Modified Elephant Trunk Research Articles

ALTERNATIVE STRATEGIES FOR LEFT SUBCLAVIAN ARTERY REVASCULARIZATION DURING ZONE–2 AORTIC ARCH SURGERYEMENT

Abstract Objective Anatomical extension of surgical treatment of thoracic aortic pathologies involving the aortic arch is still controversial. The adoption of distal anastomosis in aortic arch zone–2 (Z2–AAR), in order to facilitate bleeding control, has been widely recommended. In such case the revascularization of left subclavian artery (LSA) may add further concerns. Here we report our different strategy of LSA revascularization in 2 different scenario of Z2–AAR Clinical. Cases Case#1 17 yo male patient affected by Loeys–Dietz Syndrome and a previous David procedure at age of 11yo. He presented complaining chest pain and CT scan revealed a dilatation (5,8 cm) of ascending aorta and an intimal flap with preserved previous distal anastomosis. Surgical strategy #1 (Left subclavian artery in situ): Arch replacement (Zone 2 distal anastomosis) with Siena Graft 24mm and modified Elephant Trunk Tecnique (2cm distal endoluminal graft). Innominate artery and left carotid artery reimplantation. Distal Anastomosis Siena 24 (Z2). Case #2 78 yo male with a previous (6 month before) Biological AVR (Trifecta 25) + ascending aorta replacement (Jotec 30). Presented complaining acute chest pain, CT Scan revealed a residual dilatation of distal ascending aorta, dissection/rupture of distal aortic arch at level of a complicated plaque. Surgical strategy #2 (Left subclavian artery reimplanted): Arch replacement (Zone 2 distal anastomosis) with Siena Graft 30mm and Elephant trunk Teccnique (10cm distal endoluminal graft). Closure of the extended ulcera. Total epiaortic vessels de–branching 10 mm Tube on LSA – Distal Anastomosis Siena 30 (Z2). Conclusion Surgical extension of aortic arch replacement is still matter of discussion. Zone–2 approach for aortic arch replacement seems a safe and effective option. In our mind strategy for left subclavian revascularization should be tailored according patient’s anatomy and potential future scenarios.

Modification of reconstruction of left ventricular outflow tract, aortic root and the intervalvular fibrous body for extensive infective endocarditis: a single-centre experience.

Extensive infective endocarditis (IE) stays a serious life-threatening disease with high mortality and morbidity. The aim of this study is to analyse our experience with our modified surgical technique for extensive IE during the last 4 years. Between March 2017 and February 2021, all patients with extensive IE required our modified technique consisting of a radical surgical resection of all infected cardiac tissues, the replacement of infected valves and a reconstruction of the intervalvular fibrous body, the aortic root and the left ventricular outflow tract with modified elephant trunk were included in this study. Our modified technique was performed on 41 patients during the study period. The age median was 74 [interquartile range (IQR): 66.5-76.5] and 61.0% (n = 25) were female. Thirty-three patients (80.5%) were in New York Heart Association Class III-IV and 7 patients (17.1%) in cardiogenic shock. The median logistic European system for cardiac operative risk evaluation II as predicted risk of mortality was 35% (IQR: 28-78%). The median cardiopulmonary bypass time and cross-clamping time were 126 (IQR: 86.5-191) and 78 (IQR: 55.5-108) min, respectively. Intraoperative mortality and 30-day mortality were 4.8% (2 patients) and 19.5% (8 patients), respectively. Low cardiac output with necessity for mechanical support, stroke and new renal dialysis developed in 9.8% (4 patients), 17.1% (7 patients) and 22.0% (9 patients), respectively. New pacemaker implantation was noted in 39.0% (16 patients). Intensive care stay and hospital stay had medians of 6 (IQR: 5-12) and 14 (IQR: 12.5-20.5) days, respectively. One-year mortality and 4-year mortality were 34.1% (14 patients) and 39.0% (16 patients), respectively. Kaplan-Meier survival estimates were 60.3% (95% confidence interval: 46.2-78.6%) at 3 years. Our modified technique can be performed in patients with extensive IE with acceptable early and mid-term morbidity and mortality. We believe that this technique is an available option for this ill-fated group of patients.

Surgical outcomes of total arch replacement with modified elephant trunk technique in type A aortic dissection: insights from single-center experience.

Total arch replacement with modified elephant trunk technique plays an important role in treating acute type A aortic dissection in China. We aim to summarize the therapeutic effects of this procedure in our center over a 17-year period. Consecutive patients treated at our hospital due to type A aortic dissection from January 2004 to January 2021 were studied. Relevant data of these patients undergoing total arch replacement with modified elephant trunk technique were collected and analyzed. A total of 589 patients were included with a mean age of 53.1 ± 12.2 years. The mean of cardiopulmonary bypass, cross-clamping, and selected cerebral perfusion time were 199.6 ± 41.9, 119.0 ± 27.2, and 25.1 ± 5.0 min, respectively. In-hospital death occurred in 46 patients. Multivariate analysis identified four significant risk factors for in-hospital mortality: preexisting renal hypoperfusion (OR 5.43; 95% CI 1.31 - 22.44; P = 0.020), cerebral malperfusion (OR 11.87; 95% CI 4.13 - 34.12; P < 0.001), visceral malperfusion (OR 4.27; 95% CI 1.01 - 18.14; P = 0.049), and cross-clamp time ≥ 130 min (OR 3.26; 95% CI 1.72 - 6.19; P < 0.001). The 5, 10, and 15 years survival rates were 86.4%, 82.6%, and 70.2%, respectively. Total arch replacement with modified elephant trunk technique is an effective treatment for acute type A aortic dissection with satisfactory perioperative results. Patients with preexisting renal hypoperfusion, cerebral malperfusion, visceral malperfusion, and long cross-clamp time are at a higher risk of in-hospital death.

Surgical "elephant trunk" arch replacement with a branched arch prosthesis: two alternative operative techniques.

IntroductionElephant trunk repair of the aortic arch cannot be performed with a branched prosthesis.AimWe conceived two different modifications of the original technique to perform an arch replacement with a branched graft, while arranging an adequate landing zone for a subsequent thoracic endovascular aortic repair, without the need of dedicated material.Material and methodsEight consecutive patients underwent arch replacement with one of our techniques. Five were emergency patients with acute aortic dissection, and 3 suffered chronic expansive disease. The “modified elephant trunk” includes a separate anastomosis of an endo-luminal prosthetic segment in the descending aorta. Subsequently, the branched arch prosthesis is anastomosed to the distal aortic stump with the attached trunk. In the “prophylactic debranching”, a tail is left on the distal end of the arch prosthesis, so that the branches for the supra-aortic vessels will remain displaced proximally, allowing a “zone 1” available for landing.ResultsThree patients experienced transient cerebral deficits (1 transient ischemic attack and post-operative delirium in 2 cases), 1 required re-operation for bleeding and 2 needed prolonged intubation. One died of multi-organ failure.ConclusionsBoth techniques proved to be easily reproducible, and allow an adequate landing zone for a subsequent endovascular procedure, while retaining the advantages of using a tetra-furcated prosthesis. They are a viable alternative when a hybrid prosthesis cannot be implanted.

A modified frozen elephant trunk technique for acute Stanford type A aortic dissection

