Correction of Complex Aorta Disease Using the Frozen Elephant Trunk and Bentall’s Procedures

Even with the recent progress in the surgical treatment of complex diseases of the aorta, these operations remain challenging for most surgeons (1-4). 

Nevertheless, complex diseases of the ascending thoracic aorta (ATA), descending thoracic aorta (DTA), and the aortic arch (ARC) are associated with higher morbimortality. One-step surgical correction of these conditions with the use of integrated prosthesis using the frozen elephant trunk technique is safe and has shown good results since its first use (2-8). 

In this video, the authors demonstrate how to perform surgical correction of an aneurism of ATA, DTA, and ARC using an E-vita Open prosthesis associated with a mechanical valve tube graft.

The Patient

A asymptomatic seventy-two-year-old man with a history of hypertension and smoking was diagnosed with aneurysm of the aortic root, ascending aorta, aortic arch, and descending aorta. Respectively, they were dilated at 56 mm, 50 mm, 46 mm, and 45 mm maximum diameters. At his preoperative evaluation, the patient did not show any coronary disease in an angiography, but in a transthoracic echocardiogram, surgeons observed severe aortic valve regurgitation and higher left ventricle diameters (47 x 64 mm) associated with impairment of left ventricular systolic function (LVEF 45 percent).

The Surgery

To begin, a sternotomy, tissue dissection, and cardiopulmonary bypass were completed. During tissue dissection, it was possible to see the ascending aorta aneurysm. The brachiocephalic artery was also individualized for the arterial cannulation at the brachiocephalic artery. The cardiopulmonary bypass circuit was completed with right atrium cannulation for the venous line and with right superior pulmonary vein cannulation for left chambers drainage.

After aortic clamping and aortotomy were completed, cardioplegia was infused directly to both coronary ostia. Then, selective cerebral perfusion was started by both carotids through the arterial line and direct infusion of the left carotid artery through direct vision of the arch. The patient was then cooled to 25 °C.

Following the beginning of selective cerebral perfusion, the aortic arch aneurysm was resected up to the third zone of the aorta. After that, surgeons resected the remaining aortic arch tissue and individualized the aortic arch branches.

The Evita-Open prosthesis was composed with a Dacron tube graft integrated to a coated nitinol stent. In this step, the prosthesis was positioned at the descending thoracic aorta. Then a retrograde opening was started. After the stent side opening, the prosthesis was sutured toward the proximal descending aorta with reinforcement stitches at the end.

Next, surgeons performed retraction of the valve prosthesis, followed by the resection of tube graft for cervical branches anastomosis as isle at the prosthesis. At the end of selective cerebral perfusion, the team increased the blood flow, rewarmed the patient, and performed a cautious deaeration.

Next, surgeons began the Bentall procedure. They completed resection of the native aortic valve and of the remaining aneurismatic tissues with isolation of the coronary ostium. Then, anastomosis of a 25 mm tube graft prosthesis toward the aortic annulus was completed followed by the reimplantation of coronary ostium with a terminal-terminal anastomosis of the two prostheses.

Weaning of cardiopulmonary bypass was uneventful, and the time of total CPB, ischemia and selective cerebral perfusion were 135, 118, and 46 minutes respectively. There was no need for a blood transfusion at the end of the procedure. 

References

1. Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg. 1983 Feb;31(1):37-40. doi: 10.1055/s-2007-1020290. PMID: 6189250
2. Kato M, Ohnishi K, Kaneko M, Ueda T, Kishi D, Mizushima T, Matsuda H. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation. 1996 Nov 1;94(9 Suppl):II188-93. PMID: 8901744
3. Coselli JS, Oberwalder P. Successful repair of mega aorta using reversed elephant trunk procedure. J Vasc Surg. 1998 Jan;27(1):183-8. doi: 10.1016/s0741-5214(98)70308-8. PMID: 9474099.
4. Shrestha M, Bachet J, Bavaria J, Carrel TP, De Paulis R, Di Bartolomeo R, Etz CD, Grabenwöger M, Grimm M, Haverich A, Jakob H, Martens A, Mestres CA, Pacini D, Resch T, Schepens M, Urbanski PP, Czerny M. Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular Domain of EACTS. Eur J Cardiothorac Surg. 2015 May;47(5):759-69. doi: 10.1093/ejcts/ezv085. Epub 2015 Mar 13. PMID: 25769463.
5. Dias RR, Duncan JA, Vianna DS, de Faria LB, Fernandes F, Ramirez FJ, Mady C, Jatene FB. Surgical treatment of complex aneurysms and thoracic aortic dissections with the Frozen Elephant Trunk technique. Rev Bras Cir Cardiovasc. 2015 Mar-Apr;30(2):205-10. doi: 10.5935/1678-9741.20140119. PMID: 26107452; PMCID: PMC4462966.
6. Griepp, RB, Stinson, EB., Hollingsworth, JF., & Buehler, D. (1975). Prosthetic replacement of the aortic arch. The Journal of Thoracic and Cardiovascular Surgery, 70(6), 1051-1063.
7. Crawford, E. S., Saleh, S. A., & Schuessler, J. S. (1979). Treatment of aneurysm of transverse aortic arch. The Journal of Thoracic and Cardiovascular Surgery, 78(3), 383-393.
8. Jakob, H., Tsagakis, K., Leyh, R., Buck, T., & Herold, U. (2005). Development of an integrated stent graft-dacron prosthesis for intended one-stage repair in complex thoracic aortic disease. Herz-Kardiovaskulare Erkrankungen, 30(8), 766-782.
9. Kamiya H, Hagl C, Kropivnitskaya I, Böthig D, Kallenbach K, Khaladj N, Martens A, Haverich A, Karck M. The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: a propensity score analysis. J Thorac Cardiovasc Surg. 2007 Feb;133(2):501-9. doi: 10.1016/j.jtcvs.2006.09.045. PMID: 17258589.

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