Single-Stage Treatment of Aneurysm of the Distal Aortic Arch and Proximal Descending Aorta Using the Frozen Elephant Trunk Procedure. Case Report

AbstractAneurysms of the thoracic aorta involving the distal arch and the proximal descending aorta have traditionally been treated with two open procedures. During the first stage, the aortic arch pathology has been addressed through a median sternotomy. Several weeks or months later, a second stage followed and included completing the repair of the descending aorta through a lateral thoracotomy.We, herein, report a single stage repair of an aneurysm involving the distal aortic arch and the proximal descending aorta using the frozen elephant trunk operative technique. Vascular hybrid stent graft prosthesis, specifically designed for treatment of extensive aortic aneurysms, has been used to replace the arch component and exclude the descending aorta component of the aneurysm through a median sternotomy, using bilateral antegrade cerebral perfusion and mild systemic hypothermia for intraoperative organ protection.

Download Full-text

Single-Stage Treatment of Extensive Aortic Pathology Using the Frozen Elephant Trunk Procedure

The Heart Surgery Forum ◽

10.1532/hsf.3063 ◽

2020 ◽

Vol 23 (5) ◽

pp. E606-E610

Author(s):

Petar Risteski ◽

Vasil Papestiev ◽

Stefanija Hadzievska ◽

Nadica Mehmedovic ◽

Nikola Lazovski ◽

...

Keyword(s):

Aortic Arch ◽

Single Stage ◽

Frozen Elephant Trunk ◽

Organ Protection ◽

Elephant Trunk ◽

Descending Aorta ◽

Cardiac Morbidity ◽

Aortic Pathology ◽

Cord Injury ◽

Elephant Trunk Procedure

Background: Extensive pathology involving the aortic arch and descending aorta traditionally has been treated with two open procedures. We report our institutional experience with a single stage frozen elephant trunk procedure for treatment of extensive aortic pathology. Methods: Between June 2018 and October 2019, nine patients (eight males, 89%, mean age 61 ± 6 years) with extensive aortic pathology were operated using the frozen elephant trunk procedure. Five (56%) patients underwent primary operation for chronic arch and proximal descending aneurysm in two (22%) patients, chronic type B aortic dissection in two (22%) patients and penetrating aortic ulcer in one (11%) patient. The other four (44%) patients received reoperative surgery for chronic post-dissection aneurysms. For organ protection during the aortic arch procedure, we used selective antegrade cerebral perfusion and mild systemic hypothermia at 28°C. Results: Early mortality was not observed. A single (11%) patient developed focal stroke. Unilateral vocal cord palsy was present in two (22%) patients. Spinal cord injury was not observed. Reexploration for bleeding was required in two (22%) patients. Prolonged ventilation, liver and kidney failure as well as cardiac morbidity were not observed. Two patients (22%) with anticipated Endoleak type Ib received TEVAR extension at follow up. Mid-term mortality was observed in two (22%) patients, due to pneumonia. Conclusion: The frozen elephant trunk procedure can be used for a single-stage treatment of patients with extensive aortic pathology, due to chronic degenerative aneurysms or post-dissection aneurysms involving the aortic arch and the descending aorta, with acceptable mortality and morbidity.

Download Full-text

Minimally Invasive Aortic Arch Repair: Technical Considerations and Mid-Term Outcomes

The Heart Surgery Forum ◽

10.1532/hsf.3235 ◽

2020 ◽

Vol 23 (6) ◽

pp. E803-E808

Author(s):

Petar Risteski ◽

Medhat Radwan ◽

Gjoko Boshkoski ◽

Razan Salem ◽

Annarita Iavazzo ◽

...

Keyword(s):

Aortic Arch ◽

Median Sternotomy ◽

Minimal Invasive ◽

Minimal Access ◽

Organ Protection ◽

Elephant Trunk ◽

Aortic Arch Surgery ◽

Cord Injury ◽

Systemic Hypothermia ◽

Aortic Arch Repair

Background: Reports of minimal invasive aortic arch surgery are scarce. We reviewed our experience with minimal access aortic arch surgery performed through an upper mini-sternotomy, with emphasis on details of operative technique and early and mid-term outcomes. Methods: The medical records of 123 adult patients (mean age 66 ± 12 years), who underwent primary elective minimal access aortic arch surgery in two aortic referral centers, were reviewed. The most common indication was degenerative aortic arch aneurysm in 92 (75%) patients. Standard operative and organ protection techniques used in all patients were upper mini-sternotomy, uninterrupted antegrade cerebral perfusion, and moderate systemic hypothermia (27.4 ± 1°C). Results: Sixty-eight (55%) patients received partial aortic arch replacement; the remaining 55 (45%) patients received total arch replacement, further extended with either a frozen elephant trunk in 43 (35%) patients or a conventional elephant trunk procedure in nine (7%) patients. No conversion to full sternotomy was required. New permanent renal failure occurred in one (0.8%) patient, stroke in two (1.6%), and spinal cord injury in four (3.3%) patients. Early mortality was observed in four (3.3%) patients. At five years, survival was 80 ± 6% and freedom from reoperation was 96 ± 3%. Conclusion: Minimal invasive aortic arch repair through an upper mini-sternotomy can be safely performed, with early and mid-term outcomes well comparable to series performed through a standard median sternotomy.

Download Full-text

Is Total Aortic Arch Replacement with Frozen Elephant Trunk Procedure in Septuagenarians Justified?

