Elephant Trunk Anastomosis Proximal to Origin of Innominate Artery in Total Arch Replacement Kazuhiro Taniguchi, MD, PhD, Koichi Toda, MD, PhD, Hiroki.

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Background (1) ・ In 1998, we developed a modified elephant trunk (ET) technique using a single four-branched arch graft with a sewing “collar” and “long.

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Elephant Trunk Anastomosis Proximal to Origin of Innominate Artery in Total Arch Replacement Kazuhiro Taniguchi, MD, PhD, Koichi Toda, MD, PhD, Hiroki Hata, MD, PhD, Yasuhiro Shudo, MD, Hajime Matsue, MD, PhD, Toshiki Takahashi, MD, PhD, Satoru Kuki, MD, PhD The Annals of Thoracic Surgery Volume 84, Issue 5, Pages 1729-1734 (November 2007) DOI: 10.1016/j.athoracsur.2007.05.087 Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (A) Systemic perfusion strategy through the right axillary artery. (B) Selective cerebral perfusion system used during hypothermic circulatory arrest. (A = artery.) The Annals of Thoracic Surgery 2007 84, 1729-1734DOI: (10.1016/j.athoracsur.2007.05.087) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 (A) Cardiopulmonary bypass is established. The ascending aorta is clamped and opened. (B) The proximal anastomosis is performed first. Of note, the four-branched graft is sutured in such a way so that the three branches of the graft exit from the right anterolateral aspect of the graft, which corresponds to the commissure between the right coronary and noncoronary cusps. The Annals of Thoracic Surgery 2007 84, 1729-1734DOI: (10.1016/j.athoracsur.2007.05.087) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 A divided tube graft (“elephant trunk”) is inserted into the descending aorta (inset, arrow) with the aid of a catching catheter under an open distal condition. A 2-0 or 3-0 Tevdek suture (polyester; Akiyama Medical Manufacturing Co Ltd, Tokyo, Japan) is placed onto the lesser curvature of the elephant trunk so that the graft is not stretched while pulling it down. The distal end of the elephant trunk in this case was marked with metal clips. The Annals of Thoracic Surgery 2007 84, 1729-1734DOI: (10.1016/j.athoracsur.2007.05.087) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) A distal anastomosis is performed at the base of the innominate artery. (B) The arch vessels are reconstructed sequentially while rewarming the patient. The Annals of Thoracic Surgery 2007 84, 1729-1734DOI: (10.1016/j.athoracsur.2007.05.087) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions