1. Open Distal Fenestration of Chronic Dissection Facilitates Endovascular Elephant Trunk Completion: Late Outcomes 
Muhammad Aftab, MD, Jay J. Idrees, MD, Frank Cikach, BS, Jose L. Navia, MD, Donald Hammer, MD, Eric E. Roselli, MD 
The Annals of Thoracic Surgery 
Volume 104, Issue 6, Pages (December 2017)
DOI: /j.athoracsur
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
This figure demonstrates the technique [12]. (A) Preoperative computed tomography (CT) shows the dissection (arrow). (B) Distal fenestration is made in the retrocardiac aorta during the first-stage elephant trunk. (C) Intraoperative image after flap resection to create a landing zone for the stent graft (arrow). (D) CT image after stage 1 shows absence of the dissection flap after resection (arrow). (E) The elephant trunk graft and descending aorta are shown after fenestration (arrow). (F) Endovascular elephant trunk completion with complete seal at the fenestrated segment. (G) Volume-rendered reconstruction CT image shows completed repair to the distal landing zone as marked by the surgical clips (arrow).
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
(A) Preoperative computed tomography (CT) image of a patient with extensive aneurysm and chronic dissection. (B) Postoperative CT image shows complete repair after first-stage elephant trunk with distal fenestration and second-stage endovascular completion. There are no endoleaks, and the stent graft is patent and intact at 27 months of follow-up. (C) Volume-rendered reconstruction CT image shows intact repair. The surgical clips mark the location of distal fenestration.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
Preoperative (left column images), between stages (middle column), and postoperative (right column) contrast-enhanced computed tomography images demonstrate the progression of treatment of chronic dissection using the staged hybrid approach with elephant trunk and distal fenestration followed by TEVAR. (ET = Elephant trunk; EEC = endovascular elephant trunk completion; pre-op = preoperative; post-op = post-operative.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
The Kaplan-Meier method shows (A) estimated survival after total arch replacement with stage 1 elephant trunk and distal descending thoracic aortic fenestration is 96%, 92%, 82%, and 82%, respectively, at 1, 3, 5, and 7 years, and (B) estimated freedom from secondary reintervention after endovascular elephant trunk completion is 90%, 78%, 74%, and 74%, respectively, at 1, 3, 5, and 7 years.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions