An Alternative Approach Using Long Elephant Trunk for Extensive Aortic Aneurysm: Elephant Trunk Anastomosis at the Base of the Innominate Artery

Background Although a staged elephant trunk procedure has been widely used, the early mortality of the first stage operation as well as the interval mortality between operations remains unsatisfactory. We developed an alternative elephant trunk procedure to reduce mortality and morbidity. Methods and Results Ascending aorta and arch vessels were minimally dissected. During systemic cooling, a four-branched arch graft with a sewing “collar” and a long “elephant trunk” was prepared. The ascending aorta was opened under selective brain perfusion with moderate hypothermia (25°C), and the elephant trunk was then pulled down into the descending aorta using the catching catheter introduced via a femoral artery. The elephant trunk anastomosis using the collar was made at the base of the innominate artery. The arch vessels were divided and closed at aortic stump, and grafted separately as a consequence of the very proximal site for the elephant trunk anastomosis. Between October 1998 and September 2001, 17 patients, ranging in age from 25 to 79 years (mean 67 years) with extensive aortic aneurysm underwent this operation. Preoperative cardiac complications included coronary artery disease in 5, aortic regurgitation in 3, and 3 of these 8 patients had poor left ventricular function with an ejection fraction less than 40%. Nine patients underwent a second stage operation, in 1 of them the permanent elephant trunk procedure was initially attempted but the second stage procedure was done because of increasing endo-leakage. The mean interval between operations was 8 days (range 1 to 14 days) in the remaining 8 patients. In 5 of 6 patients who underwent the permanent elephant trunk procedure, a decrease in the size of the aneurysm based on thromboexclusion was observed using serial computed tomography scans. A single stage repair was performed in 1 patient. The 30-day survival rate of all operations was 100%, however, there was 1 in-hospital death (6%) after the second operation. There was no stroke, however, paraplegia occurred after the first operation in 1 patient (6%) of the in-hospital death. No new phrenic or recurrent laryngeal nerve palsy occurred as a result of surgery. Conclusions The present technique using a modification of the elephant trunk technique for extensive aortic aneurysm provides acceptable mortality and morbidity. The present strategy would be an alternative for the standard elephant trunk procedure in some high-risk patients with advanced age and comorbidities.

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Aortic aneurysm: aortic arch aneurysm

ESC CardioMed ◽

10.1093/med/9780198784906.003.0609 ◽

2018 ◽

pp. 2575-2577

Author(s):

Roberto Bartolomeo ◽

Alessandro Leone ◽

Luca Di Marco ◽

Davide Pacini

Keyword(s):

Aortic Aneurysm ◽

Aortic Arch ◽

Distal Segment ◽

Aortic Aneurysms ◽

Elephant Trunk ◽

Mortality And Morbidity ◽

Medial Degeneration ◽

Hybrid Prosthesis ◽

Mycotic Aneurysms ◽

Elephant Trunk Procedure

Thoracic aortic aneurysm (TAA) is defined as aneurysmal degeneration that occurs in the thoracic aorta. The incidence of TAA is increasing with improvements in screening, as well as advances in imaging. They are often asymptomatic but in some cases, they may compress the innominate vein or airway or they may stretch the left recurrent laryngeal nerve, causing hoarseness. TAA often results from cystic medial degeneration and when it occurs at younger ages, it is classically associated with connective tissue disorders, such as Marfan syndrome or, less commonly, Ehlers–Danlos syndrome and Loeys–Dietz syndrome. Mycotic aneurysms, once the predominant cause of ascending and arch aneurysms, are rare today. Diagnosis is often casual and can be suspected on the basis of chest X-ray or as for ascending aortic aneurysms, diagnosed by transthoracic echocardiogram. However, the computed tomography angiography scan represents the gold standard examination for diagnosis. The aortic arch operation consists of the replacement of the arch with reimplantation of the supra-aortic vessels. Effective methods of cerebral, myocardial, as well as visceral protection are necessary to obtain acceptable results in terms of hospital mortality and morbidity. The ‘elephant trunk’ procedure can be an alternative technique for total arch repair; however, a recent evolution of the ‘elephant trunk’ procedure is the ‘frozen elephant trunk’ technique. This technique consists of the implantation of the stented distal segment of the hybrid prosthesis into the descending aorta through the opened aortic arch, while the proximal, non-stented segment is used for conventional replacement of the aortic arch.

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506 Uneventful pseudoaneurysm of the ascending aorta with sternal erosion in pregnancy

European Heart Journal Supplements ◽

10.1093/eurheartj/suaa210 ◽

2020 ◽

Vol 22 (Supplement_N) ◽

pp. N142-N145

Author(s):

Alice Benedetti ◽

Alvise Del Monte ◽

Maurizio Rubino ◽

Daniela Mancuso

Keyword(s):

Aortic Valve ◽

Aortic Arch ◽

Left Ventricular ◽

Ascending Aorta ◽

Aortic Arch Aneurysm ◽

Elective Cesarean Section ◽

Elephant Trunk ◽

Severe Aortic Regurgitation ◽

Intimal Flap ◽

Arch Aneurysm

Abstract A 36-year-old woman at 31 weeks’ gestation presented with exertional dyspnoea and palpitations. She had a history of bicuspid aortic valve treated with surgical aortic valvotomy for severe stenosis, followed by ascending aorta replacement for type A acute aortic dissection and Bentall operation with a mechanical valve for severe aortic regurgitation. Eight years after the last surgery, magnetic resonance angiography showed aortic arch aneurysm (49 mm) with a small intimal flap. Thereafter, the patient was lost to follow-up until the current admission. She was hemodynamically stable on presentation and physical examination was unremarkable apart from a mechanical second heart sound. The electrocardiogram showed sinus rhythm with left bundle branch block (Panel A). Transthoracic echocardiography revealed severe left ventricular dilation (EDV 90 ml/m2) with mild dysfunction (EF 50%), normal prosthetic aortic valve function, and aortic arch dilation (50 mm) (Panel B and C). After a multidisciplinary evaluation, elective cesarean section was performed at 34 weeks’ gestation. A post-delivery aortic computed tomography angiography revealed aortic arch aneurysm (52 mm) with intimal flap and two pseudoaneurysms of the anterior aortic wall causing sternal erosion (Panel D, E, F and G). Subsequently, the patient underwent ascending aorta and aortic arch replacement by Frozen Elephant Trunk technique with a 24 x130 mm prosthesis between the aortic root and the descending aorta. The postoperative course was uneventful, and the patient was discharged to a cardiac rehabilitation centre.

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Impact on hospital mortality and morbidity of right ventricular involvement among patients with acute left ventricular infarction

Sao Paulo Medical Journal ◽

10.1590/s1516-31802006000400003 ◽

2006 ◽

Vol 124 (4) ◽

pp. 186-191 ◽

Cited By ~ 6

Author(s):

Afonso Celso Pereira ◽

Roberto Alexandre Franken ◽

Sandra Regina Schwarzwälder Sprovieri ◽

Valdir Golin

Keyword(s):

Myocardial Infarction ◽

Hospital Mortality ◽

Right Ventricular ◽

Left Ventricular ◽

Hospital Death ◽

Inferior Wall ◽

Mortality And Morbidity ◽

Killip Class ◽

Increased Risk ◽

The Impact

CONTEXT AND OBJECTIVE: There is uncertainty regarding the risk of major complications in patients with left ventricular (LV) infarction complicated by right ventricular (RV) involvement. The aim of this study was to evaluate the impact on hospital mortality and morbidity of right ventricular involvement among patients with acute left ventricular myocardial infarction. DESIGN AND SETTING: Prospective cohort study, at Emergency Care Unit of Hospital Central da Irmandade da Santa Casa de Misericórdia de São Paulo. METHODS: 183 patients with acute myocardial infarction participated in this study: 145 with LV infarction alone and 38 with both LV and RV infarction. The presence of complications and hospital death were compared between groups. RESULTS: 21% of the patients studied had LV + RV infarction. In this group, involvement of the dorsal and/or inferior wall was predominant on electrocardiogram (p < 0.0001). The frequencies of Killip class IV upon admission and 24 hours later were greater in the LV + RV group, along with electrical and hemodynamic complications, among others, and death. The probability of complications among the LV + RV patients was 9.7 times greater (odds ratio, OR = 9.7468; 95% confidence interval, CI: 2.8673 to 33.1325; p < 0.0001) and probability of death was 5.1 times greater (OR = 5.13; 95% CI: 2.2795 to 11.5510; p = 0.0001), in relation to patients with LV infarction alone. CONCLUSIONS: Patients with LV infarction with RV involvement present increased risk of early morbidity and mortality.

