[Bleeding complication from the elephant trunk graft at the 2nd stage operation of the total aortic replacement]

We described a rare complication that occurred during the 2nd stage of a total aortic replacement. The patient was a 72-year-old male who presented with type B acute aortic dissection complicated by distal arch aneurysm. Following the replacement of the total arch aorta with an elephant trunk graft (22 mm Gelweave graft), the descending and abdominal aorta enlarged rapidly. After about 3 months, he was scheduled for the 2nd operation. Through the 8th intercostal space and under partial cardiopulmonary bypass, the descending and the abdominal aorta was replaced with a 20 mm Gelweave-Coselli graft. The 12th intercostal artery, celiac trunk, superior mesenteric artery (SMA), and bilateral renal arteries were reconstructed. During the operation, severe bleeding began from the entire elephant trunk graft. After heparin neutralization and a massive transfusion of blood, fresh frozen plasma, and platelet-rich plasma, the bleeding was controlled. However, paraplegia occurred probably because of severe intraoperative hypotension. Careful attention should be paid during the 2nd stage of an elephant trunk operation.