The Elephant Trunk Procedure for Aortic Aneurysm Repair

Fig. 1A—Stage I of elephant trunk procedure: surgical repair of ascending thoracic aorta. A, Illustration depicts surface anatomy of type A aortic dissection with thrombosed false lumen and aneurysm.

Fig. 1B—Stage I of elephant trunk procedure: surgical repair of ascending thoracic aorta. B, Oblique sagittal section shows extent of aortic dissection. Upper inset shows ascending aorta, arch, and proximal descending aorta. Lower inset shows axial cross-section of true and false lumens, latter of which is thrombosed.

Fig. 1C—Stage I of elephant trunk procedure: surgical repair of ascending thoracic aorta. C, Illustration and inset show division of ascending aorta and roof of aortic arch (dashed lines). Great vessels and portion of roof are isolated and retained for later anastomosis with graft.

Fig. 1D—Stage I of elephant trunk procedure: surgical repair of ascending thoracic aorta. D, Removal of ascending aorta and arch. Upper inset shows great vessels and lower inset, exposed aortic root.

Fig. 2A—Step-by-step demonstration of graft invagination for anastomosis preparation and creation of elephant trunk prosthesis. A, Folding graft in on itself. Outer wall of graft (pink) will be limb that remains in descending aorta. Inner wall of graft (blue) will be pulled superiorly for anastomosis with ascending root and great vessels.

Fig. 2B—Step-by-step demonstration of graft invagination for anastomosis preparation and creation of elephant trunk prosthesis. B, Graft placement into descending aortic lumen. Inset shows coronal cross section.

Fig. 2C—Step-by-step demonstration of graft invagination for anastomosis preparation and creation of elephant trunk prosthesis. C, Anastomosis of graft with descending thoracic aorta. Inset shows coronal cross section.

Fig. 2D—Step-by-step demonstration of graft invagination for anastomosis preparation and creation of elephant trunk prosthesis. D, Proximal end of retracted graft is sutured to aortic root. Superior limb of graft (blue) is being pulled proximally (arrow) from descending aortic lumen after anastomosis, leaving descending limb (elephant trunk) in descending thoracic aorta. Inset shows coronal cross section.

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Fig. 2E—Step-by-step demonstration of graft invagination for anastomosis preparation and creation of elephant trunk prosthesis. E, Complete anastomosis of superior (ascending) limb of graft prosthesis.

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Fig. 3A—41-year-old woman with aortic dissection who presented for follow-up after undergoing ascending aortic repair and elephant trunk procedure. A, Axial IV contrast-enhanced CT images show elephant trunk prosthesis (arrows) in descending thoracic aorta.

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Fig. 3B—41-year-old woman with aortic dissection who presented for follow-up after undergoing ascending aortic repair and elephant trunk procedure. B, Axial IV contrast-enhanced CT images show elephant trunk prosthesis (arrows) in descending thoracic aorta.

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Fig. 3C—41-year-old woman with aortic dissection who presented for follow-up after undergoing ascending aortic repair and elephant trunk procedure. C, Axial IV contrast-enhanced CT images show elephant trunk prosthesis (arrows) in descending thoracic aorta.

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Fig. 3D—41-year-old woman with aortic dissection who presented for follow-up after undergoing ascending aortic repair and elephant trunk procedure. D, Coronal (D) and sagittal oblique (E) volume renderings nicely convey 3D relationship of free-floating elephant trunk graft (arrows) in descending thoracic aorta.

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Fig. 3E—41-year-old woman with aortic dissection who presented for follow-up after undergoing ascending aortic repair and elephant trunk procedure. E, Coronal (D) and sagittal oblique (E) volume renderings nicely convey 3D relationship of free-floating elephant trunk graft (arrows) in descending thoracic aorta.

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Fig. 3F—41-year-old woman with aortic dissection who presented for follow-up after undergoing ascending aortic repair and elephant trunk procedure. F, Sagittal oblique multiplanar reconstruction shows both elephant trunk prosthesis (arrows) and residual dissection (arrowheads) in descending thoracic aorta.

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Fig. 4A—Stage II of elephant trunk procedure: surgical repair of descending thoracic aorta. A, Incision (dashed lines) of 8–10 cm is made through posterolateral descending thoracic aortic wall, exposing elephant trunk graft.

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Fig. 4B—Stage II of elephant trunk procedure: surgical repair of descending thoracic aorta. B, Anastomosis of distal end of elephant trunk to descending thoracic aorta.

