Two-Stage Repair of a DeBakey Type I Aortic Dissection Using the Elephant Trunk Technique
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A 65-year-old man, who had a previous type A aortic dissection in 2011, developed a pseudoaneurysm at the proximal and distal aortic anastomoses of this prior ascending aortic repair. At the time of previous aortic repair, he had also undergone a mechanical aortic valve replacement. Echocardiogram demonstrated moderate paravalvular regurgitation of the aortic valve.
He underwent reoperative aortic root and total arch replacement with stage I elephant trunk procedure, which was followed a year later by an open thoracoabdominal aortic replacement (a stage II elephant trunk repair). A composite valve graft comprised of a 25 mm valve and 30 mm graft was created and used to replace the dilated aortic root. During the first stage elephant trunk procedure, the aortic arch was replaced using deep hypothermic circulatory arrest and antegrade cerebral perfusion. The innominate and left carotid arteries were transected 1 cm above their origins and serially anastomosed to the limbs of a trifurcation graft. Selective antegrade perfusion was subsequently instituted via the main limb of the trifurcation graft. The aortic arch was then transected proximal to the origin of the left subclavian artery. The septum was excised for a distance of 20 cm. A 26 mm graft was invaginated into itself, was placed into the proximal descending thoracic aorta, and the distal anastomosis was completed. The main limb of the trifurcation graft was anastomosed to the 26 mm graft in end-to-side fashion, and the 26 mm graft was anastomosed to the composite valve graft. The third limb of the trifurcation graft was anastomosed to the left subclavian artery underneath the clavicle. The patient was weaned from cardiopulmonary bypass. His postoperative course was uneventful. The patient was discharged on the eighth postoperative day.
During routine follow-up one year later, computed tomography angiogram demonstrated a dilation of the type II thoracoabdominal aortic aneurysm, from 4.6 cm to 5.6 cm. The authors proceeded with the second stage elephant trunk repair. The left common femoral artery and vein were exposed and cannulated for cardiopulmonary bypass. A standard left thoracoabdominal incision was performed. The patient was placed on partial cardiopulmonary bypass. A retroperitoneal plane was developed, and the entire aorta was exposed. Proximal and distal clamps were applied just distal to the left subclavian artery and middescending aorta, respectively. The aorta was opened and all intercostal arteries were ligated. The prior elephant trunk was identified and anastomosed to a 30 mm graft in an end-to-end fashion. The aortic cross-clamp was repositioned from the middescending aorta to below the renal arteries. The abdominal aorta was opened, and distal thoracic arteries were ligated. Selective cold blood perfusion at a rate of 300 cc/min was continuously delivered to the celiac, superior mesenteric, and right and left renal arteries. The main limb of a bifurcation graft was beveled and anastomosed around the celiac, superior mesenteric, and right renal arteries. The second limb of the bifurcation graft was anastomosed to the left renal artery in end-to-end fashion. The distal anastomosis was performed. The main limb of the bifurcation graft was attached to the 30 mm graft in end-to-side fashion. The patient was weaned off partial cardiopulmonary bypass without difficulty. The patient was discharged on postoperative day eight without complications. He continues to progress well in follow-up visits.
A two-stage repair of a DeBakey type I aortic dissection using the elephant trunk technique is a feasible therapeutic option in a complex high-risk patient.