Eur J Cardiothorac Surg 2000;18:246-248
© 2000 Elsevier Science NL
A novel modification of elephant trunk technique using a single four-branched arch graft for extensive thoracic aortic aneurysm
Satoru Kuki,
Kazuhiro Taniguchi,
Takafumi Masai,
Shunji Endo
Department of Cardiovascular Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Sakai 591-8025, Japan
Received 8 September 1999;
received in revised form 17 February 2000;
accepted 23 May 2000.
Corresponding author. Tel.: +81-722-52-3561; fax: +81-722-50-7540
e-mail: skuki{at}orh.go.jp
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Abstract
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Surgical repair for the extensive thoracic aortic aneurysm remains unsatisfactory, especially in elderly patients. We developed a total arch replacement with modified elephant trunk technique under moderately hypothermic cardiopulmonary bypass and selective brain perfusion, in which a 4-branched arch graft with a sewing ‘collar’ enabled the distal anastomosis just proximal to the innominate artery with open distal method and a long ‘elephant trunk’ was inserted into the descending aorta by the forceps catheter via the femoral artery. This modification is easy and less invasive, and reduces the risk of postoperative complications.
Key Words: Thoracic aneurysm • Arch replacement • Elephant trunk • Selective brain perfusion
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1. Introduction
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The staged approach introduced by Borst and coworkers has been widely used for combined arch and descending aortic disease [1,2], and single-stage repair has also been advocated in recent reports [3,4]. Even in the recent progress in adjunct methods, surgical repair for the extensive thoracic aortic aneurysms remains unsatisfactory, being associated with considerable mortality and morbidity, especially in elderly patients. Neurological damage, hemorrhagic complications, and myocardial damage are the relevant important factors.
Recently, we have developed a less invasive aortic arch replacement using single four-branched arch graft with a ‘collar’ and a long ‘elephant trunk’ to reduce the risk of postoperative complications.
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2. Operative technique
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Through median sternotomy ascending aorta and arch vessels were minimally dissected. The right subclavian artery was first dissected through infraclavicular skin incision and prepared for systemic arterial return with a thin wall cannula (Bio-Medicus®, Medtronic, USA). In case of perfusing the left subclavian artery, an 8-mm ringed graft (Gelsoft®, Sulzer Vascutek, UK) was sutured with side-to-end anastomosis and the perfusion was performed via the prosthesis. Venous return to the pump oxygenator was done through the bicaval cannulas. Cardiopulmonary bypass was then instituted with cooling of the nasopharyngeal temperature to 25°C. During cardiopulmonary bypass, arterial blood pH was managed according to the alpha-stat strategy. When the heart went into fibrillation, a left atrial vent was introduced into the right superior pulmonary vein. At 25°C an angled 12-F cannula (DLP®, Medtronic, USA) was inserted in the left common carotid artery as distally as possible from the aortic arch, and a selective brain perfusion was started with a single roller pump. The brain perfusion pressure was monitored in the innominate artery and maintained in the range 40–50 mmHg with the flow rates around 600 ml/min. The ascending aorta was cross-clamped and heart arrest was induced by antegrade blood cardioplegia and subsequently maintained by retrograde blood cardioplegia. During the systemic cooling, a four-branched arch graft (Hemashield Gold® woven double velour, Meadox, USA) with a sewing ‘collar’ and an ‘elephant trunk’ (ET) of 20 cm in length was prepared. The graft size was determined by the diameter of the uninvolved descending aorta obtained from the preoperative contrast-enhanced CT scans. The graft of 24 or 26 mm was practically used. The aortic clamp was then removed and ascending aorta was then transected just proximal to the innominate artery. The ET prosthesis was inserted into the descending aorta by pulling the edge of ET with 7Fr. biopsy forceps catheter (Alpha Medical, USA) that was introduced using guide wire technique via a femoral artery (Fig. 1A)
. The anastomosis between the collar of the graft and the distal aorta was carried out under open distal method using 4-0 polypropylene (Prolene®, Ethicon, USA) over-and-over suture with reinforcement of a felt strip (Fig. 1B). After the distal anastomosis, systemic perfusion was restarted through the side branch of the graft. For deairing of the descending aorta, the patient was tilted, head up, retrograde perfusion was carried out through the cannula in the femoral artery at the flow rate of 1.0–1.5 l/min, for 1–2 min. In the recent cases, a retrograde perfusion through the cannula of inferior vena cava was performed for the deairing of descending aorta. The proximal anastomosis was carried out at the ascending aorta distal to sinotubular ridge. During the proximal anastomosis, rewarming was completed up to 33°C of bladder temperature. After terminal warm blood cardioplegia was given for 5–10 min retrogradely, the heart was reperfused and deaired in an usual manner. Lastly, arch vessels were reconstructed by end-to-end anastomosis to the side branches in each other using 5-0 Prolene® (Fig. 1C). The postoperative CT scan was performed prior to the second operation. Usually the distal end of ET located at the level of Th7–8.
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Fig. 1. Schematic illustration of the modified elephant trunk technique. (A) Under the brain perfusion and open-distal method, the ascending aorta was transected just proximal to the innominate artery. The elephant trunk prosthesis was inserted into the descending aorta by the forceps catheter. (B) The anastomosis between the collar of the prosthesis and the distal aorta was carried out over-and-over suture with reinforcement of a Teflon felt strip. (C) The proximal anastomosis was carried out just distal to sinotubular ridge. Arch vessels were reconstructed by end-to-end anastomosis to the side branches of the prosthesis.
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From October 1998 to April 1999, five consecutive patients ranging in age from 62 to 78 years (mean, 71 years) underwent aortic repair for the extensive thoracic aneurysms. All patients recovered satisfactorily after the first-stage operation. Cardiopulmonary bypass time, selective brain perfusion time, and open distal time were 245±40, 168±36 and 40±9 min, respectively. There were no neurological complications of stroke and paraplegia. Four patients except for a 76-year-old woman were extubated within 24 h of operation. All patients had the second-stage elephant trunk procedure with a mean inter-val of 8.8 days (range 7–14 days), and remain well.
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3. Discussion
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The original ‘elephant trunk’ technique was developed by Borst and coworkers in 1983 [1], and various modifications have been reported since then [5–7]. The basic principles of the ‘elephant trunk’ are replacement of the ascending aorta and transverse aortic arch, placing the distal suture line just distally to the left subclavian artery and leaving a free-floating portion of the graft within the proximal descending aorta to be used in the further aortic repair. The goal of the present modification of the elephant trunk procedure is to yield a secure anastomosis with sewing collar of the graft and to place the distal anastomosis just proximal to the innominate artery without distal perfusion. This open-distal method at the proximal aorta enables fast and accurate anastomosis in bloodless field and prevents injuries to both recurrent laryngeal and phrenic nerves, and lessens complications related to intraoperative hemorrhage. The safe limit of open distal method has been thought to be 30 min at 25°C. In the present series, we required a mean duration of the open distal time of 40 min because of our initial experience of the long ET technique. Although there was no distal organ complication, we should have accomplished the distal anastomosis within the safe limit of time. The length of the conventional ET prosthesis was advocated to be no more than approximately 15 cm [8]. The distal end of the present ET prosthesis of 20 cm in length locates usually at the level of Th6–8, so that the major intercostal arteries locating at the level of Th9–L2 are preserved, which contributes to decreasing the risk of paraplegia. Throughout the first- and the second-stage operation, the left recurrent laryngeal and phrenic nerves were not mobilized and well protected, so that this technique can eradicate the risk of the injuries to recurrent laryngeal as well as phrenic nerves. Finally, our favorable experience was obtained from a relatively small numbers of patients, and has to be confirmed by a much larger series of patients.
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Footnotes
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Presented at the 13th Annual Meeting of the European Association for Cardio-thoracic Surgery, Glasgow, Scotland, UK, September 5–8, 1999.
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Appendix A Conference discussion
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Dr F. Wellens (Aalst, Belgium): Can you comment on the absence of postoperative morbidity after a long operative procedure followed by a second thoracotomy 1 week later, and this in a subset of older patients with extensive atherosclerotic disease.
Dr Masai: The number of the patients evaluated in this study was relatively small, so further surgeries have to be carried out to permit more confident conclusion. We believe that one of the most important factors related to the mortality and morbidity for the arch repair is cerebral damage due to the atherosclerotic debris or thrombus in the arch during operation, and spinal cord, vagus and phrenic nerve injuries are also important. That is why we developed this less invasive operation. We believe our technique can minimize the risk of cerebral damage without manipulating the arch itself and can avoid the vagal and phrenic nerve palsy.
Dr Wellens: Do you have any practical experience with the stent grafting?
Dr Masai: No, not yet, but in the future we will try it.
Dr H. Borst (Munich, Germany): You indicated that you might not have to do an arch resection after this type of procedure, I suppose because the space between the graft and the aorta is going to thrombose.
Dr Masai: Pardon me. Once again, please?
Dr Borst: You indicated that this new method might not require a secondary arch replacement and I suppose that this is because the space between the graft and the aorta might thrombose.
Dr Masai: Yes.
Dr Borst: Is that the idea? Have you seen that?
Dr Masai: I am not sure now. We believe that in some cases for chronic dissection the second operation will not be necessary, but we think there is a controversy. In the patient with a large descending aorta, we have to do a second procedure.
Dr Borst: I sort of doubt it, because if this space really thromboses along the arch and along the large portion of the descending aorta, you might not have to operate on the patient again. We all know now that there is a lot of thrombosis around an elephant trunk. The only trouble is that if you have a patient on anticoagulants, you cannot rely on that to happen.
Dr Masai: I didn't use any anticoagulants, and I have seen some thrombus formation along the elephant trunk in the second operation.
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References
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- Borst H.G., Walterbusch G., Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37-40.[Medline]
- Borst H.G., Frank G., Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988;95:11-13.[Abstract]
- Minale C., Splittgerber F.H., Wendt G., Messmer B.J. One-stage intrathoracic repair of extended aortic aneurysms. J Card Surg 1994;9:604-613.[Medline]
- Westaby S., Katsumata T. Proximal aortic perfusion for complex arch and descending aortic disease. J Thorac Cardiovasc Surg 1998;115:162-167.[Abstract/Free Full Text]
- Svensson L.G. Rationale and technique for replacement of ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Cardiac Surg 1992;7:301-312.[Medline]
- Emery R.W., Arom K.V., Nicoloff D.M. Modification of the elephant trunk procedure for treatment of acute aortic dissection. J Card Surg 1995;10:65-67.[Medline]
- Kusuhara K., Shiraishi S., Iwakura A. A new staged operation for extensive aortic aneurysm by means of the modified "elephant trunk" technique. J Thorac Cardiovasc Surg 1995;110:267-269.[Free Full Text]
- Svensson L.G., Crawford E.S. Cardiovascular and vascular disease of the aorta. Philadelphia, PA: W.B. Saunders, 1997:286-293.
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Abstract
1. Introduction
