title: Optimal graft diameter and location reduce postoperative complications after total arch replacement with long elephant trunk for arch aneurysm.
abstract: OBJECTIVE
  Total arch replacement with an elephant trunk is a standard treatment for arch aneurysm, but serious complications, such as paraplegia and peripheral embolization caused by flapping of the elephant trunk, remain. Moreover, dilation of the descending aorta and retrograde flow into the peri-graft space at the distal elephant trunk are frequent problems. We hypothesized that optimal graft diameter and location would reduce complications after total arch replacement with a long elephant trunk by achieving complete thrombosis and minimal dilation of the descending aorta around the elephant trunk.
  
  
  METHODS
  We treated 65 patients with arch aneurysm by total arch replacement with a long elephant trunk anastomosed at the base of the innominate artery. The graft diameter was undersized (10%-20% of the distal aorta's diameter). Elephant trunk length was determined by preoperative computed tomography to locate the distal end at Th6 to Th8. Thrombosis around the elephant trunk, diameter of the descending aorta, and distance between the descending aorta and the graft near the distal end of the elephant trunk were evaluated using computed tomography.
  
  
  RESULTS
  The distal end of the elephant trunk was located at Th 8 ± 1. There were no operative deaths, 3 patients (5%) died in the hospital, and 3 patients (5%) experienced spinal cord injury, including 1 in whom permanent paraplegia developed. Computed tomography revealed complete thrombosis around the elephant trunk in 58 patients (89%). The descending aorta did not dilate further, and distance between the descending aorta and the graft progressively decreased.
  
  
  CONCLUSIONS
  Optimal graft diameter and location minimized postoperative complications, with complete thrombosis and no dilation of the descending aorta around the long elephant trunk in most patients.
authors.affiliation: Department of Cardiovascular Surgery, Japan Labor Health and Welfare Organization, Osaka Rosai Hospital, Sakai, Osaka, Japan.
authors.forename: Haruhiko
authors.initials: H
authors.lastname: Kondoh
authors.forename: Toshihiro
authors.initials: T
authors.lastname: Funatsu
authors.forename: Koich
authors.initials: K
authors.lastname: Toda
authors.forename: Satoshi
authors.initials: S
authors.lastname: Kainuma
authors.forename: Satoru
authors.initials: S
authors.lastname: Kuki
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Taniguchi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D016122:Brachiocephalic Trunk / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011474:Prosthesis Design; D013927:Thrombosis / Q000209:etiology; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods