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(Circulation. 2007;115:e455-e456.)
© 2007 American Heart Association, Inc.

Images in Cardiovascular Medicine

"Elephant Trunk" Mimicking Thoracic Aortic Dissection

The Role of Intravascular Ultrasound

Mario Zanchetta, MD; Diego Calzolari, MD; Luigi Pedon, MD; Francesca Faresin, MD; Salvatore Ronsivalle, MD

From the Department of Cardiovascular Disease, Cittadella, Padua, Italy.

Correspondence to Mario Zanchetta, MD, FACA, FSCAI, FESC, Dipartimento di Malattie Cardiovascolari, Ospedale Civile, Via Riva Ospedale, 35013, Cittadella, Padova, Italy. E-mail emodinacit{at}ulss15.pd.it

A 68-year-old woman, with a history of hypertension and extensive aortic aneurysm associated with severe aortic valvular regurgitation, underwent aortic valve and ascending aorta replacement (Prisma Plus Stentless, 23 mm, Model 2500P, Edwards Life Sciences, Horw, Switzerland) and separate graft replacement of the aortic arch (vascular prosthesis, 8 mm, Gelweave Vascutek, Inchinnan, Scotland, UK) with the "elephant trunk" technique (Gelweave Vascuteck vascular prothesis, 24 mm).

Five months later, she was admitted to our emergency room because of stenocardia and severe upper abdominal pain with dizziness. A contrast-enhanced computed tomography scan showed a suspicious image of a membrane-like structure resembling a dissection flap in the anterolateral aspect of the descending thoracic aorta (Figure, A) close to the distal free end of the elephant trunk. The descending thoracic and abdominal aortas were of normal diameter, with no signs of dissection at any level.

View larger version (131K): [in this window] [in a new window]   A, Axial contrast-enhanced computed tomography scan shows a membrane-like structure (arrow) in the descending aorta, simulating an intimal flap close to the distal free end of the elephant trunk. B, Right anterior, oblique-view aortogram reveals a mimicking localized spiral dissection (arrows) parallel to the aortic wall. C, Intravascular ultrasound at the distal free end of vascular prosthesis shows its incomplete, asymmetric expansion, resulting in a very complex, bizarre (spade-shaped) new lumen. An almost circumferential echo-free space (arrow) between the vascular prosthesis and aortic vessel wall can be appreciated; it is responsible for corresponding computed tomography and angiographic ambiguous findings. D) Right anterior, oblique-view aortogram after secondary elephant trunk fixation, with 7 cm of overlap of the endovascular stent graft into the free-floating elephant trunk. E) Intravascular ultrasound at the same level of Figure 1C reveals perfect stent-graft expansion and geometry, with complete adherence to the aortic vessel wall. F) Oblique, sagittal, contrast-enhanced computed tomography scan imaging at follow-up of the composite graft.

The patient was referred to our institution for angiography to further explore the diagnosis of aortic dissection. Thoracic aortogram was not conclusive, revealing a mimicking localized intimal tear parallel to the aortic wall, without a mobile intimal flap (Figure, B). To further characterize these findings, an intravascular ultrasound examination was performed, using a 9-French, 9-MHz, Ultra ICE catheter (EP Technologies, Boston Scientific Corp, San Jose, Calif). During a manual pullback from the level of the left subclavian artery origin to the diaphragmatic hiatus, the inner aortic lumen and wall were examined. The equivocal computed tomography and angiographic images close to the distal free end of the elephant trunk were reinterpreted as an incomplete, asymmetric expansion of the vascular prosthesis, with enhanced blood within the graft lumen and outside the graft wall but within the lumen of the native aorta (Figure, C). Secondary elephant trunk fixation by endovascular stent grafting (Valiant Thoracic Stent Graft 32x150, Medtronic Vascular, Santa Rosa, Calif) was performed under fluoroscopic guidance (Figure, D); this was followed by a repeated intravascular ultrasound examination, which showed complete expansion of the skeletonized elephant trunk on the aortic wall (Figure, E). No neurological deficit occurred, and follow-up computed tomography scan confirmed the absence of endoleaks (Figure, F).

Familiarity with these images, coupled with detailed knowledge of surgical technique, is essential for accurately evaluating postoperative findings and avoiding misdiagnosis.

	Acknowledgments

 
Disclosures

None.

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Issue Highlights
Circulation 2007 115: 2459. [Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Zanchetta, M. Articles by Ronsivalle, S. Search for Related Content PubMed PubMed Citation Articles by Zanchetta, M. Articles by Ronsivalle, S. Pubmed/NCBI databases Medline Plus Health Information CT Scans Related Collections Coronary imaging: angiography/ultrasound/Doppler/CC CT and MRI CV surgery: aortic and vascular disease Related Article