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

摘要

Surgical ProcedureFollow-UpResultsSecure 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.MethodsSince 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.ResultsThe 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%.ConclusionsThe 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.CTSNet classification:26Although endovascular treatment has evolved to include arch aneurysm treatment, total arch replacement (TAR) is still necessary and important for patients with arch aneurysm. Total arch replacement remains a cardiovascular surgical procedure with high mortality and morbidity, and several techniques have been employed to improve surgical outcomes. Distal anastomosis is one of the most important factors in predicting TAR outcomes, but it is difficult and stressful for?several surgeons, considering the narrow and deep working space [