Aortic remodelling effect of the frozen elephant trunk technique on Stanford type A acute aortic dissection

Total arch replacement using the frozen elephant trunk procedure is performed for true lumen expansion of the descending aorta in patients with type A acute aortic dissection. However, the remodelling effect of the frozen elephant trunk on the dissected descending aorta is unclear. We aimed to evaluate the effect of the frozen elephant trunk on postoperative descending aortic remodelling after surgery. Between December 2012 and January 2020, we retrospectively investigated 24 patients who underwent total arch replacement using the frozen elephant trunk for type A acute aortic dissection. Remodelling of the descending aorta was evaluated using computed tomography. The aortic remodelling effect, based on aortic true lumen ratio, was determined for (i) DeBakey type (type I versus type III retrograde); (ii) thoracic endovascular aneurysm repair reintervention status (reintervention versus no reintervention); and (iii) stent length of the frozen elephant trunk (60 vs 90 mm). Postoperative true lumen ratio significantly increased in the type I dissection group. The true lumen ratio in the no-reintervention group, which had many patients with the type I dissection, significantly increased after the frozen elephant trunk. Aortic remodelling due to the frozen elephant trunk can be expected after type I acute aortic dissections.     

Impending rupture of the descending aorta by enlargement of the false lumen after graft replacement with the elephant trunk technique: Report of a case

We report herein a case of an impending rupture of the descending aorta caused by an enlargement of the false lumen after a graft replacement using the elephant trunk technique. The patient was a 51-year-old woman who had received a graft replacement of the ascending aorta for an acute Stanford type A aortic dissection 6 years previously. An enhanced computed tomographic scan and digital subtraction angiography revealed pseudoaneurysms at the proximal and distal anastmotic site, and a residual dissection of the aortic arch. A graft replacement of the ascending aorta to the aortic arch was performed with the distal site using the elephant trunk technique. Five days after the operation, massive bleeding from the drainage tube occurred. A chest enhanced computed tomographic scan suggested an impending rupture of the descending aorta caused by an enlargement of the false lumen. A graft replacement of the descending aorta was carried out. Postoperatively she had no complications, and digital subtraction angiography showed an excellent reconstruction of the thoracic aorta. One month after the second operation, she was discharged from hospital.     

Secondary elephant trunk fixation with endovascular stent grafting for extensive/multiple thoracic aortic aneurysm.

Four patients who underwent secondary elephant trunk fixation by endovascular stent grafting are presented and the advantage of this method to treat multiple/extensive thoracic aortic aneurysm is discussed. In two of them, the elephant trunk installation has been performed at another hospital for extensive aortic aneurysm. In two other patients, the aortic arch replacement and the elephant trunk installation were performed through median sternotomy, initially for multiple aortic lesions, including both arch and descending aorta. No neurological deficit, stroke nor spinal cord injury was encountered during the follow-up period (24-40 months). The diameter of the aneurysms decreased markedly in three patients. In one patient, the aneurysm expanded gradually and type II endoleak was treated by coil embolization. In one patient, who showed marked shrinkage of the aneurysm, the stent graft kinked mildly. Based on the low mortality rate of well-established aortic arch surgery, concomitant elephant trunk installation which was followed by the secondary fixation with endovascular stent grafting might be useful to treat multiple/extensive thoracic aneurysm from distal arch to descending aorta.     

Aortic arch repair for Stanford type A aortic dissection with distal anastomosis to the proximal level of the distal aortic arch

