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J Thorac Cardiovasc Surg 1995;110:267-269
© 1995 Mosby, Inc.

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A new staged operation for extensive aortic aneurysm by means of the modified "elephant trunk" technique

Hamamatsu, Japan

From the Division of Cardiovascular Surgery, Hamamatsu Rosai Hospital, Hamamatsu, Japan.

A new first-stage operation through a median sternotomy for extensive aortic aneurysm involving the ascending aorta, the aortic arch, and the descending aorta is presented

OPERATIVE PROCEDURES

Minimum dissection of the ascending aorta and the proximal aortic arch is done through a median sternotomy. Cardiopulmonary bypass is established by femoral and bicaval venous cannulations. The patient is cooled to a nasopharyngeal temperature of 18º C. Then circulatory arrest is obtained with continuous retrograde cerebral perfusion (CRCP). ¹ Myocardial protection is obtained by retrograde cardioplegia with crystalloid solution and blood. A longitudinal incision is made on the ascending aortic aneurysm and is extended minimally to the aortic arch. Circumferential incisions are added on the ascending aorta at the level of normal wall and at the proximal portion to the arch vessels (Fig. 1, A). No occlusive clamps are used. A long gelatin-coated woven Dacron graft is inserted into the descending aortic aneurysm as an "elephant trunk" prosthesis. ² Then a side-to-side anastomosis of the graft to the aortic portion of the arch vessels is performed with 3-0 polypropylene running sutures (Fig. 2, A). The space between the graft and the proximal stump of the aortic arch aneurysm to the arch vessels is closed with 3-0 polypropylene running sutures with a Teflon felt strip placed circumferentially on the outer side. In this procedure, the aneurysmal stump can be trimmed to accommodate a large size discrepancy between the graft and the aneurysmal stump (Fig. 2, B). Fibrin glue is applied on the suture lines.

View larger version (39K): [in this window] [in a new window]   Fig. 1. A, Entire aneurysm and incision lines. The ascending aorta is incised longitudinally and transected at the level of normal wall and at the proximal portion to the arch vessels. The obliquely lined part is trimmed to fit the size of the aneurysmal stump to the graft inserted later. B, Completion of the first stage of the operation with the whole aneurysm.

View larger version (91K): [in this window] [in a new window]   Fig. 2. A, A long gelatin-coated woven Dacron graft is inserted into the descending aortic aneurysm as an "elephant trunk" and anastomosed to the arch vessels in a side-to-side fashion as a unit. B, The space between the graft and the proximal stump of the aneurysm to the arch vessels is closed by polypropylene sutures with a Teflon felt strip, and a V-shaped defect of the stump of the aneurysm is sutured. C, The graft is clamped to confirm no leakage from the suture lines by continuing CRCP and retrograde arterial perfusion. Antegrade perfusion through the graft and rewarming are started while CRCP and retrograde arterial perfusion are suspended. Then an end-to-end anastomosis of the graft to the ascending aorta is made.

DISCUSSION

Total repair of aneurysms involving the ascending aorta, the aortic arch, and the descending aorta remains challenging, with high morbidity and mortality, especially in older patients. However, operative techniques and adjuncts are now being developed rapidly. The so-called "elephant trunk" two-stage approach ² is less invasive and technically easier than a one-stage replacement of the entire aorta. In this method, however, the descending aortic portion of the distal anastomosis to the graft needs to have normal tissue and be of normal size. The anastomosis has to be made in a deep aortic or aneurysmal cavity, which is difficult, even though this procedure has been technically improved by using the graft invaginated on itself. ³

Our method can be applied in any extensive aortic aneurysm involving the aortic arch and the descending aorta by a modification in which the seal between the aneurysm and the graft is made on the aorta proximal to the arch vessels rather than distal to them.

We usually use circulatory arrest with CRCP as an adjunct in operations around the aortic arch. ¹ It makes our method easier and safer than using only circulatory arrest, because taping or clamping of the aorta or the arch vessels, which may cause injuries of the arterial intima, dissections, or protruding atheromatous masses from the arterial wall, is not necessary.

The distal procedure of closing the space between the graft and the proximal stump of the aneurysm is technically easy because it can be done closer to the surgeons. The use of a Teflon felt strip reinforces the aortic wall and ensures hemostasis. Bleeding from the anastomosis of the graft to the aortic portion of the arch vessels may require attention, but the hemostasis will be completed, because the anastomotic suture lines are included in the lumen of the aneurysm and the pressure gradient between the inner and outer sides of the graft at the anastomosis is minimal. Borst, and associates, ³ in 1988, reported thromboexclusion phenomenon ⁴ in one patient of eight who had undergone "elephant trunk" techniques. We are expecting such phenomenon with our method as well.

CLINICAL APPLICATION

This method was successfully applied in a 77-year-old woman with a large aneurysm extending from the ascending aorta to the descending aorta. Its maximum diameter was about 7 cm. The periods of cardiopulmonary bypass, aortic clamping, and CRCP were 192, 105, and 57 minutes, respectively. About 1 month after the operation, the enhanced computed tomographic scans and digital scan angiograms showed clots progressing distally around the graft. She is now at the point of receiving only medication or undergoing the second-stage operation for the remaining descending aortic aneurysm.

Footnotes

J THORAC CARDIOVASC SURG 1995;110:267-9

References

1. 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]
   
2. Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37-40.[Medline]
   
3. Borst HG, Frank G, Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J THORAC CARDIOVASC SURG 1988;95:11-3.[Abstract]
   
4. Carpentier A, Deloche A, Fabiani JN, et al. New surgical approach to aortic dissection: flow reversal and thromboexclusion. J THORAC CARDIOVASC SURG 1981;81:659-68.[Abstract]
   

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