10.1055/s-0040-1705318 ◽

2020 ◽

Author(s):

E. Beckmann ◽

A. Martens ◽

H. Krüger ◽

A. Stettinger ◽

T. Kaufeld ◽

...

Keyword(s):

Aortic Arch ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Aortic Arch Replacement ◽

Total Aortic Arch Replacement ◽

Elephant Trunk Procedure

Download Full-text

Faculty Opinions recommendation of Total aortic arch replacement with the frozen elephant trunk procedure in acute DeBakey type I aortic dissections.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.727227099.793527919 ◽

2017 ◽

Author(s):

John Augoustides

Keyword(s):

Aortic Arch ◽

Type I ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Aortic Arch Replacement ◽

Total Aortic Arch Replacement ◽

Elephant Trunk Procedure ◽

Aortic Dissections

Download Full-text

Single-Stage Surgical Repair of Kommerell Diverticulum with Annuloaortic Ectasia via a Median Sternotomy: Frozen Elephant Trunk Technique with an Antler-Like Shape Reconstruction of Arch Branches

Annals of Vascular Diseases ◽

10.3400/avd.cr.17-00126 ◽

2018 ◽

Vol 11 (3) ◽

pp. 343-345

Author(s):

Yoshitaka Yamane ◽

Tomokuni Furukawa ◽

Kazunori Yamada

Keyword(s):

Surgical Repair ◽

Median Sternotomy ◽

Shape Reconstruction ◽

Single Stage ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Annuloaortic Ectasia ◽

Elephant Trunk Technique ◽

Frozen Elephant Trunk Technique ◽

Kommerell Diverticulum

Download Full-text

Suturing Fenestration of the Left Subclavian Artery Orifice in Frozen Elephant Trunk Procedure

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0040-1715434 ◽

2020 ◽

Author(s):

Mitsumasa Hata ◽

Shinji Wakui ◽

Yusuke Ishii ◽

Rei Hinoura ◽

Susumu Isaka ◽

...

Keyword(s):

Aortic Arch ◽

Stent Graft ◽

Subclavian Artery ◽

Distal Part ◽

Left Subclavian Artery ◽

Frozen Elephant Trunk ◽

Bleeding Events ◽

Elephant Trunk ◽

Novel Technique ◽

Elephant Trunk Procedure

AbstractThe frozen elephant trunk (FET) procedure enables easier replacement of the entire aortic arch because it does not require reaching the distal part of the left subclavian artery (LSCA). However, it requires additional management for reconstruction of the LSCA, which is associated with bleeding events. However, the fenestrated FET technique confers a risk of endoleakage from the fenestration site. We report our unique novel technique in which the proximal side of the hybrid stent graft is cut into V-shape around the subclavian artery and sutured continuously around the orifice of the subclavian artery during aortic stump fixation.

Download Full-text

Five-year experience of frozen elephant trunk procedure for thoracic aortic aneurysms

Kardiologiya i serdechno-sosudistaya khirurgiya ◽

10.17116/kardio201811443 ◽

2018 ◽

Vol 11 (4) ◽

pp. 43 ◽

Cited By ~ 1

Author(s):

B. N. Kozlov ◽

D. S. Panfilov ◽

M. S. Kuznetsov ◽

G. G. Nasrashvili ◽

V. M. Shipulin

Keyword(s):

Aortic Aneurysms ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Thoracic Aortic Aneurysms ◽

Elephant Trunk Procedure

Download Full-text

Aortic aneurysm: aortic arch aneurysm

ESC CardioMed ◽

10.1093/med/9780198784906.003.0609 ◽

2018 ◽

pp. 2575-2577

Author(s):

Roberto Bartolomeo ◽

Alessandro Leone ◽

Luca Di Marco ◽

Davide Pacini

Keyword(s):

Aortic Aneurysm ◽

Aortic Arch ◽

Distal Segment ◽

Aortic Aneurysms ◽

Elephant Trunk ◽

Mortality And Morbidity ◽

Medial Degeneration ◽

Hybrid Prosthesis ◽

Mycotic Aneurysms ◽

Elephant Trunk Procedure

Thoracic aortic aneurysm (TAA) is defined as aneurysmal degeneration that occurs in the thoracic aorta. The incidence of TAA is increasing with improvements in screening, as well as advances in imaging. They are often asymptomatic but in some cases, they may compress the innominate vein or airway or they may stretch the left recurrent laryngeal nerve, causing hoarseness. TAA often results from cystic medial degeneration and when it occurs at younger ages, it is classically associated with connective tissue disorders, such as Marfan syndrome or, less commonly, Ehlers–Danlos syndrome and Loeys–Dietz syndrome. Mycotic aneurysms, once the predominant cause of ascending and arch aneurysms, are rare today. Diagnosis is often casual and can be suspected on the basis of chest X-ray or as for ascending aortic aneurysms, diagnosed by transthoracic echocardiogram. However, the computed tomography angiography scan represents the gold standard examination for diagnosis. The aortic arch operation consists of the replacement of the arch with reimplantation of the supra-aortic vessels. Effective methods of cerebral, myocardial, as well as visceral protection are necessary to obtain acceptable results in terms of hospital mortality and morbidity. The ‘elephant trunk’ procedure can be an alternative technique for total arch repair; however, a recent evolution of the ‘elephant trunk’ procedure is the ‘frozen elephant trunk’ technique. This technique consists of the implantation of the stented distal segment of the hybrid prosthesis into the descending aorta through the opened aortic arch, while the proximal, non-stented segment is used for conventional replacement of the aortic arch.

Download Full-text