1. The Reversed Elephant Trunk Technique Used for Treatment of Complex Aneurysms of the Entire Thoracic Aorta 
Joseph S. Coselli, MD, Scott A. LeMaire, MD, Stacey A. Carter, BA, Lori D. Conklin, MD 
The Annals of Thoracic Surgery 
Volume 80, Issue 6, Pages (December 2005)
DOI: /j.athoracsur
Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

2. Figure 1
Drawing of an aneurysm involving the ascending aorta, transverse aortic arch and thoracoabdominal aorta.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

3. Figure 2
The initial steps of the reversed elephant trunk technique: after aortic clamping, the aneurysm is opened, the graft is inverted upon itself (arrow in inset) and the folded edge is sutured end-to-end to the proximal descending aorta.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

4. Figure 3
After completion of the proximal anastomosis, the intercostal arteries have been reattached to an opening in the side of the graft. In this circumstance, the distal anastomosis is being constructed as a bevel at the level of the visceral and renal vessels.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

5. Figure 4
Postoperative drawing illustrating the completed thoracoabdominal repair with the invaginated reversed elephant trunk graft suspended in the proximal portion of the graft.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

6. Figure 5
The second stage of the reversed elephant trunk procedure involves opening the transverse aortic arch via median sternotomy under profound hypothermic circulatory arrest. The invaginated graft segment within the proximal descending thoracic aorta is withdrawn (arrow).
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

7. Figure 6
The reversed elephant trunk eliminates the need for a distal anastomosis during the proximal repair; the brachiocephalic vessels are reattached to an opening in the side of the graft.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

8. Figure 7
Cardiopulmonary bypass is reestablished and rewarming begun as the proximal anastomosis is carried at the sinotubular junction.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

9. Figure 8
Postoperative drawing following completion of the reversed elephant trunk procedure for repair of the entire thoracic aorta.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

10. Figure 9
Kaplan-Meier survival curve for the 38 patients who underwent the first-stage operation using the reversed elephant trunk technique.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

11. Figure 10
Mid-term survival curves were similar in patients who underwent the second-stage repair (solid line) and patients who did not undergo the second-stage repair (dotted line; p = 0.59).
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions