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).
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.
Available from: PubMed Central
- "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.  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.
Available from: Maximilian Andreas Pichlmaier
- "0 Heinemann  1995 72 24 (33%) 10 (13.8%) 5 (7%) 3 (4.2%) 0 Palma  1997 70 14 (20%) 2 (2.8%) 2 (2.8%) 0 Type B dissections Ando  "
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ABSTRACT: The treatment of complex aortic pathology involving both the ascending and descending aortic segments at the same time represents a surgical challenge, with high postoperative morbidity and mortality rates reported. Over the past 27 years, different open surgical and endovascular techniques have been introduced and applied in various two-stage- or one-stage approaches to such cases. Thus, in 1983, Hans Borst significantly changed the traditional two-stage approach by introducing his elephant trunk technique. Leaving a segment of Dacron prosthesis reaching into the descending aorta during the first stage, the second-stage replacement of the residual dilated descending aorta was made far easier. The presence of interval mortality between the two stages, the unaffected need for two large operations to complete aortic repair, and the general failure of some patients to return for the second-stage repair set the scene for the development of one-stage procedures, both open surgical or hybrid surgical and endovascular, such as the frozen elephant trunk. However, the size of the operation, on the one hand, and the risk of spinal cord injury and need for surgical or endovascular completion during follow-up, on the other, have dampened enthusiasm. Recently, the introduction of supra-aortic debranching and endovascular aortic arch stent-graft repair has yet extended treatment to high-risk patients unsuitable to the more aggressive surgery, but mid- and long-term follow-up results are lacking. The lack of randomization and the presence of procedural and complication-related limitations for each technique do not allow for definitive conclusions about the ideal procedure to treat complex aortic pathology. However, the technical revolution experienced over the past 27 years, along with the improvement in perioperative management, has produced outstanding morbidity and mortality results even in this challenging patient population, but the decision regarding which pathology correlates with what operation remains highly debated and dependent also on regional competence.
Available from: Tae-Gook Jun
- "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.
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