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Rationale and Technique for Replacement of the Ascending Aorta, Arch, and Distal Aorta Using a Modified Elephant Trunk Procedure

Journal of Cardiac Surgery ◽

10.1111/j.1540-8191.1992.tb01020.x ◽

1992 ◽

Vol 7 (4) ◽

pp. 301-312 ◽

Cited By ~ 91

Author(s):

LARS G. SVENSSON

Keyword(s):

Ascending Aorta ◽

Elephant Trunk ◽

Elephant Trunk Procedure

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Syphilitic heart - a case report

National Journal of Clinical Anatomy ◽

10.1055/s-0039-3401702 ◽

2013 ◽

Vol 02 (02) ◽

pp. 089-092

Author(s):

K C Jyothi ◽

Shetty Shailaja ◽

K C Mahadeva ◽

M Kapil Dev

Keyword(s):

Ventricular Hypertrophy ◽

Left Subclavian Artery ◽

Left Ventricular ◽

Ascending Aorta ◽

Mortality And Morbidity ◽

Tertiary Syphilis ◽

Appropriate Treatment ◽

Male Cadaver ◽

Great Vessels ◽

Syphilitic Aortitis

AbstractHeart and its great vessels are involved in tertiary syphilis in the form of syphilitic aortitis often 20 years or more after primary infection is contracted. In a 60 year old male cadaver, we found an enlarged heart with aneurysm of ascending aorta and semilunar septa was found protruding in to the lumen of arch of aorta distal to the origin of left subclavian artery. Right pulmonary vessels were dilated. Right and left atrial cavity were dilated, left ventricular hypertrophy with dilatation was noted. Hispathological findings of the specimens were suggestive of syphilitic aortitis. Cardiovascular syphilis though uncommon is still a significant cause of mortality and morbidity, which can be reduced by adequate screening, accurate diagnosis and appropriate treatment.

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Direct distal aortic arch graft cannulation after the elephant trunk procedure: technique for central cannulation during second-stage repair

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezu371 ◽

2014 ◽

Vol 48 (1) ◽

pp. 163-165

Author(s):

Eduard Quintana ◽

Alberto Pochettino

Keyword(s):

Aortic Arch ◽

Elephant Trunk ◽

Second Stage ◽

Elephant Trunk Procedure ◽

Central Cannulation

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A novel method of treament of ascending aortic aneurysm

Cardiac Surgery and Interventional Cardiology ◽

10.31928/2305-3127-2020.4.2933 ◽

2020 ◽

pp. 29-33

Author(s):

V.B. Demyanchuk ◽

◽

V.V. Pogrebnyak ◽

O.I. Kvasha ◽

B.M. Todurov ◽

...

Keyword(s):

Surgical Treatment ◽

Aortic Aneurysm ◽

Left Ventricular ◽

Vascular Prosthesis ◽

Ascending Aorta ◽

Aortic Aneurysms ◽

Surgical Trauma ◽

Long Term Treatment ◽

Duration Of Surgery ◽

Prosthesis Fixation

The need for surgical treatment of ascending aortic aneurysms is due to a number of severe complications that occur during the natural course of the disease, such as aortic dissection and rupture. Such interventions show good immediate and long-term treatment outcomes, but they are often accompanied by high blood loss and surgical trauma, which in elderly patients with concomitant pathology can lead to serious cardiac and extracardiac complications and prolongation of treatment in general. We present a technology of external wrapping of the aorta that reduces surgical trauma while maintaining effect of operation. A clinical case of application of this technology in a 63-year-old patient hospitalized to the clinic of the Heart Institute, Ministry of Health of Ukraine, with a diagnosis of aortic insufficiency of the 3rd degree (tricuspid aortic valve), dilatation of the root and ascending aorta, tricuspid insufficiency of the 2nd degree, high pulmonary hypertension, heart failure with reduced left ventricular systolic function. The use of the proposed method has following advantages compared to the established method of fixation of the vascular prosthesis: fixation of the proximal part of the vascular prosthesis is performed using vascular suture material; elimination of the risk of damage to the aortic wall; elimination of the risk of massive bleeding from the aorta at the site of the prosthesis fixation; decreased duration of surgery. Key words: aortic aneurysm, surgical treatment, wrapping of the ascending aorta.

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