from each patient. Between October 1998 and December 2005, we performed the present technique in 52 consecutive patients ranging in age from 25 to 83 years old (mean, 70 ± 10 years) (Table 1).
The technique was uniformly applicable for qualified patients with a wide variety of thoracic aortic pathologies, including localized transverse and distal arch aneurysms, diffuse aneurysmal disease (ie, chronic aortic dissection, Marfan syndrome, mega aorta), and multiple aneurysms (Table 2). Postoperatively, the distal end of the elephant trunk was located at the T5 to T10 level (mean, T8 level). There were no instances of graft kinking, stroke, or cardiac and hemorrhagic complications, and new phrenic or recurrent laryngeal nerve palsy did not develop in any of the patients. However, paraplegia due to a T6 level spinal cord injury developed in 1 patient, and paraparesis from a T1 to T4 level spinal cord injury in another patient. In these 2 patients, the open distal times were 16 and 22 minutes, respectively, and the distal ends of the elephant trunks were located at the T10 and T8 levels, respectively.
Survival within 30 days after surgery was 100%; however, there were 3 (6%) in-hospital deaths during the same period of hospitalization. Of those, 1 patient with morbid obesity, diabetes mellitus, and chronic renal failure died of complications from a tracheostomy and mediastinitis 3 months after surgery; 1 patient died due to a rupture of the thoracoabdominal aortic aneurysm on postoperative day 45; and another patient, a 79-year-old man with preoperative renal failure, died from septic multiple organ failure due to purulent cholecystitis 32 days after the second-stage operation.
In 30 of 52 patients, postoperative computed tomographic scans showed successful exclusion of the aortic arch aneurysm and complete covering of the atherosclerotic arch with the elephant trunk graft; thus, a second-stage operation was not required. Eleven patients underwent scheduled, rapid two-stage operations with intervals of 1 to 14 days. Six patients required a second-stage operation for the descending aorta more than 4 weeks after the initial operation because of incomplete thrombosis of the distal aneurysmal lumen around the elephant trunk. The remaining 5 patients are being followed-up for anticipated distal descending and thoracoabdominal aortic aneurysm surgery in the future. No anastomotic complications (eg, kinking, pseudoaneurysm, and so forth) occurred at the site of anastomosis between the branch grafts and the native vessels. The mean follow-up period after surgery was 49 ± 25 months (range, 14 to 98 months).
The mean duration of hypothermic systemic circulatory arrest (open distal time) was 24 ± 5 minutes at a nasopharyngeal temperature of 25°C. The mean duration of selective cerebral perfusion was 86 ± 9 minutes, whereas the mean cardiac arrest time was 122 ± 48 minutes. Thus, our technique led to shorter times for hypothermic circulatory arrest and selective cerebral perfusion compared with a conventional arch replacement procedure.
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Comment
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Although no instances of permanent stroke occurred, the 4% incidence of paraplegia or paraparesis in our series is of concern, because it is higher than in other series that used a standard arch repair technique [1] or frozen elephant trunk procedure [6]. Although the exact mechanism remains unclear [7], particular conditions related to our method might account for the significant incidence of paraplegia. We have observed that the maximum stretch length of an 18-cm Hemashield graft (Boston Scientific Corp) is 25 cm. If the same length of elephant trunk is inserted using our technique, it is likely that the graft becomes stretched longer than expected, thereby obliterating the orifices of the distal intercostal arteries. To solve this problem, we have recently refined the method by placing a 2-0 or 3-0 Tevdek suture (Akiyama Medical Manufacturing Co, Ltd, Tokyo, Japan) onto the lesser curvature of the elephant trunk, so as to fix its length and prevent stretching (Fig 3). It is also possible that during insertion of the elephant trunk a large quantity of debris or cholesterin is generated from the atheromatous intima or aneurysmal cavity, which can lead to embolization of the segmental intercostal or lumber arteries. Therefore, it is considered important to flush out any debris or air by retrograde perfusion before restoring systemic perfusion.
The technique described herein was shown to be safe and easy to perform. An advantage of our method is that all the anastomoses are visible to the surgeon; thus, any bleeding points can be easily controlled. Reconstruction of the arch vessels was also not difficult, especially in patients with an arch or distal arch aneurysm that terminates in the proximal descending aorta. Another advantage is that this technique could serve as a permanent elephant trunk [5]. A second-stage operation through a lateral thoracotomy was not required in the majority of the patients.
Using our method, the period of hypothermic circulatory arrest required for insertion of a long elephant trunk and distal anastomosis was considerably shorter than that with standard elephant trunk procedures that use a distal anastomosis beyond the left subclavian artery [2, 8] or between the left carotid and subclavian arteries [9].
Finally, though uncertainty remains regarding the optimal size and length of the elephant trunk and necessity of a stented end [6, 10], our experience suggests that the distal end of the elephant trunk should be located at or above the T6 to T8 level to avoid paraplegia as a result of spinal cord injury.
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Disclosures and Freedom of Investigation
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This study was supported by research funds to promote the hospital functions of the Japan Labour Health and Welfare Organization. The authors have no commercial association or sources of support that may pose a conflict of interest. The authors had full control of the study, methods used, outcome measurements, data analysis, and production of the written report.
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Disclaimer
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The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.
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Acknowledgments
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The authors wish to thank Kiyoshi Yoshida, CE and Keiji Yamamoto, CE of the Perfusion Technology Section, as well as former attending cardiovascular surgeons for their contributions to this study.
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References
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- Kazui T, Washiyama N, Bashar AHM, et al. Total arch replacement using aortic arch branched graft with the aid of antegrade selective cerebral perfusion Ann Thorac Surg 2000;70:3-8.
- Strauch JT, Spielvogel D, Lauten A, et al. Technical advances in total aortic arch replacement Ann Thorac Surg 2004;77:581-590.
- Borst HG, Frank G, Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach J Thorac Cardiovasc Surg 1988;95:11-13.
- 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.
- Kuki S, Taniguchi K, Masai T, et al. An alternative approach using long elephant trunk for extensive aortic aneurysm: elephant trunk anastomosis at the base of the innominate artery Circulation 2002;106(suppl I):I253-I258.
- Karck M, Chavan M, Khaladj N, Friedrich H, Hagl C, Haverich A. The frozen elephant trunk technique for the treatment of extensive thoracic aortic aneurysms: operative results and follow-up Eur J Cardiothorac Surg 2005;18:286-290.
- Miyairi T, Kotsuka Y, Ezure M, et al. Open stent-grafting for aortic arch aneurysm is associated with increased risk of paraplegia Ann Thorac Surg 2002;74:83-89.
- LeMaire SA, Carter SA, Coselli JS. The elephant trunk technique for staged repair of complex aneurysms of the entire thoracic aorta Ann Thorac Surg 2006;81:1561-1569.
- Svensson LG, Kaushik SD, Marinko E. Elephant trunk anastomosis between left carotid and subclavian arteries for aneurysmal distal aortic arch Ann Thorac Surg 2001;701:1050-1052.
- 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):II188-II193.
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Abstract
Introduction