BackgroundAcute Stanford type A aortic dissection is often fatal, with a high mortality rate and requiring emergency intervention. Salvage surgery aims to keep the patient alive by addressing severe aortic regurgitation, tamponade, primary tear, and organ malperfusion and, if possible, prevent the late dissection-related complications in the proximal and downstream aorta. Unfortunately, no optimal standard treatment or technique to treat this disease exists. Total arch replacement with frozen elephant trunk technique plays an important role in treating acute type A aortic dissection. We aim to describe a modified elephant trunk technique and report its short-term outcomes.MethodsFrom February 2018 to August 2019, 16 patients diagnosed with acute Stanford type A aortic dissection underwent surgery with the modified frozen elephant trunk technique at Xiamen Heart Center (male/female: 9/7; average age: 56.1 ± 7.6 years). All perioperative variables were recorded and analyzed. We measured the diameters of the ascending aorta, aortic arch, and descending aorta on the bifurcation of the pulmonary and abdominal aortas and compared the diameters at admission, before discharge, and 3 months after discharge.ResultsFifteen patients (93.8%) had hypertension. The primary tears were located in the lesser curvature of the aortic arch and ascending aorta in 5 (31.3%) and 9 patients (56.3%), respectively, and no entry was found in 2 patients (12.5%). The dissection extended to the iliac artery and distal descending aorta in 14 (87.6%) and 2 patients (12.5%), respectively. The duration of cardiopulmonary bypass (CPB), cross-clamping, and antegrade cerebral perfusion were 215.8 ± 40.5, 140.8 ± 32.3, and 55.1 ± 15.2 min, respectively. Aortic valve repair was performed in 15 patients (93.8%). Bentall procedure was performed in one patient (6.3%). Another patient received coronary artery repair (6.3%). The diameters at all levels were greater on discharge than those on admission, except the aortic arch. After 3 months, the true lumen diameter distal to the frozen elephant trunk increased, indicating false lumen thrombosis and/or aortic remodeling.ConclusionsThe modified frozen elephant trunk technique for acute Stanford type A aortic dissection is safe and feasible and could be used for organ malperfusion. Short-term outcomes are encouraging, but long-term outcomes require further investigation.

OC51 NEW TECHNIQUE IN TYPE I ACUTE AORTIC DISSECTION FOR ARCH STABILIZATION AND FUTURE LANDING ZONE CREATION WITHOUT ARCH REPLACEMENT: THE SALERNO CANOE TECHNIQUE

Background and Aim: We present a simplified elephant trunk procedure to treat type I acute aortic dissections. This technique transfers the anastomotic site of a modified elephant trunk prosthesis from zone 3 to zone 0 (before anonymous trunk). Methods: From November 2015 to April 2018, 38 patients underwent an ascending aorta replacement for type I acute aortic dissection. In order to stabilize the arch and prepare a future landing zone, after the reconstruction of proximal and distal dissected aortic walls using inside and outside felt strips, we introduce into the aortic arch a Dacron prosthesis resected to create a “fenestration” under the supra-aortic branch vessels. The distal part of this prosthesis is left free floating into the descending aorta. The concave arch was also anchored to the prosthesis and through a catheter placed distally into the tube graft we perfused the thoracic aorta. Having the prosthesis a final shape of a canoe, we named the procedure “the Salerno Canoe Technique”. Results: Five patients died (13.2%). We observed a 5% reduction compared to our previous mortality. In one patient severe abdominal hypoperfusion due to secondary hypertensive false lumen was successful treated by an endovascular thoracic prosthesis landed proximally into the “canoe prosthesis”. Conclusions: Compared to conventional elephant trunk technique this procedure is simpler and less circulatory arrest time-consuming (only mean 12 min increase respect to ascending aorta replacement alone). It allows an extensive arch stabilization, a safe perfusion of the descending thoracic aorta and a landing zone for future endovascular procedures.

Modified Elephant Trunk Technique in Distal Anastomosis With the Aid of Antegrade Selective Cerebral Perfusion for Total Arch Replacement

