Four-branched graft inversion technique for the distal anastomosis in acute aortic dissection

Background Distal anastomosis bleeding is an issue during total arch replacement with the frozen elephant trunk technique. We used the 4-branched graft inversion technique for the distal anastomosis in acute aortic dissection. The aim was to evaluate the feasibility and benefits of the technique used during the frozen elephant trunk procedure for acute aortic dissection. Methods From January 2017 to July 2019, 109 patients underwent total arch replacement for type A acute aortic dissections. Patients were divided according to the technique used for the distal anastomosis as follows: group G (n = 57; 4-branched graft inversion technique) and group C (n = 52; conventional method with Teflon felt). The postoperative variables were analysed. Results The hospital mortality rate was 9.2% (10/109). The mean cardiopulmonary bypass, cardiac arrest, and circulatory arrest times were 234.95 ± 71.88 min, 168.25 ± 61.33 min, and 39.19 ± 9.45 min, respectively. The circulatory arrest and cardiac arrest times were shorter in the graft inversion group than in the conventional group (36.46 ± 7.88 min vs. 42.19 ± 10.17 min, P = 0.001 and 156.21 ± 55.99 min vs. 181.44 ± 64.68 min, P = 0.031, respectively). There were 7 cases of stroke (6.4%) and 5 cases of paraplegia (4.6%). Additionally, 13 patients (11.9%) required temporary continuous renal replacement therapy. Respiratory failure occurred in 19 patients (17.4%). There were no significant differences in postoperative complications between the two groups. Conclusions The 4-branched graft inversion technique provides effective and confirmed haemostasis during total aortic arch replacement using the frozen elephant trunk procedure.

Giant Distal Anastomotic Pseudoaneurysm 35 Years after Bentall Operation Mimicking an “Elephant Trunk”

We present the case of a giant distal aortic pseudoaneurysm 35 years after a classic mechanical Bentall operation. Computed tomography and coronary angiography showed that this originated from the distal suture line. The proximal suture and coronary ostia appeared to be intact. At reoperation, we found a complete dehiscence of distal suture line: the graft was floating in the pseudoaneurysm, mimicking an “elephant trunk” procedure. This complication suggested a systematic and accurate follow-up of patients who underwent an original Bentall procedure.

STABILISE Technique via a Transapical Approach to Repair Residual Type A Aortic Dissection

The stent-assisted balloon-induced intimal disruption and relamination in aortic dissection or STABILISE concept is a novel endovascular strategy in Type A and Type B dissections. We report a case of Type A aortic dissection repair combining, first, an open thoracic aortic surgery with an elephant trunk procedure and, second, an endovascular treatment using the STABILISE technique via a combined transapical approach commonly used for transcatheter aortic valve implantation and a femoral pathway.

The zone 2 concept and distal stent graft positioning in TH 2–3 are associated with high rates of secondary aortic interventions in frozen elephant trunk surgery

OBJECTIVES The goal of this study was to investigate the association between the localization of the distal anastomosis (zone 2/3), the stent graft length (100–160 mm), the position of the distal end of the hybrid prosthesis and the need for secondary aortic intervention (SAI) in acute and chronic thoracic aortic disease after the frozen elephant trunk procedure. METHODS From 2009 through 2020, a total of 232 patients (137 men; mean age, 61.7 ± 13.8 years) were treated with the frozen elephant trunk procedure. The main indications were acute aortic dissection type A (n = 106, 46%), chronic aortic dissection type A (n = 52, 22%) and degenerative thoracic aortic aneurysm (n = 74, 32%). RESULTS The rate of SAI was significantly higher when we performed a distal anastomosis in zone 2 rather than in zone 3, whereas the rate of SAI was less frequent if the distal positioning of the hybrid prosthesis was below TH 4–5. Combining the zone 2 concept and the short stent graft length (100 mm) was associated with a significantly higher rate of SAIs. Patients with a distal anastomosis in zone 2 were significantly less likely to have a recurrent laryngeal nerve injury (P < 0.001). However, no association between a specific arch zone of a distal anastomosis and the occurrence of spinal cord injury was observed. CONCLUSIONS Rates of SAIs are highest in patients who were treated with a distal anastomosis in zone 2 and a short stent graft (100 mm) with the distal end of the hybrid prosthesis at vertebral level TH 2–3.