The“elephant trunk”operation, first described by Borst and associates, is a multistage operation for diffuse aneurysmal disease. We report a 59-year-old man complaining of hoarseness, who had a diffuse aneurysm extending from the ascending aorta to the upper abdominal aorta with occlusive disease in the neck branches. His aorta was replaced in two stages using the“elephant trunk”operation. The first stage operation, replacement of the ascending aorta and transverse aortic arch, was performed through a median sternotomy under selective cerebral perfusion. The second stage operation, replacement of the descending thoracic and upper abdominal aorta, was performed under F-F bypass. He had occlusive disease on bilateral carotid arteries with a history of brain infarction, had lost his left lower limb because of arteriosclerosis, and had undergone replacement of the infrarenal abdominal aorta because of an aneurysm. Despite a complicated preoperative general condition, the postoperative course was uneventful. The“elephant trunk” operation facilitates staged operation for diffuse aneurysmal disease as presented here, and thereby improves opeative result by reducing surgical stress.

A rare case of ascending aortic aneurysm due to post stenotic dilatation associated with aortic valve stenosis in a 67-year-old man was treated surgically. Aortic valve stenosis with a systolic pressure gradient of 87mmHg was recognized. Thoracic aortogram and CTscan revealed dilatation of the ascending aorta which was 85mm in diameter. Because the ascending aorta was obviously dilated and its wall was thin at operation, the possibility of rupture was considered to be high. Aortic valve replacement using a 23mm SJM prosthetic valve was performed and graft replacement of the ascending aorta with a 28mm collagen-shield graft was carried out simultaneously. He was discharged in excellent condition on the 45th postoperative day. Pathological examination of the aortic wall revealed an apparently thin wall, but the three layer structure of the wall and elastic laminae were well preserved. Inflammation and atherosclerotic findings were not detected. It was concluded that post stenotic dilatation associated with aortic valve stenosis can develop aneurysm that eventually requires surgical treatment.

Nine patients with type IIIb dissecting aortic aneurysm underwent graft replacement of the thoracic and abdominal aorta between 1988 and 1992. The spiral opening method was used to expose the thoracic and abdominal aorta. Temporal bypass was employed in 2 patients and F-F bypass in 7 patients. Visceral arteries were perfused selectively during aortic cross-clamp. The entire descending thoracic aorta and abdominal aorta was reconstructed in 6 patients and the proximal descending thoracic aorta to renal arteries in 3 patients. The Crawford graft inclusion technique was used in all cases. Three patients required emergency surgery for rupture in one and impending rupture in 2. Operative deaths occurred in 2 patients (22.2%). Morbidity included renal failure (2), bleeding requiring reoperation (2), arrythmia (1), paraplegia (1), paraparesis (1), respiratory failure (1) and ileus (1). In the past two years, we operated on 5 cases of type IIIb dissecting aneurysms and there was neither operative death nor paraplegia.