2012;21: long elephant trunk pull-through TEVAR long elephant trunk LET pull-through PT A 2 B 1 1 TEVAR LET 1 3 inclusion compos

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1 2012;21: long elephant trunk pull-through TEVAR long elephant trunk LET pull-through PT A 2 B 1 1 TEVAR LET 1 3 inclusion composite graft PT LET PT TEVAR 2012;21: Pull-through TEVAR 1 TEVAR long elephant trunk LET pull-through 2, 3 (Fig. 1) X Tel: LET LET inclusion Inclusion LET LET 23

664 21 5 Fig. 1 Schematic drawing of case 1. Pull-through technique via median sternotomy and laparotomy. Proximal anastomosis was performed with inclusion technique.

2 Fig. 1 Schematic drawing of case 1. Pull-through technique via median sternotomy and laparotomy. Proximal anastomosis was performed with inclusion technique. Intimal flap was resected as possible and the distal end of LET was fixed at the abdominal aorta just proximal to the celiac artery. LET, long elephant trunk; CA, celiac artery; SMA, superior mesenteric artery; RA, renal artery Fig. 2 Modification of LET for pull-through technique. Composite LET consisted of two different sizes of graft was made prior to operation. Longitudinal stitch was placed onto the lesser curvature of the graft. A: Composite LET. B: Reversed composite LET. LET, long elephant trunk LET pullthrough 4 1 Fig A 10 pull-through inclusion inclusion LET pullthrough 24 mm 30 mm 2 composite LET Fig. 2A 2 Fig A 24

3 pull-through 665 Fig. 3 Schematic drawing of case 2. The LET was pulled down the descending aorta. Both proximal and distal end of the LET were anastomosed with inclusion technique. Distal anastomosis was performed through the posterior pericardium with fenestration. LET, long elephant trunk; CA, celiac artery; SMA, superior mesenteric artery; RA, renal artery Fig. 4 Schematic drawing of case 3. Complete aneurysmal thrombosis around the LET was achieved without distal anastomosis of the LET. LET, long elephant trunk; TAA, thoracic aortic aneurysm pull-through LET inclusion 3 Fig cm 30 mm 22 mm 2 composite LET pull-through Fig. 2B LET 4 Fig B 25

4 Fig. 5 Schematic drawing of case 4. Graft replacement of total arch and entire descending aorta was performed via median sternotomy. The LET pulled through the true lumen was placed without distal anastomosis. Bleeding was stopped and false lumen was thrombosed completely. LET, long elephant trunk; CA, celiac artery; SMA, superior mesenteric artery; RA, renal artery 15 cm LET CT LET pull-through TEVAR 3 LET TEVAR LET 1 3 inclusion , 6 TEVAR ET TEVAR 1 TEVAR LET pull-through Pull-through exclusion LET 2000 Kuki 7 8, 9 80 LET LET LET pull-through Pull-through X 26

5 pull-through LET 2 10 mm 2 composite graft Composite LET 2 LET LET pull-through TEVAR TEVAR pull-through LET LET pull-through 1 Greenberg RK, Haddad F, Svensson L, et al. Hybrid approaches to thoracic aortic aneurysms: the role of endovascular elephant trunk completion. Circulation 2005;112: pull-through 2009;62: Koizumi K, Ueda T, Shimizu H, et al. Pull-through technique for entire thoracic aortic dissection without additional left thoracotomy. Interact Cardiovasc Thorac Surg 2011;12: Kouchoukos NT, Mauney MC, Masetti P, et al. Optimization of aortic arch replacement with a one-stage approach. Ann Thorac Surg 2007;83:S811-S814; discussion S824-S Borst HG, Frank G, Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988;95: Safi HJ, Miller CC, Estrera AL, et al. Optimization of aortic arch replacement: two-stage approach. Ann Thorac Surg 2007;83:S815- S818; discussion S824-S Kuki S, Taniguchi K, Masai T, et al. A novel modification of elephant trunk technique using a single four-branched arch graft for extensive thoracic aortic aneurysm. Eur J Cardiothorac Surg 2000;18: Toda K, Taniguchi K, Masai T, et al. Arch aneurysm repair with long elephant trunk: a 10-year experience in 111 patients. Ann Thorac Surg 2009;88: Hata H, Toda K, Shudo Y, et al. Repair for acute type A aortic dissection with a long elephant trunk technique. J Thorac Cardiovasc Surg 2009;137:

6 The Pull-through Technique Using the Long Elephant Trunk for Extensive Thoracic Aortic Aneurysm Tetsuro Uchida, Cholsu Kim, Yoshiyuki Maekawa, Eiichi Oba, Jun Hayashi, Yukihiro Yoshimura and Mitsuaki Sadahiro Second Department of Surgery, Yamagata University Faculty of Medicine Key words: Pull-through technique, Extensive thoracic aortic aneurysm, Long elephant trunk Objectives and methods: We performed graft replacement of the entire descending thoracic aorta using the pullthrough technique in patients with high mortality and morbidity who were unsuitable for endovascular repair. The purpose of this study was to determine the surgical outcomes, feasibility and problems concerning this method. Results: A total of 4 patients (1 man and 3 women, mean age, 72 years) with extensive thoracic aortic aneurysm underwent surgical repair using the long elephant trunk (LET) via a median sternotomy, but without an additional left thoracotomy. Two patients who had previously undergone total arch replacement for aortic dissection showed enlargement of the false lumen of the entire downstream descending aorta. One patient presented with rupture of a dissecting aneurysm of the descending aorta and another had an extensive atherosclerotic thoracic aortic aneurysm. The current technique was employed because of the difficulty in performing a left thoracotomy, due to abdominal vessels arising from the false lumen but without significant fenestration, and an unfavorable anchoring site of the endovascular stent graft. The distal end of the LET was fixed at the abdominal aorta just proximal to the celiac artery in 1 patient and the descending aorta in 3 patients. Distal anastomosis was performed in 2 patients in a double-barrel fashion. Subsequent distal anastomosis was not required in the other 2 patients. Complete aneurysmal thrombosis around the LET was achieved in all patients and no further procedures were required. Although the intercostal artery was not reconstructed in any case, paraplegia was not observed. The postoperative courses were uneventful except for 1 patient who died of gastrointestinal bleeding. In 1 case with a highly elongated aorta, we sutured the lesser curvature of the LET in order to fix its length and prevent over-stretching when the LET was pulled to the downstream aorta. However, if the size discrepancy between the proximal and distal aorta was too large, a composite LET which consisted of 2 different sizes of graft was pulled through the descending aorta. Conclusion: We recommend the pullthrough technique as a less invasive alternative to a conventional left thoracotomy and endovascular aortic repair in selected high-risk patients. Jpn J Vasc Surg 2012;21:

脈管学55巻11号　pp

脈管学55巻11号　pp Online publication December 10, 2015 191 原著 55 21 1 2 2 1 2 2 2 2 1 要旨 : 8 21 19 2 4 1 20 SMA short segment J Jpn Coll Angiol 2015; 55: 191 196 Key words: superior mesenteric artery, dissection, conservative