Surgical Technique of Total Arch Replacement for Failed Thoracic Endovascular Aortic Repair Yasunori Iida, MD, Yukio Obitsu, MD, Nobusato Koizumi, MD,

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Surgical Technique of Total Arch Replacement for Failed Thoracic Endovascular Aortic Repair Yasunori Iida, MD, Yukio Obitsu, MD, Nobusato Koizumi, MD, Yoshihiko Yokoi, MD, Satoshi Kawaguchi, MD, Hiroshi Shigematsu, MD The Annals of Thoracic Surgery Volume 90, Issue 2, Pages 677-678 (August 2010) DOI: 10.1016/j.athoracsur.2009.09.037 Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 A three-dimensional contrast-enhanced computed tomographic scan shows the distal arch aneurysm and migration of the previous stent-graft (arrow). The Annals of Thoracic Surgery 2010 90, 677-678DOI: (10.1016/j.athoracsur.2009.09.037) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 (A) The distal aorta was trimmed to the level of the stent graft. (B) The proximal residual stent was removed by cutting the surgical suture of the stent-graft. The Annals of Thoracic Surgery 2010 90, 677-678DOI: (10.1016/j.athoracsur.2009.09.037) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 (A) An elephant trunk was inserted to reinforce the distal anastomotic site from the inside of the previous graft. (B) The elephant trunk anastomosis, incorporating the aortic wall, previous stent graft, and outer zonal felt strip, was accomplished. The Annals of Thoracic Surgery 2010 90, 677-678DOI: (10.1016/j.athoracsur.2009.09.037) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A, B) No endoleak was recognized on either postoperative computed tomographic scan. The Annals of Thoracic Surgery 2010 90, 677-678DOI: (10.1016/j.athoracsur.2009.09.037) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions