Direct distal aortic arch graft cannulation after the elephant trunk procedure: technique for central cannulation during second-stage repair.

Arterial cannulation after the elephant trunk (ET) procedure at the time of second-stage distal repair can be achieved through multiple routes. Common strategies for arterial perfusion at the time of second-stage aortic repair include retrograde perfusion (femoral/iliac vessels), transapical or left subclavian artery cannulation. In the event these cannulation options are not practical or advisable, we offer an alternative approach through cannulation of the distal aortic arch Dacron graft through the left thorax. Advantages include forward distal perfusion, minimal proximal ischaemic time, prevention of thromboembolic events from thrombus attached to the ET and avoidance of malperfusion syndromes.