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Ann Thorac Surg 1998;66:82-87
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Elephant trunk procedure for surgical treatment of aortic dissection¹

^a Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan

Accepted for publication February 11, 1998.

Address reprint requests to Dr Ando, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565, Japan

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Background. In surgical intervention for aortic dissection, a highly radical operation can be performed by distal anastomosis with a true lumen resulting in thrombotic closure of the dissecting lumen. In this anastomosis, the elephant trunk procedure, in which a graft is inserted into the distal true lumen, prevents blood flow leakage into the dissecting lumen at the anastomosis site and also strengthens this area.

Methods. We performed this procedure in 15 patients (8 men and 7 women). Acute aortic dissection was observed in 9 patients and chronic dissection in 6. Stanford type A dissection was diagnosed in 10 patients and type B in 5.

Results. Graft replacement of the ascending aorta and total aortic arch was performed in 10 patients and descending aortic replacement in 5. A graft with a diameter of 16 to 24 mm was inserted into the true lumen of the descending aorta, and the false lumen was closed. Subsequently, distal anastomosis was performed on the true lumen. There were two hospital deaths. Postoperative digital subtraction angiography showed good results in living patients, and computed tomographic scanning showed thrombotic closure in the dissecting lumen of the descending aorta.

Conclusions. The elephant trunk procedure is useful for closing the false lumen of the distal aorta.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
In the reconstruction of aortic dissection, a highly radical operation can be performed by distal anastomosis with a true lumen resulting in thrombotic closure of the false lumen. It is well recognized that the prognosis of patients with thrombosed distal false lumen is superior to that of those with patent false lumen. In this anastomosis, the elephant trunk procedure, in which a graft is inserted into the distal true lumen, prevents blood flow leakage into the false lumen at the anastomosis site and also strengthens this area.

We performed this procedure in 15 patients between January 1995 and December 1996 and analyzed the results.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Patients
In Stanford type A aortic dissection, the elephant trunk procedure was performed in 10 patients, 6 men and 4 women from 40 to 67 years of age (mean, 56 years). Acute dissection was observed in 8 patients and chronic dissection in 2. The site of the initial intimal tear was the distal arch in 5 patients, aortic arch in 4, and descending aorta in 1 patient. Three patients had aortic regurgitation, 1 patient had acute myocardial infarction, and 1 patient had coronary heart disease and old cerebral infarction, preoperatively (Table 1).

Surgical techniques
Figure 1A shows the elephant trunk procedure in type A dissection. Deep hypothermia, circulatory arrest, and retrograde cerebral perfusion were used for cerebral protection. When distal anastomosis was performed, the descending aorta just below the left subclavian artery was transected, a graft was inserted into the true lumen of the descending aorta, and the false lumen was closed. Subsequently, the arch graft was anastomosed to the true lumen of the descending aorta. Figure 1B shows the elephant trunk procedure in type B dissection. After the false lumen of the descending aorta was closed by the elephant trunk method, distal anastomosis was performed on the true lumen of the descending aorta. Table 2 shows the surgical techniques in type A and B aortic dissections. In type A aortic dissection, graft replacement of the ascending aorta and total aortic arch, as well as reconstruction of three cervical vessels with a middle-sized graft, was performed in all patients because 9 patients had the initial intimal tear in the aortic arch and 1 patient had the entry in the proximal descending aorta. Concomitant procedures were coronary artery bypass grafting in 2 patients, aortic valve resuspension in 2, valved conduit operation in 1, and infrarenal Y-grafting in 2 patients. In type B dissection, graft replacement of the proximal descending aorta was performed in all patients. As an adjunctive procedure, deep hypothermia and circulatory arrest with retrograde cerebral perfusion was used to avoid the clamp on the aortic arch in 4 patients who had aortic arch involvement, and a partial cardiopulmonary bypass was used in 1 patient in whom the aortic clamp was possible on the descending aorta just below the left subclavian artery.

View larger version (31K): [in this window] [in a new window]   Fig 1. (A) Elephant trunk procedure in type A aortic dissection. Graft replacement of the ascending aorta and total aortic arch was performed. (B) Elephant trunk procedure in type B aortic dissection. Graft replacement of the descending aorta was performed.

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment References

View larger version (120K): [in this window] [in a new window]   Fig 2. Treatment for acute type A dissection with annuloaortic ectasia. (A) Postoperative digital subtraction angiograms (arrow shows elephant trunk), (B) preoperative (Preop), and (C) postoperative (Post Op) computed tomographic scans from a 40-year-old man (patient 5) treated with graft replacement of the ascending aorta and total aortic arch with a valved conduit. After operation, the false lumen in the proximal descending aorta was closed with thrombi (C, arrows).

View larger version (130K): [in this window] [in a new window]   Fig 3. Treatment for chronic type B dissection. (A) Preoperative (Preop) and (B) postoperative (Post Op) digital subtraction angiograms (arrow shows elephant trunk) and computed tomographic scans from a 44-year-old man (patient 12) treated with graft replacement of the descending aorta. After operation, the false lumen in the total descending aorta was closed with thrombi (B, arrows).

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment References

Borst and colleagues [5, 6] introduced the elephant trunk procedure, and others have adopted this technique [7, 8]. This procedure is applicable to aneurysms of the aortic arch and proximal descending aorta, and is useful to prepare for a second surgical procedure. To prevent blood flow leakage into the distal false lumen, we used a modification of the elephant trunk technique for the reconstruction of the aortic dissection that also strengthens the anastomosis site. Ergin and associates [9] found a 56% patency of distal false lumens in sutured anastomoses. This patent distal false lumen decreased the survival rate in long term. They concluded that the anastomotic technique is an important factor related to complications of the distal false lumen. We also experienced a 28% patency of distal false lumens in the descending aorta without using this technique. This technique provided thrombotic closure of the distal false lumen just below the distal anastomosis of the descending aorta in 14 recent patients. The improvement of long-term prognosis after surgical repair of aortic dissections will be largely dependent on the reduction of complications related to the distal false lumen. Problems with this elephant trunk procedure include the obstruction of outflow vessels and stenosis of the true lumen. Therefore, we used this technique in the anastomosis of the distal arch and middle portion of the descending aorta. If the true lumen was very thin, this technique was abandoned.

Deep hypothermia with retrograde cerebral perfusion and selective cerebral perfusion are both widely used to prevent brain ischemia during aortic arch and proximal descending aortic reconstructions. We used retrograde cerebral perfusion [10, 11] as an adjunct in 14 patients.

In conclusion, we performed the elephant trunk procedure for the treatment of aortic dissection in 15 recent patients. Postoperative computed tomographic scanning showed thrombotic closure in the dissecting lumen of the descending aorta. The elephant trunk procedure, in which a graft is inserted into the true lumen of the distal aorta, is useful for closing the false lumen of the descending aorta.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
¹ This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals

	References

Top Footnotes Abstract Introduction Material and methods Results Comment References

 

1. DeBakey M.E., McCollum C.H., Crawford E.S., et al. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery 1982;92:1118-1134.[Medline]
2. Heinemann M., Laas J., Karck M., Borst H.G. Thoracic aortic aneurysms after acute type A aortic dissection: necessity for follow-up. Ann Thorac Surg 1990;49:580-584.[Abstract]
3. Daily P.O., Trueblood H.W., Stinson E.B., Wuerflein R.D., Shumway N.E. Management of acute aortic dissections. Ann Thorac Surg 1970;10:237-247.[Medline]
4. Ando M., Nakajima N., Adachi S., Nakaya M., Kawashima Y. Simultaneous graft replacement of the ascending aorta and total aortic arch for type A aortic dissection. Ann Thorac Surg 1994;57:669-676.[Abstract]
5. Borst H.G., Walterbusch G., Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37-40.[Medline]
6. Borst H.G., Frank G., Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988;95:11-13.[Abstract]
7. Crawford E.S., Coselli J.S., Svensson L.G., Safi H.J., Hess K.R. Diffuse aneurysmal disease (chronic aortic dissection, Marfan’s, and mega aorta syndromes) and multiple aneurysm: treatment by subtotal and total aortic replacement emphasizing the elephant trunk operation. Ann Surg 1990;211:521-537.[Medline]
8. Svensson L.G. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Card Surg 1992;7:301-312.[Medline]
9. Ergin M.A., Phillips R.A., Galla J.D., et al. Significance of distal false lumen after type A dissection repair. Ann Thorac Surg 1994;57:820-825.[Abstract]
10. Ueda Y., Miki S., Kusuhara K., Okita Y., Tahata T., Yamanaka K. Deep hypothermic systemic circulatory arrest and continuous retrograde cerebral perfusion for surgery of aortic arch aneurysm. Eur J Cardiothorac Surg 1992;6:36-41.[Abstract]
11. Takamoto S., Okita Y., Ando M., Morota T., Handa N., Kawashima Y. Retrograde cerebral circulation for distal aortic arch surgery through a left thoracotomy. J Card Surg 1994;9:576-583.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Motomi Ando Shinichi Takamoto Yutaka Okita Tetsuro Morota Soichiro Kitamura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ando, M. Articles by Kitamura, S. Search for Related Content PubMed PubMed Citation Articles by Ando, M. Articles by Kitamura, S.