A median sternotomy is considered to have several advantages over a left thoracotomy as a route for the surgical treatment of a distal aortic arch aneurysm, including less pain and less lung damage. In a median sternotomy, distal anastomosis is such an important problem that we herein present a useful technique to prevent surgical bleeding from it. An invaginated 40-mm-long graft is inserted into the distal aorta, sutured to the aortic wall, unfolded, and anastomosed with a four-limbed tube graft. We applied this "mini-elephant trunk" technique to total arch replacement for both a saccural distal aneurysm, where the distal aorta was transected, and a fusiform aneurysm, where the invaginated graft was sutured by the "inclusion" method. This technique enables a greater surface contact area between the graft and the aortic wall at the distal anastomosis, thus resulting in a reduced risk of bleeding.
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