BACKGROUND: In acute type A dissection, replacing the ascending aorta with the transverse aortic arch recently has been recommended for event-free long-term survival. Since 1994, we have performed our new transverse aortic arch replacement, in which the distal end of the graft is anastomosed between the left common carotid artery and the left subclavian artery to reduce the risk by obtaining a good surgical view, resulting in good hemostasis. The "elephant trunk technique" was used in anticipation of a staged descending aortic operation for residual dissecting aorta. We analyzed the surgical survival of patients with Stanford type A aortic dissection undergoing our operative procedure using hypothermic selective antegrade cerebral perfusion. METHODS: We performed our new technique in 27 patients (aged 61 +/- 11 years, 15 male and 12 female patients, 22 patients with acute type A dissection, and 5 patients with chronic dissection). RESULTS: One in-hospital death (3.7% in total: 4.5% in acute dissection, 0% in chronic dissection) occurred in patients undergoing our new technique. Actuarial survival (including early death) was 91% at 5 years after the operation. One late death occurred as the result of a malignant tumor. Four patients underwent a staged reoperation for aneurysmal dilatation of the residual descending aorta or renal and splenic embolism as the result of thrombus from the false lumen 2 to 11 months (mean interval 6 months) after the initial operation. They have been doing well since the reoperation. CONCLUSIONS: Our "distal anastomosis to the proximal level of the distal aortic arch" technique made aortic arch replacement easier and improved the survival of the arch replacement for aortic dissection, especially for acute type A dissection, by securing hemostasis in the suture line. Combining the elephant trunk technique with our new procedure is useful to perform a staged aortic replacement for dilatation and complication of the false lumen in the descending aorta.     

Aortic arch replacement with covered stent-graft as elephant trunk for a type A acute aortic dissection

We report a case of aortic arch replacement with a covered stent-graft as an "elephant trunk". A 54-year-old woman was diagnosed with Stanford type A aortic dissection. The initial intimal tear was located in the distal aortic arch. Under deep hypothermic circulatory arrest and retrograde cerebral perfusion, the distal end of the arch graft, which was turned inside out and reinforced with a Z-stent, was inserted into the distal true lumen as an "elephant trunk". Distal anastomosis was performed between the aortic wall and the inverted external graft. Graft replacement of the aortic arch and ascending aorta was followed by proximal arch grafting. Coronary artery bypass grafting to RCA was performed concomitantly. The postoperative course was uneventful, and the distal false lumen became thrombosed. This procedure is effective for reliable distal anastomosis and prevention of blood leakage into the distal false lumen.     

Der Frozen-Elephant-Trunk

The frozen elephant trunk (FET) technique is a hybrid procedure combining conventional and endovascular aortic surgery to allow 1?stage treatment of the aortic arch and the proximal descending aorta. The indications for the FET operation include several aortic pathologies, such as aneurysms, acute and chronic dissections with involvement of the (distal) arch and the proximal descending aorta. The hybrid prosthesis consists of a vascular graft for transverse arch replacement with supra-aortic revascularization and a distally located stent for endovascular treatment of the descending aorta. After antegrade stent grafting of the distal aortic segment, partial or total aortic arch replacement is performed via the conventional open technique. The FET operation is nowdays routinely performed in specialized aortic centers worldwide. This article gives an overview with resoect to the clinical indications, technical aspects and postoperative results of the FET operation.     

支架"象鼻"术治疗DeBakey Ⅰ型主动脉夹层动脉瘤

目的 探讨支架"象鼻"手术治疗DeBakey Ⅰ型主动脉夹层动脉瘤(AD)的方法和效果.方法 12例DeBakey Ⅰ型AD患者,平均年龄48.1岁.采用深低温停循环(DHCA),右腋动脉顺行灌注(SCP)脑保护,实施支架"象鼻"手术(即升主动脉和全弓置换及降主动脉腔内支架植入).结果 术后死亡1例,手术死亡率8.3%.术中体外循环时间(163.2±17.7)min,停循环时间(41.6±12.3)min.随访3～6个月,无死亡病例.结论 支架"象鼻"手术简单,停循环时间短,治疗DeBakey I型夹层主动脉瘤安全、有效.     

主动脉夹层的细化分型及其应用

目的探讨在Stanford分型的基础上根据主动脉夹层的部位和病变程度再进行细化分型,对指导临床选择手术时机、确定治疗方案和手术方式,以及判断预后的价值。方法1994年1月至2004年12月我院治疗主动脉夹层708例。其中Stanford A型夹层477例：（1）根据主动脉根部病变程度分为3型。A1型（主动脉窦部正常型）212例,行保留主动脉窦部的主动脉替换;A2型（主动脉窦部轻度受累型）72例,行主动脉窦部成形63例、David手术9例;A3型（主动脉窦部重度受累型）193例,行主动脉根部替换术（Bentall手术）。（2）根据主动脉弓部病变分为2型。C型（复杂型）78例,行主动脉弓部替换＋象鼻术;S型（单纯型）399例,行部分主动脉弓部替换。Stanford B型夹层231例,（1）根据主动脉扩张的范围分为3型：B1型：降主动脉无扩张或仅有近端扩张,147例,行腔内带膜支架主动脉腔内修复术103例（B1S型）、部分胸降主动脉替换术32例、部分胸降主动脉替换术＋远端支架象鼻术12例;B2型：全部胸降主动脉扩张,53例,行部分胸降主动脉替换术＋主动脉成形32例、全部胸降主动脉替换术21例;B3型：全部胸降主动脉及腹主动脉扩张,31例行胸腹主动脉替换术。（2）根据左锁骨下动脉和远端主动脉弓部是否受夹层累及分为2型：C型（复杂型）：夹层累及左锁骨下动脉或远端的主动脉弓部,44例,在深低温停循环下手术治疗;S型（单纯型）：远端主动脉弓部和左锁骨下动脉未受夹层累及,187例,介入治疗103例、手术治疗84例（常温阻断下手术60例,股动脉-股静脉转流下手术24例）。结果Stanford A型夹层住院病死率为4．6％（22／477）,并发症发生率为14．5％（69／477）。Stanford B型夹层：介入治疗组病死率1．9％（2／103）,并发症发生率为2．9％（3／103）,轻度内漏发生率为9．7％（10／103）;手术治疗组住院病死率为3．1％（4／128）,并发症发生率为18．8％（24／128）。结论细化主动脉夹层的分型对于术前判断手术时机、制定手术方案和初步判断预后,具有重要的指导作用。     

术中支架系统在主动脉夹层外科手术中的应用

目的 总结术中支架系统在主动脉夹层外科手术中应用的临床经验.方法 1 17例主动脉夹层病人,在深低温停循环下行含术中支架系统直视下置入的手术.Stanford A型50例中行Bentall+全弓+支架象鼻术(CRONUS术中支架系统直视下置入)28例,Wheat+全弓+支架象鼻术8例,升主动脉及全弓置换+支架象鼻术14例.Stanford B型67例均行支架象鼻术.结果 体外循环(159±31)min,主动脉阻断(95±23)min,脑灌注(27±8)min.住院死亡3例.发生一过性脑功能紊乱11例,脑血管意外6例,血管吻合口出血开胸止血5例,声音嘶哑2例,肾功能衰竭1例.术后CT均显示,术中支架系统位置良好,血流通畅,无内漏,降主动脉真腔较术前明显扩大,未闭的降主动脉假腔血栓形成.结论 术中支架系统在主动脉夹层手术中的应用是安全、有效的.其能准确封闭血管内膜破口,实现血管壁的重建,简化手术,创伤小,并发症少,疗效确切.     

“改良”次全弓置换加支架象鼻手术治疗Stanford A型主动脉夹层

目的总结和评价"改良"次全弓置换加支架象鼻手术治疗Stanford A型主动脉夹层患者的临床疗效。方法 2009年12月至2011年1月,中国医科大学附属第一医院接收47例Stanford A型主动脉夹层患者行"改良"次全弓置换加支架象鼻手术,其中男35例,女12例;年龄29～86(57.9±16.0)岁。患者均依据术前主动脉计算机断层扫描动脉成像诊断分型,在深低温停循环选择性脑灌注下施行手术;近心端采用升主动脉置换术29例,Bentall手术11例,Wheat手术4例,David手术3例;同期行冠状动脉旁路移植术(CABG)5例。结果体外循环时间(136±32)min,主动脉阻断时间(97±28)min,深低温停循环选择性脑灌注时间(27±11)min。47例患者中住院期间死亡2例(4.25%,2/47),术后一过性精神障碍2例(4.25%,2/47),术后出现截瘫1例(2.12%,1/47),二次开胸止血4例。生存的45例患者均于出院前及术后6个月行主动脉3维CT血管造影(3D CTA)检查显示,降主动脉内支架血管膨胀良好,气管隆突及腹腔干平面真腔较术前明显扩大(P0.05);术后随访1～13个月,无因夹层进展需二次手术及动脉瘤破裂患者。结论 "改良"次全弓置换术加支架象鼻手术是治疗弓部三分支血管无破口的Stanford A型主动脉夹层安全、有效的方法,改良之处在于简化手术,缩短了手术时间、体外循环和深低温停循环时间,减少了手术相关并发症的发生;近期效果良好。     

