Frozen Elephant Trunk Surgery Without Circulatory Arrest in Type A Acute Aortic Dissection

In this video, we show in a step-by-step fashion how we could perform what is, to the best of our knowledge, the first total arch replacement with Frozen Elephant Trunk (FET) without circulatory arrest (CA) in a patient with type A acute dissection.

Our concept, based on the recognition of CA as the last important FET limitation, involves the cannulation of the innominate and femoral arteries to ensure continuous upper and lower body perfusion and the connection of a stentgraft (transfemorally released) to a branched arch prosthesis while a balloon catheter is inflated at the level of the stentgraft to guarantee a perfectly bloodless operative field (1-3).

If, on the one hand, we acknowledge the presented technique requires advanced open and endovascular skills, on the other it shows CA can be actually avoided in FET. Moreover, our case endorses Aortic Teams that, through collaborative efforts of cardiac and vascular surgeons, may support progress and innovation in aortic arch surgery going far beyond any optimistic imagination. In fact, working separately, 5 years ago no cardiac and vascular surgeon in our Institute could have imagined performing successfully the procedure described here. We hope our work will inspire other surgeons to find new solutions that allow to avoid circulation arrest in aortic arch surgery, as these are expected to improve our patients’ outcomes.

References

1. Di Eusanio M, Cefarelli M, Alfonsi J, Berretta P, Gatta E. Arch Surgery for Type Ia Endoleak: How to Remain Normothermic and Avoid Circulatory Arrest. Ann Thorac Surg. 2020 Aug;110(2):e139-e141. doi: 10.1016/j.athoracsur.2020.03.014. Epub 2020 Apr 8. PMID: 32275909.
2. Di Eusanio M, Cefarelli M, Alfonsi J, Berretta P, Gatta E. Normothermic frozen elephant trunk surgery without circulatory arrest: how we do it in Ancona. Ann Cardiothorac Surg. 2020 May;9(3):244-245. doi: 10.21037/acs.2020.02.01. PMID: 32551261; PMCID: PMC7298249.
3. Di Eusanio M, Cefarelli M, Alfonsi J, Berretta P, Gatta E. Arch Replacement Without Hypothermic Circulatory Arrest for Type Ia Endoleak: How We Do It In Ancona. May 2020. doi:10.25373/ctsnet.12320696

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