Elephant trunk procedure for surgical treatment of aortic dissection

Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan.
The Annals of Thoracic Surgery (Impact Factor: 3.85). 08/1998; 66(1):82-7.
Source: PubMed


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

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    • "Several authors have recommended surgical extension to TAR using a modified elephant trunk technique in the following settings: tear in the arch (excluding the minor curvature), tear in the descending aorta ("retrograde dissection"), reentry in the arch or the proximal descending aorta, Marfan syndrome, arch aneurysm or dilatation, atheromatous arch, massive arch dissection, and an age of <70 years [4,5,14,15]. Kato et al. [16] suggested that total arch graft replacement accompanied by descending thoracic aortic stent graft implantation might provide better results during both the early and late stages, especially with regards to the outcomes of the false lumen patency. "
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    ABSTRACT: Total arch replacement (TAR) is being more widely performed due to recent advances in operative techniques and cerebral protective strategies. In this study, the authors reviewed the relationship between TAR and early- and mid-term changes of the false lumen after TAR in acute type A aortic dissection. Twenty-six patients (aged, 54.7±13.3 years) who underwent TAR for acute type A dissection between June 2004 and February 2012 were reviewed. The relationship between the percentage change in the aortic diameter and the false lumen patency status was assessed by examining the early and late postoperative computed tomography imaging studies. There were two in-hospital mortalities, one late death, and three follow-up loses. The mean follow-up duration for the final 21 patients studied was 54±19.0 months (range, 20 to 82 months). The incidence of false lumen thrombosis within 2 weeks of surgery in the proximal, middle, and distal thoracic aorta, and the suprarenal and infrarenal abdominal aorta were 67%, 38%, 38%, 48%, and 33%, respectively, and 57%, 67%, 52%, 33%, and 33% for those examined at a mean of 49±18 months after surgery, respectively. The false lumen regressed in 11 patients (42.3%). The aortic diameters were larger in the patients with a patent false lumen than those with a thrombosed false lumen at all levels of the descending aorta (p<0.05). TAR and a more complete primary tear-resection can be accomplished with a relatively low-risk of morbidity and mortality. Enlargement of the distal aorta significantly correlated with the false lumen patency status.
    Korean Journal of Thoracic and Cardiovascular Surgery 02/2013; 46(1):33-40. DOI:10.5090/kjtcs.2013.46.1.33
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    • "With the recent advancement in the diagnostic technique for acute aortic dissection, the pre-operative work-up, post-operative management, and the methods of cardiopulmonary bypass, attempts have been made to enhance the early surgical results as well as to reduce the incidence of follow-up complications.4-6) It has been reported that the occurrence of secondary aneurysms due to a patent false lumen is the risk factor affecting the long-term treatment outcomes, so the distal extent of resection should include the intimal tear and could produce good treatment outcomes.7-9) "
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    ABSTRACT: Stanford type A aortic dissection is a potentially catastrophic event that requires surgical repair, on an emergency basis. The extent of arch repair that should be carried out during emergency surgery of this type is controversial. This study was designed to evaluate the results of arch replacement carried out during acute type A dissection. 28 patients with Stanford type A dissection and who underwent arch replacement between 1995 and 2006 were reviewed. Hospital mortality was 3.6% (1 patient), and transient neurocognitive dysfunction was observed in 5 patients. During the follow-up period (mean 26+/-20 months; range 1 to 66 months), 3 patients underwent reoperation due to descending thoracic or abdominal aortic aneurysm. There was no late death. Follow up computed tomography was performed in 15 patients and false lumen disappeared totally or partially in 10 patients (66.7%). Arch replacement for acute Stanford type A dissection may decrease the risk of late complications related to false lumen and lead to an excellent midterm survival rate.
    Korean Circulation Journal 07/2009; 39(7):270-4. DOI:10.4070/kcj.2009.39.7.270 · 0.75 Impact Factor
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    ABSTRACT: Die chirurgische Therapie kombinierter Pathologien der Aorta ascendens, des Aortenbogens sowie der Aorta descendens stellt auch heute noch hohe Ansprüche an den Operateur. 1983 wurde zur Therapie solch komplexer Aortenaneurysmen von Borst et al. das Verfahren der Elephant-trunk-Technik etabliert und hat seitdem als anerkanntes Standardverfahren die chirurgische Behandlung dieser Pathologien erleichtert. Als Erweiterung dieses Verfahrens wurde vor einigen Jahren die Frozen-elephant-trunk-Technik (Hybridverfahren) eingeführt. Sie erlaubt die einzeitige definitive Versorgung von segmentübergreifenden Aneurysmen der Aorta ascendens, des Aortenbogens und der Aorta descendens über eine mediane Sternotomie unter Verwendung einer neuartigen Gefäßprothese mit Stentanteil, der antegrad in die Aorta descendens eingebracht wird. Anschließend wird der Aortenbogen und ggf. auch die Aorta ascendens in konventioneller Weise ersetzt. Das neue Verfahren kann mit einem Risiko verwendet werden, das demjenigen der konventionellen Elephant-trunk-Technik vergleichbar ist. Sein wesentlicher Vorteil liegt darin, dass es sich hierbei um einen einzeitigen Eingriff handelt und damit ein mit der konventionellen Variante erforderlicher Zweiteingriff entfallen kann. Obwohl sich die chirurgische Strategie an der individuellen Pathologie des Patienten orientiert, könnte die Frozen-elephant-trunk-Technik das bisherige konventionelle Verfahren als Behandlungsstandard für ausgedehnte Aortenaneurysmen ersetzen. Surgical treatment of combined pathologies of the ascending aorta, aortic arch and the descending aorta still makes great demands on the surgeon. In 1983 Borst et al. established the elephant trunk procedure for treatment of such complex aortic aneurysms, which subsequently became the recognized standard procedure and has simplified the surgical treatment of these pathologies. The frozen elephant trunk technique (hybrid procedure) was recently introduced as an extension of this procedure. This procedure permits the single-stage definitive treatment of intersegmental aneurysms extending over the ascending aorta, the aortic arch and the descending aorta via transmediastinal sternotomy using a new type of prosthetic bypass graft with stent portion, which is inserted anterograde in the descending aorta. The aortic arch and, if necessary, the ascending aorta are subsequently replaced in the conventional manner. The new procedure can be implemented with a risk probability which is comparable to that of the elephant trunk technique. The main advantage is that this is a single-stage approach and the second stage which is necessary by the conventional approach can be omitted. Although the surgical strategy is oriented to the individual pathology of each patient, the frozen elephant trunk technique could replace the previous conventional procedure as the treatment standard for extensive aortic aneurysms.
    Gefässchirurgie 14(3):183-190. DOI:10.1007/s00772-009-0695-z · 0.24 Impact Factor
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