Secure distal anastomosis and reliable brain protection are indispensable for successful total arch replacement (TAR). In 2002, we introduced a modified elephant trunk technique, a novel approach to distal anastomosis, and employed antegrade selective cerebral perfusion. We retrospectively analyzed 107 consecutive patients to evaluate the efficacy of this technique for TAR with antegrade selective cerebral perfusion. Since 2002 we have employed moderate hypothermic circulatory arrest, selective antegrade cerebral perfusion, and open distal anastomosis with a modified elephant trunk technique in TAR. Between February 2002 and September 2011, 107 TARs were performed in 88 males and 19 females (age, 33 to 88 years; mean, 70.9±9.5 years). Etiologies of cases were as follows: 89 true aneurysm due to atherosclerosis; 5 infectious aneurysm; 1 aortic dilation with bicuspid aortic valve; 12 aortic dissection, including 1 of acute aortic dissection case; and 2 Marfan syndrome. Concomitant procedures included 19 coronary artery bypass grafting (CABG) cases, 2 aortic valve replacement cases, 1 mitral valve plasty case, 1 Bentall procedure case, and 1 case of Bentall with CABG. The operative mortality within 30 days was 0.9% (1 of 107), and overall hospital mortality was 1.9% (2 of 107). Temporary and permanent neurologic dysfunction occurred in 5 patients each (4.7%). The Kaplan-Meier survival analysis revealed a 5-year survival rate of 91.8%. The modified elephant trunk technique using selective antegrade cerebral perfusion provided secure distal anastomosis and demonstrated excellent results, with low operative mortality and few neurologic complications.

Surgery for acute aortic dissection using the Chinese CRONUS stented elephant trunk technique: Experience with 252 patients

The elephant trunk method was introduced to treat aortic disease. There are a variety of modified elephant trunk methods, including the stented elephant trunk. We retrospectively reviewed our experience and evaluated the effectiveness of surgical treatment for acute aortic dissection using the Chinese CRONUS stented elephant trunk technique. From August 2005 to December 2012, 252 patients with acute aortic dissection underwent surgical treatment using the Chinese CRONUS stented elephant trunk technique at the Renmin Hospital of Wuhan University. We review the characteristics of the patients, the surgical method, and the prognosis. Furthermore, we modified the stented elephant trunk technique to simplify the surgical procedure using stented elephant trunk fenestration in 81 patients. The procedure was technically successful in all patients. The mean duration of cardiopulmonary bypass, myocardial ischemia, and circulatory arrest was 158±34 minutes, 98±24 minutes, and 27±9 minutes, respectively. The mean stay in the intensive care unit was 74±11 hours. The in-hospital mortality rate was 3.2% (8/252). A 92.2% (225/244) follow-up rate was achieved. Five patients died during follow-up. The diameter of the descending aorta significantly decreased in 173 patients (78.6%), did not change 39 patients (17.7%), and dilated in 8 patients (3.7%). In surgery for acute aortic dissection, the Chinese CRONUS stented elephant trunk technique had a low prevalence of morbidity and mortality in our patients. The satisfactory effects demonstrated that the technique is safe and effective in closing the residual false lumen of the descending aorta. Stented elephant trunk fenestration could further simplify the surgical procedure with minimal invasion.

Dr. Sun's Procedure for Type A Aortic Dissection: Total Arch Replacement Using Tetrafurcate Graft With Stented Elephant Trunk Implantation.

Sun's procedure is a modified elephant trunk technique that integrates the advantages of open surgical and endovascular repairs as a treatment of type A aortic dissection. It is named after Dr. Li-Zhong Sun and refers to total arch replacement using a four-branched graft with implantation of a special stented endovascular graft. Since its introduction, it has produced excellent early and late clinical outcomes. We present a video of this procedure and make an overview regarding the technical aspects, surgical indications, and clinical outcomes of Sun's procedure.

The Bentall Procedure without the Use of a Prepared Valved-Conduit: A Step Backwards?

A repeat Bentall procedure or a Bentall procedure in an immobile aortic root such as a prior homograft that has calcified can be problematic. Separating the valve from the conduit and with a modified elephant trunk concept we have simplified the proximal graft anastomosis using a running suture technique. This is followed by coronary ostia implantation and then by lowering the aortic valve onto the aortic annulus using a running suture technique.