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Fig. 4C—Stage II of elephant trunk procedure: surgical repair of descending thoracic aorta. C, Completed two-stage surgical repair of dissection involving ascending and descending thoracic aorta.

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Fig. 5A—71-year-old woman with extensive thoracic aneurysm. A, Coronal (A) and sagittal (B) multiplanar reconstructions show aneurysm of thoracic and abdominal aorta with moderate mural thrombus in descending thoracic aorta and proximal abdominal aorta.

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Fig. 5B—71-year-old woman with extensive thoracic aneurysm. B, Coronal (A) and sagittal (B) multiplanar reconstructions show aneurysm of thoracic and abdominal aorta with moderate mural thrombus in descending thoracic aorta and proximal abdominal aorta.

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Fig. 5C —71-year-old woman with extensive thoracic aneurysm. C, Patient underwent ascending aorta repair with elephant trunk prosthesis in descending thoracic aorta. Coronal (C) and sagittal (D) volume renderings and sagittal oblique maximum intensity projection (E) show ascending aortic graft, elephant trunk in descending aorta, and metallic markers (arrows, E) at free end of graft.

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Fig. 5D —71-year-old woman with extensive thoracic aneurysm. D, Patient underwent ascending aorta repair with elephant trunk prosthesis in descending thoracic aorta. Coronal (C) and sagittal (D) volume renderings and sagittal oblique maximum intensity projection (E) show ascending aortic graft, elephant trunk in descending aorta, and metallic markers (arrows, E) at free end of graft.

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Fig. 5E —71-year-old woman with extensive thoracic aneurysm. E, Patient underwent ascending aorta repair with elephant trunk prosthesis in descending thoracic aorta. Coronal (C) and sagittal (D) volume renderings and sagittal oblique maximum intensity projection (E) show ascending aortic graft, elephant trunk in descending aorta, and metallic markers (arrows, E) at free end of graft.

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Fig. 5F —71-year-old woman with extensive thoracic aneurysm. F, Multiple stents were placed in descending thoracic aortic aneurysm under fluoroscopy, beginning at distal portion of elephant trunk prosthesis; end of graft is identified by radiopaque markers (arrows, F).

Fig. 5G —71-year-old woman with extensive thoracic aneurysm. G, Multiple stents were placed in descending thoracic aortic aneurysm under fluoroscopy, beginning at distal portion of elephant trunk prosthesis; end of graft is identified by radiopaque markers (arrows, F).

Fig. 5H —71-year-old woman with extensive thoracic aneurysm. H, Multiple stents were placed in descending thoracic aortic aneurysm under fluoroscopy, beginning at distal portion of elephant trunk prosthesis; end of graft is identified by radiopaque markers (arrows, F).

Fig. 5I —71-year-old woman with extensive thoracic aneurysm. I, Sagittal oblique color-coded volume-rendering image shows thoracic aorta after staged surgical repair of ascending thoracic aorta and placement of multiple stents in descending thoracic aorta.

Pamela T. Johnson et al.2012. The Elephant Trunk Procedure for Aortic Aneurysm Repair: An Illustrated Guide to Surgical Technique With CT Correlation. American Journal of Roentgenology December 2011, Volume 197, Number 6

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Monitoring ECMO

Keberhasilan dari pemasangan ECMO adalah bagaimana tim dapat memantau kondisi pasien secara berkelanjutan di ruang intensif sesuai dengan tujuan awal dari indikasi pemasangan ECMO. Beberapa hal yang perlu diperhatikan bagi team ECMO (baik perawat, dokter ataupun perfusionis) :

1. Sirkuit

ECMO Flows dan MAP (Mean Atrial Pressure)

Perubahan flow atau aliran darah pasien sangat penting untung dimonitor. Penurunan flow akan mengakibatkan penurunan preload atau afterload secara berlebihan. Penurunan preload dapat diakibatkan karena hipovolume atau karena adanya bleeding.

2. Gas Exchange Support

MSweet

3. SvO2 and Lactate

4. Pulsatility

5. Rhythm

Referensi:

1. Mabel Chung. Monitoring of the Adult Patient on Venoarterial Extracorporeal Membrane Oxygenation. The Scientific World Journal.Volume 2014 (2014), Article ID 393258, 10 pages.
2. Aditya Badheka; Sara E. Stucker. Efficacy of Flow Monitoring During ECMO. ASAIO Journal. 63(4):496–500, JUL 2017.

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