Deep Dive Into Aortic Surgery: Three Tips and Tricks for Redo Total Arch and Frozen Elephant Trunk

Redo median sternotomy, total arch replacement, and the frozen elephant trunk procedures for chronic aortic dissection comprise a complex operation. In this video, Professor Yan first explains his operative approach. Then, three tips and tricks for redo total arch and frozen elephant trunk are highlighted:

1.    Electro-evaporative technique for adhesiolysis.
2.    Left axillary artery extra-anatomic bypass.
3.    A deep dive into dissection flap fenestration.

Tip 1: Electro-Evaporative Technique for Adhesiolysis (4:18-10:12)

Originally described by Dr. Paul H. Sugarbaker, the electro-evaporative surgical technique utilizes a nonstick 3 mm ball-tipped electrode, set at a high voltage to effectively divide the adhesion tissues (1, 2). Combined with intermittent saline irrigation, this technique significantly reduces blood loss during redo operations. 

Generous warm saline solution is injected under gentle pressure between the heart and the pericardium with a bulb syringe. The saline solution has a tendency to be absorbed gradually by adhesions or areolar connective tissues, creating a small amount of separation along the tissue planes. This hydrodissection process clearly delineated the dissection planes.

The ball-tipped diathermy creates an eclectic arc at the blunt tip that contours around the heart and the aorta, rather than cutting through the vascular structures. It is an effective dissecting tool for adhesiolysis in redo surgery. The main advantages of the electro-evaporative technique include creating a bloodless operative field, minimizing vascular injury and speeding the adhesiolysis process.

Tip 2: Left Axillary Artery Extra-Anatomic Bypass (10:12-13:42)

Left axillary artery extra-anatomic bypass is an underutilized cannulation strategy in arch and thoracoabdominal aortic surgery. Although this approach is not commonly used, it can greatly simplify aortic arch surgery. It enables antegrade systemic perfusion and maintains spinal cord perfusion. Since the left subclavian artery is already debranched with an 8 mm graft, by bringing this perfusion limb through the left chest and ligating the left subclavian artery at its origin, this ex-anatomic bypass avoids performing a direct end-to-end left subclavian artery anastomosis deep in the chest, which is often the most difficult anastomosis in arch surgery.

Tip 3: A Deep Dive Into Dissection Flap Fenestration (13:42-End)

Fenestration of a chronic dissection flap further down the descending aorta is not easy, as it is impossible to directly visualize the inside of the descending thoracic aorta beyond the distal arch. Often, the fenestration is done blindly, using a pair of scissors to cut the membrane during deep hypothermic circulatory arrest, but the extent of fenestration is quite limited. 

In this case, where the true lumen was very small, Professor Yan used an Ambu scope to provide a clear visualization of the dissection membrane, which was fenestrated all the way to the distal descending aorta using a pair of single use thoracoscopic scissors. As far as the author is aware, this is the first time that this technique has been described.

References

1. Sugarbaker PH. Dissection by electrocautery with a ball tip. J Surg Oncol. 1994 Aug;56(4):246-8. doi: 10.1002/jso.2930560409. PMID: 8057651.
2. Sugarbaker PH. Peritonectomy procedures. Ann Surg. 1995 Jan;221(1):29-42. doi: 10.1097/00000658-199501000-00004. PMID: 7826158; PMCID: PMC1234492.

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