Total aortic arch replacement in Stanford type A aortic dissection using a new method of implanting the stented graft

In surgery for Stanford type A aortic dissection (SAAD) with intimal tear in the arch or proximal descending aorta, we performed total arch replacement with frozen elephant trunk technique for the purpose of achieving complete exclusion of the entry. To reduce the circulatory arrest time, we developed a quick stent graft placement method in the proximal descending aorta. We reported the early results and assessed the efficacy of our new method. Between March 2006 and February 2010, 52 consecutive patients with SAAD were divided into 2 groups:group A consisted of 17 patients who received total arch replacement with our new method;group B consisted of 35 patients who received ascending aorta or partial arch replacement. The duration of operation and cardiopulmonary bypass were significantly longer in group A. However, the duration of circulatory arrest time and postoperative factors including hospital mortality did not differ in both groups. In group A, thrombus obliteration of the residual false lumen in the descending aorta was observed in 75% at 19.2±13.1 months postoperatively. Shrinkage of false lumen in the aortic arch occurred in 15 patients( 93.8%). There was no reoperation for the residual false lumen and late death. Total aortic arch replacement with our new method for SAAD is technically feasible without increasing the operative risk and might reduce the necessity for further operations.     

改良全弓置换加支架象鼻术在DeBakeyⅠ型主动脉夹层术中的应用

目的 总结改良主动脉全弓置换加支架象鼻术治疗DeBakey Ⅰ型主动脉夹层的临床经验.方法 2006年1月至2010年10月,101例DeBakey Ⅰ型主动脉夹层患者接受改良全弓置换加支架象鼻术,其中急诊手术73例.全组男性76例,女性25例;年龄21～77岁,平均(49±8)岁.手术包括升主动脉置换术31例、Bentall术29例、Wheat术7例、David术34例.支架象鼻术的同时行左锁骨下动脉开窗以重建血运.在深低温停循环时改行双侧顺行脑灌注下完成脑保护.结果 手术改良后平均心肺转流时间(212±40)min,平均心肌阻断时间(95±16)min,平均停循环时间(42±8)min.手术死亡1例,住院死亡5例,分别死于感染败血症、急性肾功能衰竭、偏瘫并发多器官功能衰竭.双侧脑灌注后脑血管意外和短暂脑神经功能障碍的发生率低于选择性脑灌注.76例患者出院前复查主动脉CT血管造影,人工血管无扭曲,血流通畅,胸降主动脉夹层假腔闭合率为78.9%.71例随访5～49个月,其中50例复查CT血管造影,胸降主动脉夹层假腔闭合率为88.0%,无晚期死亡及再次手术者.结论 改良的全弓置换加支架象鼻术治疗DeBakey Ⅰ型主动脉夹层安全、有效,可减少术后并发症.

Abstract：

Objective To summarize the clinical study of modified total aortic arch replacement and stent elephant trunk technique treatment to patients with DeBakey Ⅰ thoracic aortic dissection. Methods From January 2006 to October 2010, 101 cases of DeBakey Ⅰ aortic dissection were treated by modified total arch replacement and stent elephant trunk technique, in which emergency surgery for 73 cases. There were 76 male and 25 female patients, aged from 21 to 77 years with a mean of(49 ±8)years. Intraoperative ascending aortic replacement in 31 cases, Bentall procedure in 29 cases, Wheat procedure in 7 cases, David procedure in 34 cases. At the same time stent elephant trunk in the left subclavian artery corresponding position was windowed to rebuild the blood supply. Deep hypothermic circulatory arrest cerebral protection was completed by bilateral antegrade cerebral perfusion. Results The mean cardiopulmonary bypass time was(212 ±40)min, mean myocardial occlusion time was(95 ± 16)min, mean circulatory arrest time was (42 ±8)min. Operative mortality was 1 case and hospital mortality was 5 case, which died of septicemia,acute renal failure and hemiplegia complicated with multiple organ failure. Compared with selective cerebral perfusion, the incidence of postoperative cerebral vascular accident and transient neurological dysfunction decreased. Seventy-six cases received aorta CTA before discharged, the closure rate of descending thoracic aortic dissection false lumen was 78. 9%. Seventy-one patients were followed up for 5 to 49 months, 50cases was reviewed by CTA, of which closure rate of descending thoracic aortic dissection false lumen was 88.0%, no late death and re-surgery. Conclusions The modified total aortic arch replacement and stent elephant trunk technique treatment for patients with DeBakey Ⅰ thoracic aortic dissection was safe and effective, with less postoperative complications.     

主动脉全弓置换加硬"象鼻"术治疗DeBakey Ⅰ型主动脉夹层

目的 总结主动脉全弓置换加硬"象鼻"术治疗DeBakey I型主动脉夹层的临床经验.方法 2005年6月至2008年3月,手术治疗41例DeBakey I型主动脉夹层病人,其中男32例、女9例;年龄27～76岁,平均57岁;急性主动脉夹层31例,慢性夹层10例.均在深低温停循环、低流量脑灌注下行主动脉全弓置换加硬"象鼻"手术.其中Bentall+全弓+硬象鼻术(术中支架系统直视下置入)24例,Wheat+全弓+象鼻术6例,升主动脉及全弓置换+硬象鼻术11例.结果 平均体外循环(168±32)min,平均主动脉阻断(109±24)min,选择性脑灌注(31±11)min.术后并发症14例(34.1%),12例治愈(85.8%),2例死亡.出院前均复查CT示升主动脉、主动脉弓部人工血管,术中支架系统血流通畅,位置良好,降主动脉真腔较术前明显扩大,未闭的降主动脉假腔血栓形成,无不良事件发生.随访1～12个月,死亡1例,无再次手术者.结论 主动脉全弓置换加硬"象鼻"术是治疗DeBakey I型主动脉夹层安全、有效的方法.     

Endovascular repair after stent elephant trunk procedure for extensive thoracic aortic aneurysm

Hybrid surgical-endovascular procedure was conducted in a 46-year-old male with extensive thoracic aortic aneurysm. Ascending aorta and arch replacement combined with stent elephant trunk implantation was performed first. An open stent-graft was implanted into the descending aorta. One month later, endovascular repair was conducted. Postoperative CTA showed total coverage of the descending aorta by stent-grafts and the descending aortic aneurysm was totally thrombo-excluded. Stent elephant trunk may be a better alternative to conventional elephant trunk in hybrid surgical-endovascular approaches in treatment of extensive thoracic aortic aneurysm.     

急性Stanford A型主动脉夹层弓部病变处理决策

目的 总结急性Stanford A型主动脉夹层弓部处理的临床经验,探讨选择手术时机、确定治疗方案和手术方式的重要性.方法 2005年8月至2010年8月对210例急性Stanford A型主动脉夹层行弓部替换手术治疗.手术方式采用深低温停循环及顺行性脑灌注,半弓替换+支架象鼻手术92例;次全弓替换+支架象鼻手术50例;全弓替换+支架象鼻手术68例.术后随访,胸腹主动脉CT观察降主动脉假腔闭合情况.结果 全组体外循环(146±52)min,主动脉阻断(93±25)min,深低温停循环(35±14)min.主动脉弓部手术围手术期死亡10例(4.8%).术后18例(8.6%)发生并发症,主要包括急性肾功能不全、神经系统并发症、纵隔感染及急性呼吸功能衰竭.术后随访2～60个月,平均(27±18)个月.随访过程中无死亡,再次入院行降主动脉替换术1例.增强CT检查结果显示支架远端胸降主动脉假腔闭合率为74%.结论 主动脉弓部处理是急性Stanford A型主动脉夹层治疗的重要手段.正确的决策对于提高手术的疗效有重要意义.

