Clot formation between the folded graft layers in the reversed elephant trunk technique at the second stage of total arch replacement.

We operated on a 77-year-old woman with extensive thoracic aortic aneurysm by staged repair using the reversed elephant trunk technique. First, we performed descending aortic replacement with a 28-mm straight Dacron graft through a left lateral thoracotomy. Considering the high possibility of a proximal operation in the near future, the 10-cm invaginated proximal end of the graft was anastomosed to the aorta to facilitate subsequent operation on the upstream aorta. After a year of follow-up, a second-stage total arch replacement was performed because the aortic arch aneurysm had enlarged. The reversed elephant trunk was withdrawn under deep hypothermic circulatory arrest. Fibrin clots had formed within the folded graft, which could cause postoperative thromboembolism. After cleaning the inner surface of the withdrawn graft, the proximal branched conduit was anastomosed to it to complete the total arch replacement. We review this case and discuss possible mechanisms of and solutions for this condition.