Abstract
Objectives and methods: We performed graft replacement of the entire descending thoracic aorta using the pull-through 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 pull-through technique as a less invasive alternative to a conventional left thoracotomy and endovascular aortic repair in selected high-risk patients.