Abstract：

Objective Stanford type A acute aortic dissection is a life-threatening medical condition with high rates of morbidity and mortality that requires surgical repair, on an emergency basis. The extent of aortic arch repair that should be carried out during emergency surgery of this type is controversial. This study was conducted to report clinical experience on aortic arch repair and determine surgical indication, optimal operative procedures and strategy for Stanford type A acute aortic dissection. Methods 210 consecutive patients with acute Stanford A aortic dissection who underwent aortic arch replacement combined with implantation of stented elephant trunk into the descending aorta between August 2005 and August 2010. Surgical procedures included hemi-aortic arch replacement in 92 patients, subtotal aortic arch replacement in 50 patients and total aortic arch replacement in 68 patients. All operations were performed with the aid of deep hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP). Enhanced computed tomography scanning was performed to evaluate the postoperative outcomes, particularly the fate of the false lumen remaining in the descending thoracic aorta by aortic arch replacement combined with implantation of stented elephant trunk during follow up. Results Average cardiopulmonary bypass time was (146 ±52) min. The average cross clamp time was(93 ±25)min and average selective cerebral perfusion and circulatory arrest time was(35 ±14)min. The overall in-hospital mortality was 4. 8% (10/210) and morbidity was 8. 6% ( 18/210). Postoperative complications included acute renal failure, stroke, mediastinitis and respiratory insufficiency. During the follow-up period [mean (27 ± 18) months, ranged 2 to 60 months], 1 patient underwent reoperation due to the descending thoracic and abdominal aortic aneurysm. There was no late death. Follow-up enhanced CT scanning showed about 74% false lumens obliterated at the level of the distal border of the stent graft post operation. Conclusion Open aortic arch replacement is an effective approach and provides acceptable outcomes for type A acute aortic dissection. Optimal treatment strategy is the key factor to success in emergency surgical intervention.     

Total arch replacement with elephant trunk procedure for retrograde dissection

BACKGROUND: The surgical management of type A dissection with the intimal tear in the descending aorta--retrograde dissection--has some challenging aspects because the standard approach through a median sternotomy for ascending aortic dissection is difficult in these cases in which the intimal tear is located in the descending aorta. METHODS: From January 1995 to December 2001, 12 (8.6%) consecutive patients aged 40 to 71 years underwent total arch replacement with an elephant trunk procedure through a median sternotomy for retrograde dissection of the ascending aorta (acute: 10, chronic: 2) among 139 patients with type A dissection. The intimal tear was located in the descending aorta in all patients. Dissection extended proximally to the aortic root in 7 patients and to the ascending aorta in 5, and extended distally to the abdominal aorta in 4 and to the common iliac artery in 8. RESULTS: Hospital mortality occurred in 1 patient (8%) owing to multiple organ failure after malperfusion of the renal arteries. Postoperatively the false lumen in the descending aorta was closed in all patients who survived but the false lumen in the abdominal aorta was patent in 9. The thoracic and abdominal aorta had slight dilatation in 2 patients. CONCLUSIONS: These data suggest that total arch replacement with an elephant trunk procedure through a median sternomy should be recommended in patients with type A dissection and the intimal tear in the descending aorta. This procedure induces thrombosis of the remaining false lumen in the distal aorta postoperatively.     

马方综合征主动脉根部手术后远端主动脉病变再次外科治疗

目的 总结马方综合征主动脉根部手术后远端主动脉病变的再次外科治疗结果,探讨相关治疗策略。方法 2000年1月至2010年1月,28例马方综合征主动脉根部手术后远端主动脉病变患者进行再次手术治疗。其中男20例,女8例;年龄23～52岁,平均(38.5±8.7)岁。首次手术包括Bentall手术24例,David手术4例。Stanford A型夹层8例,主动脉根部瘤20例。再次手术包括：胸腹主动脉置换术10例,全主动脉弓置换及支架象鼻术7例,胸降主动脉置换术6例,全主动脉置换术2例,全主动脉弓置换术2例,部分主动脉弓置换术1例。两次手术间隔1 ～12年,平均(6.43 ±3.07)年。结果 术后发生神经系统并发症4例(17％),包括脑卒中1例,截瘫1例,单侧下肢一过性运动障碍2例。二次开胸止血3例,急性肾功能衰竭接受血滤治疗1例。3例因术后呼吸机辅助时间延迟接受气管切开术。术后全部随访,随访时间10～ 118个月,平均(40.8±29.5)个月。住院死亡2例(7.1％),术后1年、5年实际生存率分别为(94.5±1.3)％、(90.6±1.4)％。结论 马方综合征行主动脉根部手术后因远端主动脉病变再次外科治疗临床结果满意。对于患主动脉A型夹层的马方综合征,首次手术即采用积极的主动脉全弓置换及象鼻手术更好。     

Single-stage reoperative repair of chronic type A aortic dissection by means of the arch-first technique

OBJECTIVE: Management of the enlarged, chronically dissected aorta after previous repair of acute aortic dissection or after a previous cardiac operation may present a formidable technical challenge. Marked enlargement of the proximal descending thoracic aorta precludes safe use of staged procedures, including the elephant trunk technique. METHODS: Sixteen patients with chronic type A aortic dissection (mean age, 56 years) underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending thoracic aorta. We used single-stage replacement, with perfusion of the aortic arch first to minimize the duration of brain ischemia, with a bilateral anterior thoracotomy (clamshell) incision. Eleven patients had undergone previous repair of acute type A dissection. Five patients had type A dissection after aortic valve replacement (2 patients) and coronary artery bypass (3 patients). Marked enlargement of the aorta distal to the left subclavian artery precluded a 2-stage repair. The mean interval between the initial and reoperative procedures was 62 months (range, 5-137 months). RESULTS: There was 1 (6.2%; 70% confidence limits, 0.3%-24.7%) hospital death. Four patients required reoperation for bleeding. One patient required a right ventricular assist device that was successfully removed. Six patients required assisted ventilation for more than 72 hours, and 3 patients required a tracheostomy. All were successfully weaned from ventilatory support. No patient had a stroke or other adverse neurologic outcome. CONCLUSION: The single-stage, arch-first replacement technique is a safe and effective procedure for patients who require extensive reoperations for chronic expanding type A dissection.     

Acute Type A Dissection Treated with Combined Endovascular Repair of Arch and Surgical Bypass of Arch Vessels from Descending Aorta

We report a case of an endovascular repair of a recurrent dissecting aneurysm of the aortic arch and dissection of carotid vessels, 3 years after surgical repair of aortic valve and ascending aorta for a type A dissection. We performed a bypass from the descending aorta to right, left common carotid artery (CCA), to left subclavian artery with no cardiopulmonary bypass and thereafter, total ascending and aortic arch stent grafting. We suggest considering total aortic arch stent grafting with bypass of arch vessels in cases of complicated acute type A dissection. In cases where the ascending aorta cannot be used as donor site for bypass, we suggest the use of the descending aorta.     

The reversed and bidirectional elephant trunk technique in the treatment of complex aortic aneurysms

BACKGROUND: The elephant trunk technique with a free-floating vascular prosthesis was originally developed to facilitate a subsequent operation on the downstream aorta. We present here our experience with further developments of this technique, which we call the reversed elephant trunk and bidirectional elephant trunk. METHODS: Between January 1, 1995, and December 31, 2000, 505 adult and adolescent patients underwent operations of the thoracic aorta. A reversed elephant trunk procedure in 13 patients and a bidirectional elephant trunk procedure in 4 patients was performed to facilitate either subsequent proximal or proximal and distal aortic replacement. Nine patients underwent subsequent aortic arch replacement with the reversed prosthetic portion after a mean interval of 8 +/- 5.5 months, and 2 patients received distal extension by use of the distal portion of the free-floating graft. RESULTS: There was no hospital mortality (30 days) in this small group of patients, and no patient had aortic rupture, malperfusion caused by the technique itself, or thromboembolic complications during the waiting interval between the first and the second operations. Five patients are still being observed until the contiguous aortic size is large enough to require an operation, and one 74-year-old patient declined a second-stage operation. CONCLUSION: The reversed and bidirectional elephant trunk techniques are interesting options that may be suitable for patients having complex abnormalities of the thoracic aorta and thoracoabdominal aorta when the proximal portion of the descending aorta has to be replaced before the aortic arch with or without the ascending aorta or the distal descending aorta with or without the thoracoabdominal aorta.