Branched Graft Inversion Technique for Distal Anastomosis in Total Arch Replacement

Distal anastomosis during total arch replacement for thoracic aortic aneurysm is at times difficult, and bleeding from it is a serious problem because of its limited surgical exposure. We have modified a new procedure, the branched graft inversion (BGI) technique. We investigated the effectiveness of our technique by comparing it with the conventional stepwise technique. Between January 2008 and August 2011, 40 patients, divided into two groups of 20 each, underwent elective total arch replacement. One group underwent surgery using BGI; the stepwise technique was performed on the remaining 20 patients. Our modified BGI technique offers easy and secure distal anastomosis under good surgical procedure, resulting in shorter durations of operation, cardiopulmonary bypass, and circulatory arrest (455.1±101.3 min versus 354.7±49.3 min, p<0.001; 248.2±46.6 min versus 199.7±28.2 min, p<0.001; 76.6±27.7 min versus 61.6±10.4 min, p=0.029, respectively). As a result, this technique could be a useful in performing total arch replacement.

Total arch replacement with an open stent graft for acute type A aortic dissection: fate of the false lumen

To describe the fate of the false lumen remaining in the descending thoracic aorta after extensive primary repair of the thoracic aorta by the modified elephant trunk technique with a stent graft for acute type A aortic dissection, particularly the changes of the false lumen on enhanced CT scanning. The subjects were 65 consecutive patients who received arch replacement with an open stent graft for type A acute aortic dissection. CT scanning was performed at 1, 3, 12, 36, and 60 months postoperatively to detect thrombus formation, absorption of thrombus, and obliteration of the false lumen after its exclusion by the stent graft. The aorta was measured at four levels, which were the distal border of the stent graft, the middle and distal parts of the descending thoracic aorta, and the origin of the superior mesenteric artery. Obliteration was recognized in all patients at the distal border of the stent graft and absorption of thrombus was seen in 90% at the middle of the descending thoracic aorta within 1 year after surgery. However, the false lumen remained patent at the superior mesenteric artery (SMA) level in 50% of the patients. In patients with acute type A aortic dissection, it is possible to perform extensive primary repair of the thoracic aorta with relative safety by stent grafting, and this method may reduce the necessity for further operations to manage a residual false lumen.

Is Emergency Total Arch Replacement With a Modified Elephant Trunk Technique Justified for Acute Type A Aortic Dissection?

We assess the outcome of emergency total arch replacement with a modified elephant trunk technique for acute type A aortic dissection to clarify whether our aggressive approach is justified in certain patients. Between 2000 and 2006, 54 patients (55.1% of all) underwent emergency total arch replacement for acute type A aortic dissection. The surgery was performed using open distal anastomosis with selective antegrade cerebral perfusion under hypothermia. Total arch replacement with individual arch-vessel reconstruction was applied in the following settings: the intimal tear in the transverse arch or the proximal descending aorta, massive arch dissection, Marfan syndrome, arch aneurysm, and atheromatous arch. At the distal anastomosis, a modified elephant trunk procedure was added for secure anastomosis and early thrombosed closure of the false channel in the descending aorta. Only 2 patients (3.7%) died of low cardiac output, in whom cardiac arrest had developed preoperatively owing to rupture of the arch or to left coronary artery malperfusion. There were 4 late deaths from nonaortic events. On the follow-up computed tomographic scanning, a high incidence of early thrombosed closure of the false channel in the dissected descending aorta was found. Only 2 patients, whose tear had not been resected in the first surgery, required reoperation of the descending aorta. Total arch replacement with an elephant trunk procedure, which permits immediate survival and provides early thrombosed closure of the distal false channel, is justified in certain patients with acute type A dissection.

Midterm results of extensive primary repair of the thoracic aorta by means of total arch replacement with open stent graft placement for an acute type A aortic dissection

