Distal Landing Zone Open Fenestration Facilitates Endovascular Elephant Trunk Completion and False Lumen Thrombosis Eric E. Roselli, MD, Edgardo Sepulveda,

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Distal Landing Zone Open Fenestration Facilitates Endovascular Elephant Trunk Completion and False Lumen Thrombosis Eric E. Roselli, MD, Edgardo Sepulveda, MD, Akshat C. Pujara, BA, Jahanzaib Idrees, BS, Edward Nowicki, MD The Annals of Thoracic Surgery Volume 92, Issue 6, Pages 2078-2084 (December 2011) DOI: 10.1016/j.athoracsur.2011.08.018 Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Endovascular controversy in the treatment of chronic dissection with aneurysm: thromboexclusion of the false lumen is unpredictable because of retrograde filling and continued pressurization (arrows). The Annals of Thoracic Surgery 2011 92, 2078-2084DOI: (10.1016/j.athoracsur.2011.08.018) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Distal landing zone open fenestration procedure. (A) Heart retracted cephalad to expose distal descending aorta through posterior pericardium or left pleural space. (B) Dissection flap excised through anterior longitudinal aortotomy. Intraoperative view of chronic dissection flap through aortotomy before (blue arrow in B) and after (blue arrow in C) open fenestration. The Annals of Thoracic Surgery 2011 92, 2078-2084DOI: (10.1016/j.athoracsur.2011.08.018) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Chronic aorta with aneurysm after first-stage repair. The arrow in the illustration in panel (A) marks planned distal landing zone for second-stage endovascular completion. Axial computed tomographic scan of modified distal landing zone preoperatively (B) and postoperatively (C). Note the radiopaque metallic clip marking the modified distal landing zone. The Annals of Thoracic Surgery 2011 92, 2078-2084DOI: (10.1016/j.athoracsur.2011.08.018) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) Illustration and (B) volume-rendered computed tomography scan demonstrating completed 2-stage repair with stent graft spanning from elephant trunk to modified distal landing zone with complete circumferential seal to adventitia and exclusion of retrograde false lumen filling. The Annals of Thoracic Surgery 2011 92, 2078-2084DOI: (10.1016/j.athoracsur.2011.08.018) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Estimated survival at median follow-up of 24 months. The Annals of Thoracic Surgery 2011 92, 2078-2084DOI: (10.1016/j.athoracsur.2011.08.018) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions