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Joseph S. Coselli, MD, Peter Oberwalder, MD 

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1 Successful repair of mega aorta using reversed elephant trunk procedure 
Joseph S. Coselli, MD, Peter Oberwalder, MD  Journal of Vascular Surgery  Volume 27, Issue 1, Pages (January 1998) DOI: /S (98) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

2 Fig. 1 Preoperative drawing and aortogram of patient with mega aorta. Chronic fusiform aneurysm of ascending aorta, innominate artery, transverse aortic arch, and thoracoabdominal aorta. Aneurysm is result of chronic type III aortic dissection (thoracoabdominal aortic aneurysm, Crawford extent III). Journal of Vascular Surgery  , DOI: ( /S (98) ) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

3 Fig. 2 Steps in first stage of repair of mega aorta using “reversed elephant trunk technique.” A, Incision for left thoracoabdominal approach. B, After cross-clamping distal aortic arch and left subclavian artery, the aneurysm is opened and the wall between true and false lumen is excised. C, Inversion of graft (“reversed elephant trunk”). D, Suturing of inverted graft to proximal descending aorta after proximal intercostal arteries have been oversewn. E, After completion of proximal anastomosis, clamp is moved onto graft and intercostal arteries T10 and T11 are reattached. F, Attachment of visceral and both renal arteries at distal anastomosis. G, Flushing of graft and completion of reconstruction. Journal of Vascular Surgery  , DOI: ( /S (98) ) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

4 Fig. 3 Postoperative drawing after completion of thoracoabdominal repair with “reversed elephant trunk” invaginated in proximal portion of graft. Journal of Vascular Surgery  , DOI: ( /S (98) ) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

5 Fig. 4 Steps in second stage of “reversed elephant trunk” procedure. A, Median sternotomy, total cardiopulmonary bypass, deep hypothermic circulatory arrest, together with the use of retrograde brain perfusion, are used. B and C, Withdrawing of invaginated graft segment (“reversed elephant trunk”) from previous proximal descending aortic graft to its full length, and reattachment of left common carotid and left subclavian arteries. Journal of Vascular Surgery  , DOI: ( /S (98) ) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

6 Fig. 4 —con't Steps in second stage of “reversed elephant trunk” procedure. D, Separate interposition graft replacement of innominate artery using a 14 mm woven tube graft. E, Completion of proximal graft anastomosis in supracoronary position after reinstituting cardiopulmonary bypass and rewarming with clamping of graft just proximal to innominate artery. Journal of Vascular Surgery  , DOI: ( /S (98) ) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

7 Fig. 5 Postoperative drawing and aortogram after complete repair of mega aorta shows satisfactory graft replacement of supracoronary ascending aorta, innominate artery, transverse aortic arch, and descending and proximal abdominal aorta. Journal of Vascular Surgery  , DOI: ( /S (98) ) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

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