We sought to describe the midterm results of extensive primary repair of the thoracic aorta by means of the modified elephant trunk technique with a stent graft for acute type A aortic dissection, particularly the changes of the false lumen shown by enhanced computed tomographic scanning. The subjects were 35 consecutive patients who received arch replacement with open stent grafting for type A acute aortic dissection between December 1997 and April 2002. The mean follow-up period was 55 months (range, 30-83 months). Computed tomographic scanning was performed at 1, 3, 12, and 36 months postoperatively to detect thrombosis and obliteration of the false lumen after its exclusion by the stent graft. The diameter of the aorta was measured at 3 levels: the distal edge of the stent graft, the diaphragm, and the origin of the superior mesenteric artery. Two patients died in the initial operation, but no patients required additional surgical treatment of the thoracic aorta. The mean diameter of the stent grafts was 26.2 mm, and the mean length was 8.9 cm. Thrombus formation in the false lumen was recognized at the distal edge of the graft in all patients, at the diaphragmatic level in 26 patients, and at the superior mesenteric artery level in 15 patients. Obliteration of the false lumen was recognized at the distal edge of the graft in all patients, at the diaphragmatic level in 20 patients, and at the superior mesenteric artery level in 15 patients. The aorta distal to the stent graft showed minimal changes. In patients with acute type A aortic dissections, it is possible to perform extensive primary repair of the thoracic aorta with relative safety by using a synthetic graft with a self-expanding stent, and this method might reduce the necessity of further operations not only for the distal descending aorta but also for the thoracoabdominal aorta.

A modified elephant trunk technique: The 3-fold elephant trunk technique

A modified elephant trunk technique: The 3-fold elephant trunk technique

A Short Wholly Inside-Out Reversed Vascular Graft Facilitating Difficult Aortic Anastomosis

Aortic arch operations are sometimes very difficult because of their deep position, exposure limitation, and extensive involvement of the degenerative disease. We present a new technique derived from a modified elephant trunk technique to simplify some laborious situations.

The “elephant trunk” technique made easier

In patients with diffuse aneurysmal disease, the “elephant trunk” technique, which uses surplus intravascular graft length to facilitate subsequent operations on the downstream aorta, is an accepted method of treatment. Nevertheless, in the presence of large aneurysms without a definite neck beyond the left subclavian artery, there is an increased risk of rupture at the level of the distal anastomosis. My colleagues and I herein describe a modified elephant trunk technique performed with a new prosthesis, which was conceived to overcome the difficulties and the risks inherent in a large aneurysmal neck.

Modified elephant trunk technique for distal reconstruction of ragged descending thoracic aorta.

We present a modified elephant trunk technique with a novel indication for aortic arch aneurysm with ragged, undilated descending thoracic aorta. Our modification is simple and effective for minimizing bleeding from the distal anastomosis and has the possibility of preventing distal embolization of atheromatous plaque by ensuring sufficient contact area between the graft and the aortic wall.

Extensive primary repair of the thoracic aorta in Stanford type A acute aortic dissection by means of a synthetic vascular graft with a self-expandable stent.

To minimize any residual false lumen when operating on patients with an acute type A aortic dissection, we tried to perform extensive primary repair of the thoracic aorta with the modified elephant trunk technique. The early and midterm results of these surgical interventions are reported and evaluated. Among the acute type A aortic dissections with extensive false lumen encountered since December 1997, 19 consecutive patients, 15 DeBakey type I with the tear in the ascending, transverse, or both aortas, and 4 DeBakey type III-D with the tear located in the descending aorta, underwent insertion of a synthetic graft with a distally anchored stent in the descending thoracic aorta. The interpolation method was used as an introducer combined with total replacement of the aortic arch by using a synthetic branching graft with only a median sternotomy. One patient died, and 18 were discharged after full recovery. Postoperative computed tomographic scans showed that no residual false lumina were present proximal to the diaphragmatic level, and no false lumina were found in 10 patients. Two patients with acute ischemia of the right kidney caused by narrowing of the true lumen, as demonstrated by radiographic computed tomography, improved significantly after surgical intervention with restoration of blood flow in the true lumen. Paraplegia was not observed in any patient. In emergency operations for an acute type A aortic dissection, the operation is often limited to replacing the ascending aorta because priority is given to saving the patient's life. However, it is possible to perform extensive primary repair of the thoracic aorta with relative safety by interpolating a synthetic graft with a self-expandable stent.

Preface

Abstract A modified elephant trunk technique that was used to treat acute type A dissection is described. This technique prevents leaks at the distal anastomosis and facilitates surgery on the aneurysmatic downstream aorta following total arch replacement. In addition, it allows closure of the primary intimal tear in patients with DeBakey type III retrograde dissection.