Should the 'elephant trunk' be skeletonized? Total arch replacement combined with stented elephant trunk implantation for Stanford type A aortic dissection

Objectives To eliminate the residual false lumen in the descending thoracic aorta and improve long-term outcomes of surgical intervention for Stanford type A aortic dissection, we performed the skeletonized "elephant trunk" procedure in the ascending aorta and aortic arch replacement combined with transaortic stented graft implantation into the descending aorta for both acute and chronic type A aortic dissection, and the short-term results were compared. Methods Between April 2003 and November 2004, 60 consecutive patients (mean age, 53 ± 16.7; approximate range, 28-78 years) with acute (n = 36) or chronic (n = 24) type A aortic dissection underwent this procedure. Right axillary artery cannulation was used for cardiopulmonary bypass and selected cerebral perfusion. The stented graft, a 10-cm-long woven Dacron graft with a self-expandable stent, was implanted through the aortic arch during hypothermic circulatory arrest. Enhanced electric beam computed tomography was performed in each patient before discharge, 3 months after the operation, and once each year thereafter to evaluate the postoperative time course of the residual false lumen. Results Cardiopulmonary bypass time was 166 ± 38 minutes, and average selective cerebral perfusion and lower body arrest time was 30 ± 15 minutes. The in-hospital mortality was 3.3% (2/60). Thrombus obliteration of the residual false lumen in the descending thoracic aorta was observed in 92% and 85% of the acute and chronic aortic dissections, respectively, 3 months postoperatively. There was no late death during follow-up. Conclusions The skeletonized elephant trunk procedure is an effective way of closing the residual false lumen of the descending aorta and might contribute to better long-term outcomes for both acute and chronic type A aortic dissection.